Urethral injury usually occurs in men. Most major urethral injury is due to blunt trauma. Penetrating urethral trauma is less common, occurring mainly as a result of gunshot wounds, or, alternatively, due to inserting objects into the urethra during sexual activity or because of psychiatric illness.
Urethral injuries are classified as contusions, partial disruptions, or complete disruptions, and they may involve the posterior or anterior urethral segments. Posterior urethral injuries occur almost exclusively with pelvic fractures. Anterior urethral injuries are often consequences of a perineal straddle injury due to a fall, perineal blow, or motor vehicle crash.
Complications include infection, incontinence, erectile dysfunction, and stricture formation.
Symptoms include pain with voiding or inability to void. Blood at the urethral meatus is the most important sign of a urethral injury. Additional signs include perineal, scrotal, penile, and labial ecchymosis, edema, or both. Abnormal location of the prostate on rectal examination (so-called high-riding prostate) is an inaccurate indicator of a urethral injury. Blood on digital, rectal, or vaginal examination requires thorough evaluation.
In any male patient with suggestive symptoms or signs, the diagnosis is confirmed by retrograde urethrography. This procedure should always precede catheterization. Urethral catheterization in a male with an undetected significant urethral injury may potentiate urethral disruption (eg, convert a partial disruption to a complete disruption). Female patients require prompt cystoscopy and a thorough vaginal examination
Contusions can be safely treated with an indwelling transurethral catheter for 7 days. Partial disruptions are best treated with bladder drainage via suprapubic cystostomy. In selected cases of posterior partial disruptions, primary endoscopic urethral realignment may be attempted; if successful, this approach may limit subsequent urethral strictures.
Complete disruptions usually are treated with bladder drainage via suprapubic cystostomy. This option is simplest and can be used safely in all patients. Definitive surgery is deferred for about 8 to 12 wk until the urethral scar tissue has stabilized and the patient has recovered from any accompanying injuries.
Open repair of urethral injuries is limited to those associated with penile fractures, certain penetrating transections, and injuries in females.
Consider urethral injuries particularly in patients who have pelvic fractures or straddle injuries and who have difficulty voiding or blood at the urethral meatus.
In males, do retrograde urethrography before urethral catheterization.
In females, perform cystoscopy and vaginal examination.
Treat contusions with urethral catheterization and complete and many partial disruptions initially with suprapubic cystostomy.
Surgical reconstruction should be delayed except in select injuries (ie, penile fractures, certain penetrating injuries, and female urethral injuries).