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Urinary Tract and Genital Trauma
Penetrating injuries usually occur from gunshot wounds and involve
Figure 2: Management of Posterior Urethral
the pendulous and bulbar urethral segments equally. Injuries in Men
Diagnosis Suspected urethral injury
Blood at the meatus is usually present in anterior urethral trauma. Its
presence should preclude any attempts at urethral instrumentation,
Retrograde urethrogram
until the entire urethra is adequately imaged. In unstable patients, an
Normal
attempt can be made to pass a urethral catheter, but if there is any
difficulty a suprapubic catheter should be inserted. There are no
Prostatomembranous disruption Urethral contusion
convincing data indicating a higher rate of infection or urethral
stricture after a single attempt at catheterisation. However, if a
Complete rupture Partial rupture
urethral injury is suspected, urethrography prior to attempted
Treat with suprapubic or
transurethral catheter
catheterisation is the most prudent approach. Other symptoms that
may appear are haematuria, pain on urination or inability to void,
blood at the vaginal introitus and haematoma.
Penetrating Blunt Blunt Penetrating
Retrograde urethrography is the gold standard for the initial
evaluation of urethral injury. If posterior urethral injury is suspected, a
Primary open repair. Primary open repair.
suprapubic catheter is inserted, and a simultaneous cystogram and If patient unstable or Assess for acute surgical If patient unstable or
important associated indications: bladder neck important associated
ascending urethrogram can be carried out at a later date to assess non-urological injuries,
injury, rectal tear, pie-in-
Suprapubic
non-urological injuries,
the site, severity and length of the urethral injury. When the proximal
suprapubic cystostomy the-sky bladder
cystostomy
suprapubic cystostomy
urethra is not visualised with this technique, either MRI or endoscopy
through the suprapubic tract can be used. No Yes
Management
Suprapubic tube +
Anterior Urethra
Suprapubic endoscopic realignment; Stricture No stricture
cystostomy open if rectal or
Blunt injuries can be managed with a suprapubic catheter or with bladder injury
urethral catheterisation,
26
but suprapubic cystostomy is usually
Urethrotomy
preferred to avoid damage of the urethra and to divert the urine from
Stricture or
the site of injury. Fifty per cent of patients will develop urethral
strictures that will be managed appropriately. Most female urethral
Endoscopic realignment if patient
disruptions can be sutured primarily.
stable and lithotomy position possible or
Delayed urethroplasty Stricture
(<day 14)
Open injuries will require immediate surgical exploration. Small
Stricture No stricture Follow-up
lacerations can be sutured and end-to-end anastomosis can be
performed in complete disruptions. There is no role for urethral
substitution with either a graft or a flap in the initial management of If stricture is short (<1cm)
and flimsy
If stricture is long or denser
any urethral injury, as contamination or decreased blood supply can
compromise such a repair. So, if the defect is over 1–1.5cm in length,
the procedure should be aborted, and a delayed elective procedure is Salvage urethroplasty
Delayed endoscopic optical incision
usually carried out a minimum of three months after injury.
in referral centre
Posterior Urethra Genital Trauma
Partial tears can be managed in most cases with a suprapubic or In males, a direct blow to the erect penis may cause penile fracture,
urethral catheter. Complete ruptures of the posterior urethra should frequently occurring during intercourse. It is caused by rupturing of
be managed with a suprapubic catheter. Acute treatment options the albuginea and may be associated with lesions of corpus
include: primary endoscopic realignment, which is usually performed spongiosum and urethra. Treatment of penile trauma without
during the first 10 days after the injury; and immediate open immediate detumescence can be managed conservatively. In the
urethroplasty, which is experimental and not indicated. Delayed case of penile fracture, immediate surgical intervention with closure
treatment options include: delayed primary urethroplasty, which of the albuginea is recommended.
implies primary repair one to two weeks after injury, is mainly used in
female urethral trauma and for which there is a lack of supporting Penile fracture is presented in 20% of cases with associated urethral
evidence in male patients; delayed formal urethroplasty at or later injury. The diagnosis includes typical history and physical examination,
than three months after injury – the most commonly used approach, cavernosography (false-negatives, especially in small tears) and
this is the procedure of choice and the gold standard for treating urethrography (inability to void, blood at meatus or haematuria). The
posterior urethral distraction defects;
27,28
and delayed endoscopic conservative treatment is not recommended because of a longer
incision of the scar tissue between the urethral ends, i.e. ‘cut-to-the- hospital stay (14 days), missed urethral injuries (5%), penile abscess
light’ or similar procedure. This procedure has a high failure rate and (8%), expanding haematoma requiring late surgery (14%) and
is rarely indicated. Figure 2 shows the decision-making process for angulation (23%). With early surgical repair, the result may be a mild
posterior urethral injuries. angulation (7%) and a shorter stay (four days).
29,30
EUROPEAN UROLOGICAL REVIEW 65
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