The document provides detailed information on the anatomy, injuries, evaluation, and management of male and female urethral injuries. It describes the anatomy of the male and female urethra, classifications of posterior urethral injuries in males, clinical evaluation, and treatment approaches including early management with catheterization or repair and deferred repair after several months of suprapubic diversion. Complications of different treatment strategies are also discussed.

1. PFUDD
Dr Pritam Mandal

2. ANATOMY OF MALE URETHRA
• Length:18-20 cm
• Diameter: 8 to 9 mm
• The anterior urethra
– 16 cm long
– a) Bulbar urethra
– b) Penile urethra
• The posterior urethra
– 4cm long

3. Posterior urethra
• Preprostatic part
– 1- 1.5 cm in length
– Surrounded by internal
urethral sphincter
• Prostatic part
– 3-4 cm in length
– Greater proximity to the
anterior surface of the
prostate

4. Cystoscopic appearance of the verumontanum

5. • Membranous Urethra
– 1.5 cm in length
– least dilatable
• External urethral sphincter
mechanism consist of
– Urethral smooth muscle
– Urethral striated muscle
(of rhabdosphincter)
– Pubourethral part of
levetor ani

6. Cystoscopic appearance of the striated sphincter

7. Arterial supply
• Anterior urethra
– Bulbourethral branches
of internal pudendal
– Dorsal penile artery via
circumflex branch on
each side
• Posterior urethra
– Inferior vesical
– Internal pudendal
– Middle rectal

8. Venous drainage
• Anterior urethra
– Dorsal vein of penis
internal pudendal vein
prostatic venous plexus
internal iliac veins
• Posterior urethra
– Prostatic and vesical
venous plexus
internal iliac vein
Lymphatic drainage
• Anterior urethra
– Accompany that of glans
– Deep inguinal
• Posterior urethra
– Internal iliac

9. Innervation
• Greater cavernous nerves
are sympathetic to
preprostatic sphicter
• Rhabdosphincter is supplied
by neurons in Onuf’s
nucleus situated in 2nd
sacral segment of spinal
cord : Fibres pass via
perineal branch of pudendal
nerve

10. Histology
• The urethral epithelium is transitional in type
• Becomes squamous where it traverses the glans penis

11. ANATOMY OF FEMALE URETHRA
• 4cm long , 6mm diameter
• Proximal urethral sphincter
is lacking in female
Arterial supply
• Superior vesical and vaginal
arteries
Veinous drainage
• Vesical venous plexus –
internal pudendal vein –
internal iliac vein

12. Lymphatic Drainage
• Internal and external iliac nodes
Innervation
• Parasympathetic preganglionic fibres from 2nd and 4th sacral
segments of spinal cord
• Somatic fibres from same segment( S2-4) reach the striated
muscle
• Sensory fibres in pelvic splanchnic nerve reach to 2nd – 4th
sacral segment of spinal cord

13. POSTERIOR URETHRAL INJURIES IN MALE
Epidemiology, aetiology and pathophysiology
• Exclusively related to pelvic fractures with disruption of the
pelvic ring(10%)
• These injuries are referred to as pelvic fracture urethral
injuries (PFUI), and are mainly caused by MVAs, High impact
falls
• Divided into partial or complete ruptures
• In complete ruptures, there is a gap between the disrupted
ends of the urethra, which fills up with scar tissue

14. MECHANISM OF INJURY
• Prostatomembranous disruption occurs from major shearing
forces (necessary to fracture the pelvis) at two fixation points
of the posterior urethra
• One point is the prostatomembranous junction, where the
urogenital diaphragm is adherent to the ischiopubic rami
• The second point is the fixation point of the prostatic urethra
to the anterior pubic arch, the puboprostatic ligaments

15. Young and Burgess Classification

16. • The most frequent point of distraction is at the departure of
the bulbous urethra from the membranous urethra
• Concomitant injuries to the head, thorax, abdomen and/or
spine are frequent (up to 66%)
• Other causes:
– Penetrating: Gunshot wounds
– Induced: Urethral foreign body
– Iatrogenic: Endoscopic evaluation

17. Colapinto and McCallum classification
Type Description
I Stretched membranous urethra without rupture
II Complete rupture of the membranous urethra with an intact urogenital
diaphragm
III Membranous urethral rupture with urogenital diaphragm disruption

18. Goldman classification of urethral injuries

19. Chapple et al. suggested the following
modifications
• Anterior urethra
– 1. partial disruption
– 2. complete disruption
• Posterior urethra
– 1. posterior urethra stretched but intact
– 2. partial disruption
– 3. complete disruption
– 4. complex injury involving bladder neck or rectum

