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Urethral Trauma

By

Noel A. Armenakas

, MD, Weill Cornell Medical School

Last full review/revision Dec 2020| Content last modified Dec 2020
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Urethral injuries usually occur in men. Most major urethral injuries are 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 urethra (membranous and prostatic) or anterior urethra (bulbous and penile urethra). Posterior urethral injuries occur almost exclusively with pelvic fractures Pelvic Fractures Pelvic fractures can involve the pubic symphysis, innominate bones, acetabulum, sacroiliac joint or sacrum. They range from minimally displaced stable injuries caused by low energy falls to... read more Pelvic Fractures . Anterior urethral injuries are often consequences of a perineal blow, motor vehicle crash, or perineal straddle injury due to a fall. Iatrogenic injuries occur during transurethral instrumentation (eg, catheter placement or removal, cystoscopy Cystoscopy Cystoscopy is insertion of a rigid or flexible fiberoptic instrument into the bladder. Indications include the following: Helping diagnose urologic disorders (eg, bladder tumors, calculi in... read more Cystoscopy ).

Symptoms and Signs of Urethral Trauma

Symptoms of urethral injuries 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.

Diagnosis of Urethral Trauma

  • Retrograde urethrography

Pearls & Pitfalls

  • If male urethral injury is suspected, do not insert a urethral catheter until after urethrography.

Treatment of Urethral Trauma

  • Usually urethral catheterization (for contusions) or suprapubic cystostomy

  • Sometimes endoscopic realignment or surgical repair (for select injuries)

  • Delayed definitive surgery

Contusions can be safely treated with an indwelling transurethral catheter for about 5 to 7 days. Partial disruptions are best treated with bladder drainage via a suprapubic cystostomy Suprapubic catheterization Bladder catheterization is used to do the following: Obtain urine for examination Measure residual urine volume Relieve urinary retention or incontinence Deliver radiopaque contrast agents or... read more . In select cases of posterior partial disruptions, primary urethral realignment (endoscopic or open) may be attempted; if successful, this approach may limit subsequent urethral stenosis.

The simplest and safest option for most patients with complete disruption is bladder drainage via a suprapubic cystostomy. Definitive surgery is deferred for about 8 to 12 weeks until the urethral scar tissue has stabilized and the patient has recovered from any accompanying injuries.

Immediate open repair of urethral injuries is limited to those associated with penile fractures, penetrating injuries, and all injuries in females.

Key Points

  • Most posterior urethral injuries are associated with pelvic fractures. Anterior injuries are usually from a blunt mechanism; urethral injuries with penile fractures or from penetrating trauma occur less frequently.

  • Consider urethral injuries particularly in patients who have pelvic fractures or straddle injuries and who have blood at the urethral meatus or difficulty voiding.

  • In males, do retrograde urethrography before urethral catheterization.

  • In females, do cystoscopy and a thorough vaginal examination.

  • Treat contusions with urethral catheterization and most urethral disruptions initially with a suprapubic cystostomy; consider primary realignment in select cases.

  • Delay surgical reconstruction except in select injuries (ie, penile fractures, penetrating injuries, and female urethral injuries).

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