5th year At Medical School

1. Urethral Trauma
By Hatlan alhatlan

2. Outlines
• Background.
• History of the problem.
• Classifications.
• Epidemiology.
• Presentation.
• Investigations.
• Contraindications
• Treatment.
• Follow up , complications , prognosis.

3. Background
• Urethral injuries must be diagnosed and treated
efficiently to prevent long term sequelae..
• SO
• Why is that ?
• Patients with urethral strictures diseases
secondary to poorly managed traumatic events
are likely to have significant voiding problems and
recurring need for further interventions.

4. History of The Problem
• Most urethral injuries are associated with
well-defined events:
• Major blunt trauma such as caused by motor
vehicle collisions or falls.(+pelvic fractures)
• Penetrating injuries in the area of the urethra
may also cause urethral trauma.
• Straddle injuries (blunt trauma to the
perineum)may cause both short- and long-
term problems.

5. Classifications
• Urethral injuries can be classified into 2 broad
categories based on the anatomical site of the
trauma.
• Posterior urethral injuries are located in the
membranous and prostatic urethra. (major
blunt +pelvic fractures).
• Injuries to the anterior urethra are located
distal to the membranous urethra. blunt
trauma to the perineum (straddle injuries)

7. Epidemiology
• Posterior urethral injuries are most commonly
associated with pelvic fracture, with an
incidence of 5%-10%. With an annual rate of
20 pelvic fractures per 100,000 population.
• Anterior urethral injuries are less commonly
diagnosed emergently; thus, the actual
incidence is difficult to determine.

8. The Pathophsiology
• But let’s have an idea about the anatomy:

9. So :??
• Injury to the posterior urethra at
prostatomembranous junction in blunt pelvic trauma.
The prostatic urethra is fixed in position because of the
attachments of the puboprostatic ligaments, displacing
the ligament will tear or stretch the urethra.
• Anterior urethral injury most often results from a blunt
force blow to the perineum, producing a crushing
effect on the tissues of the urethra. (Strictures???)
• The stricture results from scarring induced by ischemia
at the site of the injury.

10. Presentation
• Requires high index of suspicion..
• Q When to suspect ?
In
1. Pelvic fracture
2. Traumatic catheterization
3. Straddle injuries,
4. Any penetrating injury near the urethra.

11. Presentation
• Symptoms :
1. Hematuria
2. Inability to void.

12. Presentation
• Physical examination :
1. Blood at the meatus
2. Palpable full bladder
3. High-riding prostate gland upon rectal
examination.
4. Extravasation of blood along the fascial planes
of the perineum is another indication of injury
to the urethra.
5. "Pie in the sky" findings revealed by
cystography usually indicate urethral disruption.

14. Investigations
• The diagnosis of urethral trauma is made by
with retrograde urethrography, which must be
performed prior to insertion of a urethral
catheter to avoid further injury to the urethra.
• It is performed using gentle injection of 20-30
(60) mL of contrast into the urethra.
• (+ sign) Extravasation of contrast
demonstrates the location of the tear.

15. • Urethrogram demonstrating partial urethral disruption.

16. • Urethrogram demonstrating complete urethral
disruption.

17. Other modalities
• Cystography:
• The static cystography allows for concurrent
bladder injury to be excluded in the acute setting.
When a delayed repair is being considered,
voiding cystography (performed through the
suprapubic catheter) demonstrates the bladder
neck and prostatic urethral anatomy and allows
for proper surgical planning.
•

18. Other modalities
• Cystoscopy
• Can be a valuable adjunct in the evaluation of a
male urethral injury.
1. In the acute setting, the feasibility of early
endoscopic realignment can be determined
2. In the delayed setting, the quality of the urethra
can be evaluated for surgical repair. When
cystoscopy is combined with retrograde
urethrography and cystography, a more accurate
estimation of stricture length can be made,
facilitating decisions in operative strategy.

19. Contraindications
• In cases of urethral trauma, patients often
have multiple injuries. Immediate urethral
repair is relatively contraindicated because
life-threatening injuries must be corrected first
in any trauma algorithm. Urethral repair
should be undertaken after the patient has
stabilized, when hemorrhage is less of a
concern

20. Treatment
• Surgical therapy :
In patient with urethral trauma , the initial
management decisions must be made in the
context of other injuries and patient stability.
• Usually multiple injuries (other sepecalities)
e.g. (life threatening injuries)

21. Surgical Therapy
• Posterior urethral injury 2dry to pelvic fractures:
1. First: Suprapubic catheter for bladder drainage
and subsequent delayed repair.(no manipulation
nor hematoma entrance).
2. Second:Ultimate repair of the PUI can be
performed 6-12 weeks after the event,
hematoma +associated injuries resolved) It is
often carried out via a perineal approach, and
repair consists of mobilizing the urethra distally
to allow a direct anastomosis after excision of
the stricture.

22. Surgical Therapy
• Bulbar urethral injuries often manifest months
to years following blunt perineal trauma (will
cause strictures) . These strictures may be
managed with excision of the stricture and
end-to-end anastomosis via a perineal
approach.
• Long strictures may require flap or grafting.
• (Exploration in cases of penetrating injury)

23. Other Options
• Early realignment of posterior urethral
injuries.
• Direct suture repair has been attempted in
the immediate postinjury period.
• Careful insertion of a urethral catheter under
fluoroscopic guidance.
• But!!
• Contamination and manipulation of
hematoma!

24. Details For The Operation
Postoperative DetailsIntraoperative DetailsPreoperative Details
suprapubic catheter may
be removed immediately
careful dissection of the
urethra
Localization of injury
urethral catheter for
drainage and stenting
Excessive mobilization of
the urethra must be
avoided to prevent
tethering of the penis.
AB for 2 weeks , remove
cath. 4 weeks

25. Follow Up :
• Follow up to assess :
1. Patient's voiding history,
2. Continence status,
3. Potency
4. Undoubtedly, follow-up should be life-long.

26. Complications
• The main complication of posterior injuries is recurrent
stricture. When managed with standard urethroplasty
techniques, recurrent stricture requiring major repeat
operation should be observed in only 1%-2% of
• Continence rates approach 100% in all series,
particularly if the bladder neck is not involved. Several
series have demonstrated only a small group of men
losing erectile capabilities following the urethroplasty
when they are potent following the actual injury.[16]
• Complications of reconstruction of anterior urethral
injuries are similar to those observed in posterior
urethral repairs.

27. Outcome and Prognosis
• Men with urethral injuries have an excellent
prognosis when managed correctly. Problems
arise if a urethral injury is unrecognized and
the urethra is further damaged by attempts at
blind catheterization.
• In those instances, future reconstruction may
be compromised and recurrent stricture rates
rise, when these corrected , good prognosis
follow.

28. Sources
• http://emedicine.medscape.com/article/4517
97-overview

29. Thanxxxxxx