20. American association of surgery of trauma
(AAST)classification
l Contusion: blood at urethral meatus and retrograde urethrography is normal
ll Stretch injury: elongation of the urethra with no extravasation on urethrography
lll Partial disruption: extravasation of urethrography contrast medium at the injury
site, with visualization in the bladder
lV Complete disruption: extravasation of urethrography contrast medium at the
injury site with no visualization in the bladder; <2 cm of urethra separation
V Complete disruption; complete transection with >2 cm of urethral separation or
extension into the prostate or vagina

21. FEMALE URETHRAL INJURIES
• PFUIs in females are rare and less common than in males
– Urethra is short and mobile, without any significant
attachments to the pubic bone
• Female urethral injuries are classified into two types:
– Longitudinal or partial (most frequent)
– Transverse or complete injuries
• Concomitant bladder or vaginal injury is possible
• At risk of developing urinary incontinence and urethrovaginal
fistula

22. EVALUATION

23. Clinical signs
• Blood at the meatus
– Cardinal sign
– The absence of it doesn’t
rule out a urethral injury
• Inability to void
– Often associated with a
complete rupture
• Haematuria and pain on
urination
– May be present in
incomplete ruptures
• Urinary extravasation and
bleeding
– Result in scrotal, penile
and/or perineal swelling
and ecchymosis

25. • Rectal examination
– To exclude an associated rectal injury (up to 5% of cases)
– May reveal a ‘high-riding’ prostate, which is an unreliable
finding
• Difficulty or inability to pass a urethral catheter
• A female urethral injury should be suspected
– Unstable pelvic fracture with blood at the vaginal introitus
– vaginal laceration, haematuria, labial swelling
– urinary retention or difficulties passing a urethral catheter

26. Urethrography
• Retrograde urethrography (RUG)
– Standard in the early evaluation
– Any extravasation outside the urethra is pathognomonic
– Incomplete rupture extravasation from the urethra
which occurs while the bladder is still filling
– A complete rupture massive extravasation without
bladder filling

27. Retrograde urethrogram of the male urethra demonstrating urethral anatomy

28. • Prior to deferred treatment, a combination of RUG and
antegrade cysto-urethrography is the standard
– To evaluate site and extent of the urethral stenosis
– To evaluate the competence of the bladder neck

29. The use of synchronous antegrade and retrograde urethral contrast studies
allows for an accurate assessment of the injury

30. Gapometry and anterior urethrometry in
the repair of posterior urethral defect
(Index of elastic lengthening)=
• < 0.35 simple perineal operation
• >0.35 elaborated perineal or transpubic
procedure
Bulboprostatic urethral gap
Length of bulbar urethra

31. Flexible cysto-urethroscopy
• A valuable alternative
• May distinguish between complete and partial rupture
• Preferred to RUG in suspected penile fracture-associated
urethral injury
• In females cysto-urethroscopy and vaginoscopy are the
diagnostic modalities of choice

32. • Prior to deferred treatment, if the competence of the bladder
neck is not clear upon antegrade cysto-urethrography, a
suprapubic cystoscopy is advised

33. Ultrasound and magnetic resonance
imaging
• In the acute phase, US scanning is used for guiding the
placement of a suprapubic catheter
• In complex PFUIs, MRI before deferred treatment provides
valuable additional information
– Better estimation of the length of the distraction defect
– Degree of prostatic displacement
– Presence/absence of a false passage

34. • Cavernosal injury noted on MRI strongly correlated with ED,
added value to pre-operative counseling and management of
ED
urethral defect corporal avulsion

35. Computed Tomography
• CT is the preferred initial radiographic modality to assess soft
tissue injury, organs of the pelvis and retroperitoneum, and
bony structures
• While urethral injury is not always evident on CT, it does
visualize the pelvic fracture and associated hematoma
• ‘Pie in the sky' sign an urethral rupture with cranial
displacement of the bladder

36. Pie in the sky' sign

37. DISEASE MANAGEMENT
Male posterior urethral injuries
Emergency room management
• ABCD of trauma
• It is preferable to establish early urinary diversion to:
– Monitor urinary output
– Treat symptomatic retention if the patient is still conscious
– Minimise urinary extravasation and its secondary effects,
such as infection and fibrosis

38. • Single attempt at urethral catheterisation can be carried out
by experienced personnel
• Insertion of a suprapubic catheter is an accepted practice in
urgent situations
• If there is any difficulty, a suprapubic catheter should be
placed under US guidance or under direct vision, for example,
during laparotomy for associated injuries

39. Immediate urethroplasty
Urethroplasty within 48 hours is not indicated:
• Poor visualisation and Inability to accurately assess the degree
of urethral disruption, due to extensive swelling and
ecchymosis
• May result in extensive unjustified urethral debridement
• The risk of severe bleeding (average 3 L) following entry into
the pelvic haematoma
• High rates of impotence (23%), incontinence (14%) and
strictures (54%

