URO URETHRAL TRAUMA

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					URETHRAL TRAUMA
Muhammad Shuja Tahir, FRCS(Edin), FCPS (Hon)




              RELEVANT SCENARIO(S)

 l      A young boy is brought to hospital with crush
        injury to lower abdomen and pelvis. Patient is
        haemo-dynamically unstable. He has history of
        bleeding per urethra.
                                                                      ?
 l      A 48 years man fell from the bicycle over a semi-
        open manhole cover. He is unable to pass urine
        but is passing few drops of blood since injury.

     Discuss plan of investigations and treatment




            LEARNING OBJECTIVES                        POSSIBLE QUESTIONS

                                              Discuss presentations of urethral
      To be able to learn;                    trauma.
      Etiology               Resuscitation    Discuss immediate treatment of
      Classification         Diagnosis        urethral trauma.
      Clinical features      Investigations
      Management             Treatment        Discuss definitive treatment of
                                              urethral trauma.
                                                                             URETHRAL TRAUMA 02




  URETHRAL TRAUMA
  Muhammad Shuja Tahir, FRCS(Edin), FCPS (Hon)




                                                ETIOLOGY
Modernization and progress has introduced fast,         CAUSES
competitive life and severe trauma to the medical       The usual causes leading to urethral trauma in young
world. Injuries to different areas of body have         age are ;
become common. Injuries to perineum and pelvis          !    Major accidents (specially fracture pelvis)
make a very important part of civil and military        !    Penile injuries
trauma. The rupture of urethra is termed as urethral    !    Avulsion or Amputation of penis
injury.                                                 !    Stab wounds
                                                        !    Kicks in the perineum
Urethral injuries are common in young males. Ure-       !    Gunshot injuries
thral disruption is commonly associated with perineal   !    Cycling accidents
and pelvic trauma. It varies in severity and true       !    Mine blasts
rupture may not be always present. It is common in      !    During prostatectomy
males than females as the urethra is longer. Rarely     !    During instrumentation of urethra such as
females also suffer from rupture of urethra following        use of metallic catheter, urethroscope,
fracture of the pelvis1,2.                                   endoscope and resectoscope.
                                                        !    Obstructed labour, (In females only)
The morbidity and complications following urethral      !    Forceps application may lead to avascular
disruption make it a very significant distal urinary         necrosis of urethra.
tract injury.                                           !    Manhole accidents
                                                        !    Animal bites




                  Bladder

                                  Prostatic
                                  urethra
 Symphysis                       Prostate
 pubis                           gland
                               Verumontanum
     Urogenital
     diaphragm
                         Membranous
                         urethra
                   Bulbous
                   urethra

             Anatomy of urethra                                                    Rupture urethra



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                                                                                              URETHRAL TRAUMA 03


!         Falling off the sailing ships                              CLINICAL FEATURES
                                                                     Anterior urethral injuries usually are result of straddle
CLASSIFICATION (VARIETIES)                                           injuries following blunt injuries to perineum. Posterior
The location, the extent and the type of urethral                    urethral injuries usually follow pelvic fractures. It may
disruption should be precisely diagnosed for                         result in complete tear of urethra below prostate in
planning of adequate management and for                              males.
monitoring the morbidity and complications. It can be
classified according to the severity of the injury such              SWELLING
as;                                                                  Swelling and bruising of penis, scrotum and
!     Complete disruption (transection)                              perineum is seen due to haematoma formation.
!     Incomplete disruption
!     Bruising of urethra                                            LEAKAGE
                                                                     Leakage and infection in females may follow post
Four different types of urethral disruption (rupture                 traumatic tears and bruises of vagina. It presents as
urethra) are described according to the site of injury ;             ! Inability to pass urine (retention of urine)
                                                                     ! Passage of blood per urethra
!         Penile urethral disruption
!         Bulbous urethral disruption                                The management of patient should be planned
!         Membranous urethral disruption                             keeping all the injuries in view and following standard
!         Prostatic urethral disruption                              trauma management.
Urethral disruption can also be classified depending
                                                                     Associated injuries such as head, chest and
upon management, morbidity and outcome of the
                                                                     abdominal injuries are also diagnosed and treated
treatment such as ;
                                                                     according to their own merits. Examination of the
! Rupture of anterior urethra (bulbous and penile)
                                                                     perineum and digital rectal examination should not
!     Rupture of posterior urethra(prostatic &
                                                                     be missed. Vaginal examination is performed in
      membranous)
                                                                     females with the history of blunt pelvic trauma to
                                                                     avoid the morbidity associated with delayed
                                                                     diagnosis of urethral injury2.

