Urethral and bladder injuries can occur from pelvic fractures or direct trauma. Posterior urethral injuries commonly occur from shearing forces in pelvic fractures and require initial suprapubic cystostomy with delayed repair to avoid complications. Anterior urethral injuries from straddle injuries may be contusions or lacerations, treated with catheterization or cystostomy depending on severity. Bladder injuries are often extraperitoneal from pelvic fractures and present as hematuria, diagnosed by cystography or CT cystography and treated with catheter drainage. Intraperitoneal bladder injuries require surgery.

1. Management of Urethral &
Bladder Injuries
Dr. Amar Ul Ala Butt
Consultant Urologist
06 R M 12967
MOH 88/458 BCH 7/1

2. URETHRAL INJURIES
& MANAGEMENT

3. Anatomy
1. Posterior urethra.
• Prostatic
• Membranous
2. Anterior urethra.
• Bulbous
• Pendolous

4. prostatic
membranous
pendulous
bulbar

5. Posterior urethral injuries.
• Posterior urethra injured in 1.6-9.9% of
pelvic fracture.
• Complete: 73%
• Partial: 27%

6. Causes.
• Shearing force.
• Direct laceration by pelvic bone fragment.
• Distraction,caused by pelvic fracture b/w
pubic symphysis & pubic rami.

7. Symptoms and Signs
• Blood at the urethral meatus. Do not, do
not, do not try to pass the catheter if it’s
present!!!
• Inability to urinate
• Palpapable bladder
• Pelvic hematoma
• Superiorly dispalced prostate

9. Diagnosis
•Immediate retrograde
urethrogam.

10. Posterior urethra laceration

11. Posterior urethra –complete
tear

12. Treatment
• Suprapubic cystostomy (Initial treatment)
• If incomplete laceration – spontaneous healing
in 2-3 weeks
• Complete laceration – reconstruction after 3
months
• Primary repair – not recommended. Surgery is
difficult because of hematomas.

13. Complications.
1. Stricture:
• Primary repair →50%
• Delayed repair→ 5%
2. Impotence:
• Primary repair →30-80%
• Delayed repair →30-35%
3. Incontinence:
• <2% pts
• Typically ass:with sacral fracture & S2-S4 nerve injury.

14. Anterior Urethral Injuries
• Causes.
• Stradle injuries→Laceration or Contusion
• Self instrumentation or iatrogenic may
cause partial disruption.

15. Symptoms & Signs
• Histry of fall
• Local pain in perineum
• History of instrumentation
• Massive prineal hematom
• Butterfly sign(hematoma)

17. Treatment
• Contusion:.if no extravasion urethra intact,after
urethrography pt:allowed to void if ok no addional
treatment.
• If bleeding present urethral cathetar can be done.
• Laceration:.S/P cystostomy→14-21 days
• Urethral cathhetar avoided bcz it converts incomplete
tear to complete one.
• Pts: who develops complete oclusion of urethra should
have S/P for 3-6 months before definite repairs.

18. Bladder Trauma
• Adult: Extraperitoneal organ
• Bladder dome = weakest point
• Blunt: 60-85%
• MVA: #1 cause
• Important to recognize
– Pelvic/abdominal wall abscess/necrosis
– Peritonitis
– Intra-abdominal abscess
– Sepsis / Death

20. Types of rupture
• Extraperitoneal
– Most common
– Pelvic # in 89-100%
– Bladder rupture in 5-10% of all pelvic #
• Intraperitoneal
– Extravasation of urine in abdomen
– Sudden force to full bladder
– Associated injuries +++ Mortality
(20%)

21. Clinical Presentation
• 98% : Gross hematuria
• 2%: Microscopic hematuria + Pelvic #
• 100%: Gross hematuria
• 85% Pelvic #
•McConnel et al. Rupture of the bladder. Urol Clin North Am. 1982.
•Carroll et al. Major bladder trauma: Mechanisms of injury and a
unified method of diagnosis and repair. Journal of Urology. 1984.
•Morey AF et al. Bladder rupture after blunt trauma :
guidelines for diagnostic imaging. Journal of Trauma-Injury
Infections & Critical Care. 51(4): 683-6, 2001 Oct.

22. Investigation
• Cystography: Gold standard
• CT Cystography : New trend
• Peng et al. AJR 1999.
– Prospective study
– 55 patients. 5 bladder rupture
– Cystography VS. CT cystography
– Ruptures confirmed by Surgery
– 100% sensitive and specific
Peng et al. CT cystography versus conventional cystography
in evaluation of bladder injury. AJR 1999; 173:1269-1272.

23. Investigation…
Deck et al. Journal of Urology, 2000.
– Retrospective study
– 316 patients with CT Cystography
– Sensitivity/Specificity = 95% and
100%
– But 78% and 99% for intraperitoneal
rupture
– Comparable to Cystography alone
– Identifies other injuries
Deck AJ et al. CT Cystography for the diagnosis of
traumatic bladder rupture. J Urol, Jul. 2000; 164(1); 43-6.

24. Standard Helical CT
• Pao et al. Acad Radiol 2000.
– With IV contrast
– Misses bladder rupture
– 100% sensitive if “free fluid” criteria
used.
– Can R/O bladder injury if NO free fluid.
– Not specific.
– Not accepted as diagnostic tool.
Pao et al. Utility of routine trauma CT in the detection of
bladder rupture. Acad Radiol 2000; 7:317-324.

25. Treatment
• Penetrating injuries: OR
• Blunt
– Intraperitoneal: Almost all OR
– Extraperitoneal: Urethral cath. drainage x 7-
10 days.

31. Conclusion
• No Foley if you suspect urethral trauma
• Pelvic # + Microhematuria GU
investigation
• Don’t remove Foley if you suspect a partial
tear of urethra afterwards.

32. THANKS