40. Early urethral management (less than six
weeks after injury)
• For partial injuries, urinary diversion is sufficient
• A complete injury will not heal, and formation of an
obliterated segment is inevitable in case of suprapubic
diversion alone
• To avoid this obliteration and a long period of suprapubic
diversion followed by deferred urethroplasty, the urethral
ends can be sutured (urethroplasty) or approximated over a
transurethral catheter (re-alignment)

41. Early urethroplasty
• Criteria for early urethroplasty :
– If associated injuries have been stabilised
– The distraction defect is short
– The perineum is soft
– The patient is able to lie down in the lithotomy position
• As the results (complications, stricture recurrence,
incontinence and impotence) are equivalent to delayed
urethroplasty

42. Early re-alignment
• Open or endoscopic technique
• In a partial injury avoids extravasation of urine in the
surrounding tissues reducing the inflammatory response
• In complete injuries correct severe distraction injuries
rather than to prevent a stricture
• The duration of catheterisation
– partial 3 weeks
– complete 6 weeks
• Voiding urethrography upon catheter removal

43. • Stricture formation is reduced and of shorter length
• No evidence of increase in incontinence and ED
• 50% of strictures after endoscopic re-alignment can be
treated endoscopically (DVIU)

44. Deferred management (greater than three
months after injury)
• The standard treatment remains deferred urethroplasty
• After at least three months of suprapubic diversion
– The pelvic haematoma is nearly always resolved
– The prostate has descended into a more normal position
– The scar tissue has stabilised and
– The patient is clinically stable and able to lie down in the
lithotomy position

45. • Perineal anastomotic repair is the surgical technique of choice
• Combined abdominoperineal approach is necessary :
– Cases of concomitant bladder neck injury
– Recto-urethral fistula

46. Female urethral injuries
• Emergency room management of PFUIs in females is the same
as in males however, subsequent management differs
• Early repair (less than or equal to seven days)
– Complication rate is the lowest
– Preferred once the patient is hemodynamically stable
• Delayed repair (greater than seven days)
– Often requires complex abdominal or combined
abdominal-vaginal reconstruction
– Elevated risk of urinary incontinence and vaginal stenosis

47. Complication rates for different treatment
strategies for PFUIs in females

48. Recommendations Strength rating
Provide appropriate training to reduce the risk of traumatic
catheterisation
Strong
Evaluate male urethral injuries with flexible cysto-urethroscopy
and/or retrograde urethrography
Strong
Evaluate female urethral injuries with cysto-urethroscopy and
vaginoscopy
Strong
Treat pelvic fracture urethral injuries (PFUIs) in
hemodynamically unstable patients by transurethral or
suprapubic catheterisation initially
Strong
Perform early endoscopic re-alignment in male PFUIs when
feasible
Weak
Do not repeat endoscopic treatments after failed re-alignment
for male PFUI
Strong

49. Recommendations Strength rating
Treat partial posterior urethral injuries initially by suprapubic or
transurethral catheter
Strong
Do not perform immediate urethroplasty (< 48 hours) in male
PFUIs
Strong
Perform early urethroplasty (two days to six weeks) for male
PFUIs with complete disruption in selected patients (stable, short
gap, soft perineum, lithotomy position possible)
Weak
Manage complete posterior urethral disruption in male PFUIs
with suprapubic diversion and deferred (at least three months)
urethroplasty
Strong
Perform early repair (within seven days) for female PFUIs (not
delayed repair or early re-alignment)
Strong

50. Management of posterior urethral injuries
in men

52. End to end urethroplasy
• If possible, it is desirable to proceed within 4 to 6 months
after trauma
• The classic reconstruction consists of a spatulated
anastomosis of the proximal anterior urethra to the apical
prostatic urethra
• The patient is consented for urethral repair via a perineal
approach and warned of the specific risks of erectile
dysfunction, incontinence, and recurrence of stricture

53. EQUIPMENT
1. Turner Warwick ring retractor with six rake blades
2. Self-retaining retractor (e.g., Travers)
3. Fine metal suction with a terminal fenestration hole
4. Haygrove staff
5. Ear, nose, and throat (ENT) speculum
6. Hammer and chisel together and bone rongeurs
7. Bone wax

54. PATIENT POSITIONING AND SURGICAL
INCISION
• The patient is placed in the lithotomy position
• The suprapubic catheter is removed, and the abdomen and
perineal skin are prepared
• A 16 fr catheter is placed in distal urethra
• An 18- to 20-Fr urethral sound is placed into the suprapubic
catheter tract ( Antegrade cystoscopy )