Classification for anterior and posterior urethral injuries is as follows;
Classification                                                         Description
    I                     Stretch injury. Elongation of the urethra without extravasation on urethrography
    II                    Contusion. Blood at the urethral meatus; no extravasation on urethrography
    III                   Partial disruption of anterior or posterior urethra. Extravasation of contrast at injury site
                          with contrast visualized in the proximal urethra or bladder
    IV                    Complete disruption of anterior urethra. Extravasation of contrast at injury site without
                          visualization of proximal urethral or bladder
    V                     Complete disruption of posterior urethra. Extravasation of contrast at injury site without
                          visualization of bladder

    VI                    Complete or partial disruption of posterior urethra with associated tear of the bladder
                          neck or vagina


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                                                                                    URETHRAL TRAUMA 04



                                    SIGNS OF URETHRAL INJURY
       Blood at meatus                                          Perineal heamatoma or labial swelling
       Blood at vaginal introitus                               Pain on urination
       Heamaturia                                               Inability to void
 The signs are present in 37-93% of postrior urethral injuries. The signs arepresent in 75% of anterior urethral
 injuries. The signs are present in more than 80% of female urethral injuries.


                                              INVESTIGATIONS
The diagnosis is confirmed with following                    before primary realignment of urethral rupture or
investigations.                                              when definitive urethral realignment or urethroplasty
                                                             is to be undertaken.
URINE EXAMINATION
This is performed after suprapubic drainage of the           URETHROGRAPHY
urine.                                                       It is a contrast medium radiological visualization of
                                                             the interior of the urethra. This is the most valuable
BLOOD EXAMINATION                                            investigation and whole of the management
! Haemoglobin percentage estimation                          depends upon its findings. It can be performed both
! Total leucocyte count                                      ultrasonic and radiologically.
! Differential leucocyte count
! Urea and Electrolytes estimation                           It is performed under strict aseptic conditions before
! Grouping and crossmatching                                 definitive treatment of urethral disruption is planned.
                                                             5-10 mls of hypaque are injected per urethra and x-
SONO-URETHROGRAPHY                                           ray films are taken in antero-posterior, lateral and
Ultra sound examination of urethra is very helpful in        oblique views. It shows whether rupture of the
the examination for anterior urethral trauma. It is non      urethra is complete or incomplete. It also shows
invasive, safe, economical and gives more                    urethral bruising. It also shows the site of the rupture
information than radio-urethrography. It shows the           and its relation to the urogenital diaphragm.
condition of periurethral tissue. It is not very useful in
posterior urethral disruption.
Urethrography can be performed as an emergency



  Right
  Kidney




           Right
           Ureter




           Ruptured Posterior Urethera                                              Ruptured Posterior Urethera
                (urethrography)                                                          (urethrography)



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                                                                                  URETHRAL TRAUMA 05



INVESTIGATIONS FOR ASSOCIATED                              exclude the associated injuries.
INJURIES
Investigations should be performed to confirm or


                                            MANAGEMENT
Management can be planned according to the grade           The associated injuries are usually so severe that
of injury.                                                 patients may not be hemodynamically stable and
                                                           may be in haemorrhagic shock.
TYPE I
No treatment required                                      The injuries to head and neck, chest and abdomen
                                                           may require immediate intervention. The urethral
TYPES II & III                                             injury itself is not life threatening but it is an injury
These can be managed conservately with                     which makes the life miserable and not worth living in
suprapubic cystostomy or urethral catheterisation.         case it is managed badly. The basic objective of
                                                           management of urethral disruption is to avoid the
                                                           complications.
TYPES IV & V
                                                           Following plan is commonly followed ;
These require open or endoscopic treatment
                                                           !    Resuscitation
(primary or delayed).                                      !    Urinary diversion
                                                           !    Diagnosis
TYPE VI                                                    !    Treatment of associated injuries
It requires primary open repair.                           !    Definitive treatment of urethral disruption
Heamodynamically unstable patients require                      (urethral rupture.)
resuscitation before they can be investigated or           !    Treatment of effects or complications of
treated.                                                        urethral disruption (rupture urethra).


Classification                                               Treatment
  I                 No treatment required

  II
                    Supra pubic catheterization
  III

  IV                Supra pubic catheterization and delayed / primary endoscopic alignment of urethra


  V                 Supra pubic catheterization and delayed / primary endoscopic alignment of urethra
                    Open urethroplasty
  VI




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                                                                                  URETHRAL TRAUMA 06



Most of the time rupture urethra is associated with        clinical features of urethral disruption when no other
pelvic and other injuries. The patient requires            perineal injury is visible.
immediate and active resuscitation. It is of prime
importance to treat the haemorrhagic shock                 Patient is usually advised not to try passing urine per
promptly.                                                  urethra without realizing that it is almost impossible
                                                           to avoid voiding when the patient is having acute
Continuous monitoring and repeated examination is          urinary retention.
very important in these patients.
                                                           The urethral catheterization should not be tried
The active resuscitative measures are used                 blindly as it can change a partial rupture into a
according to the standard ATLS protocol.                   complete rupture of urethra.