56. OPERATIVE TECHNIQUE
• Incision and Dissection of the Distal Urethra
• Excision of Scar Tissue and Identification of the Proximal
Urethra
• Anastomosis of the Urethra
• Closure and Reduction of Tension on the Anastomosis and
Postoperative Care

59. A λ-shaped incision extends from the midline of the scrotum to the ischial tuberosities

60. Colles fascia has been opened to expose the midline fusion of the bulbospongiosus
muscles and the tunica of the corpus spongiosum distal to the edge of the muscles

61. The scissors are introduced to develop the space between the muscle and the bulb
of the urethra

62. An incision is made in the midline with the scissors, exposing the length of the bulb

63. The bulbospongosus muscle is retracted to expose the full length of the bulb

64. The self-retaining retractor is placed to expose the inferior fascia of the genitourinary
diaphragm. The bulb of the corpus spongiosum (bulbospongiosum) can be mobilized
to gain access to the fibrosed area of the urethra

65. The fibrosed urethra is incised, freeing the bulb

66. The anterior urethra is opened to make an adequate lumen

67. The Haygrove staff has been passed through the suprapubic cystostomy. Resection
of the fibrotic distraction defect has allowed it to pass into the perineum

68. When the prostatic urethra is displaced and the arc that the urethra must
Traverse must be shortened, that length can be shortened by incision of the
triangular ligament

69. Incision and mobilization of the perichondrium and periosteum of the symphysis
pubis to allow placement of retractors without trauma to the erectile bodies.
Lateral displacement of the crura exposes the dorsal vein of the penis; after careful
identification, the vein can be ligated and divided

70. Completion of the dissection affords additional exposure for resection of the fibrosis
that surrounds the apex of the prostate and the proximal end of the disrupted urethra

71. If the prostate is elevated behind the symphysis pubis ,the inferior aspect of the
symphysis is resected with a Kerrison rongeur

72. As much of the bone can be removed as necessary to afford a simple approximation
of the ends of the urethra

73. Resection of the pubis and rerouting of the urethra around the crus. When the prostate is
markedly displaced, it may be necessary to expand the infrapubectomy. Sometimes, despite
separation of the crura to the full extent possible, the two ends of the urethra do not meet
when they are brought directly through the crus. It is necessary to bring the urethra lateral to
one of the crura to make up this length

74. • Closer
• Drain palcement
• Compression bandage
• Urine is diverted via the suprapubic cystostomy, and the
urethral catheter is plugged and serves as a stent only

75. Postoperative Management
• Initially kept at bed rest for 24 to 48 hours
• Drugs to prevent erection
• Ambulated and discharged with the suprapubic catheter and
stenting urethral catheter in place
• Patients are discharged on a regimen of oxybutynin and oral
antibiotic
• The drains are removed as drainage allows

76. • A voiding trial with contrast material is performed between 21
and 28 days postoperatively
• The voiding film is examined to ensure that there is no
extravasation and that the anastomosis appears widely patent
• A urine culture specimen is also obtained, and the suprapubic
catheter is plugged
• The patient is allowed to void through the urethra for 5 to 7
days, and the suprapubic catheter is then removed

77. Complications
• Acute:
– Bleeding
– Hematoma
– infection
• Long-term:
– Stenosis
– Incontinence
– Erectile dysfunction

78. With the use of the techniques discussed or similar techniques, curative rates for
reconstruction of posterior PFUIs are in the high 90% range. In large centers, failures are not
due to technical problems (i.e., anastomotic restenosis). In general, failures are indicative of
ischemia of the proximal corpus spongiosum with ensuing stenosis of the mobilized corpus
spongiosum

79. Follow up
• History(voiding symptoms)
• Uroflowmetry
• RUG/MCU
• Cystoscopy

82. Factors responsible for failed posterior
urethroplasty
• Inadequate mobilisation of bulbar urethra
• Inadequate excision of scar
• Inadequate use of Inferior Pubectomy

83. Re do urethroplasty
• If bulbar mobilization alone is insufficient to achieve tension
free and water tight anastomosis:
– Crural separation
– Inferior pubectomy
– Supracrural rerouting
– Transpubic urethroplasty

84. • If BUN (bulbar urethral necrosis) also known as long gap or
unsalvageable bulbar urethra is encountered then a
tubularized flap is selected using
– Preputial non hair-bearing skin/BMG
– Sigmoid colon
– Inner thigh flap

85. TAKE HOME MASSAGE
• High index of suspicion in pelvic fracture
• SPC and deferred urethroplasty
• Tension free anastomosis
• Take care of blood supply of corpus spongiosum
• Excellent outcome

86. THANK YOU