FLUIDS REPLACEMENT                                         It may also cause the infection of the paraurethral
Large bore intravenous cannula should be secured           haematoma. It may lead to false passage formation.
in a relatively larger vein so that larger amount of       It may not even reach the bladder and may drain the
fluids and blood can be transfused in shorter periods      perivesical urinary leakage giving a false impression
to revive the patients in shock or shock like condition.   of bladder drainage. Passage of a drop of blood per
The assessment of blood loss should be immediately         urethra after the history of perineal or urethra injury is
screevel and performed to as much precision as             an absolute indication of diversion of urinary outflow.
possible. Blood should be crossmatched carefully to
avoid unwanted reactions and spread of various             Stab suprapubic cystostomy should be performed
types of viral diseases. Correct amount of blood           under local anaesthesia immediately. It is simple,
should be transfused at a calculated speed to              minimally invasive and safe procedure3. The pain
improve the vascular volume and replace and the            due to retention urine is relieved after urinary
lost amount of blood.                                      drainage. Urethral catheterization should be avoided
                                                           in emergency situations specially if the urethral injury
ANALGESIA AND SEDATION                                     has not been diagnosed urethrographically.
The pain is severe due to pelvic and other associated
injuries. The rupture urethra alone causes lot of pain     As soon as the patient's condition permits, proper
and discomfort to the patient due to extravasation         history is taken and complete examination is
and acute retention of urine.                              performed. The clinical diagnosis is established. It
                                                           may require repeated examination to reach precise
Oral analgesics are not helpful in the condition of        diagnosis.
haemorrhagic shock because these are not
                                                           Supra pubic drainage is sufficient for bruising of the
absorbed satisfactorily through gastro-intestinal
                                                           urethra or incomplete rupture of urethra.
tract. Parenteral analgesics and sedatives are given
to relieve the pain and sedate the patient.                Urinary diversion should be performed as early as
                                                           possible to avoid unnecessary extravasation,
SUPRAPUBIC DRAINAGE OF URINE                               voiding difficulties and vulvar and perineal edema3.
History of injury to the perineum, bleeding per
urethra and inability to pass urine are diagnostic




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                                                                                 URETHRAL TRAUMA 07




Treatment of urethral disruption can be performed         cystoscope trans-vesicaly into the posterior urethra.
as;                                                       The injured area of urethra is seen and realigned. Its
!    Immediate                                            realignment is maintained by catheter stenting which
!    Definitive                                           is performed under vision in retrograde or antegrade
                                                          fashion.
IMMEDIATE TREATMENT OF                                    Primary endoscopic realignment in completely
URETHRAL DISRUPTION                                       transacted urethra results in dilatable strictures in
Emergency services are usually not as satisfactory        most of the patients. It is treatment of choice in
as planned health care. It is best not to touch the       paediatrics rupture of urethra
                                                                                         4,7,8,9,10.

urethra in emergency. It should only be handled if
definitive primary repair is planned but this method is   RAILROAD CATHETERIZATION
not free from complications and should best be            It is an obsolete operation and not performed these
avoided. The leakage of urine, haematuria and local       days even for complete rupture of urethra. It is a blind
inflammation makes it impossible to repair the            procedure and may cause false passage formation
urethra satisfactorily.                                   and may make the urethral injury even worse.

Following surgical options are available;

PRIMARY ENDOSCOPIC                                        PRIMARY ANASTOMOTIC
REALIGNMENT                                               URETHROPLASTY
                                                          Primary repair of the ruptured urethra and
Primary realignment requires placement of SPC at
                                                          suprapubic drainage of the bladder has also be
time of injury with realignment undertaken when
                                                          performed if the extravasation of urine is less and
patient is stable within 7 days.
                                                          anatomy is not so much disturbed. It increases the
It is performed in completely transacted urethra. It is
                                                          risk of stricturation and impotence in larger number
simple, relatively atraumatic and minimally invasive.
                                      4
                                                          of cases. The method is best avoided.5,6
It avoids the associated complications .
                                                          It is an open surgical method. The ruptured part of
It is an endoscopic procedure in which the                the urethra is exposed, haematoma is drained
urethroscopy is performed from urethral end and           Haemostasis is secured and repair or anastomosis
from the suprapubic region by passing a urethro-          of the transacted or injured urethra is performed




      Ruptured anterior Urethera                                                 Ruptured posterior Urethera



SURGERY - UROLOGICAL PROBLEMS                                                                                  217
                                                                                URETHRAL TRAUMA 08




under direct vision. It has its own morbidity as the      urethrotomy or dilation or urethroplasty may be
rate of impotence after open primary anastomotic          required.
urethroplasty is very high and is not within
acceptable limits5,6.                                     DELAYED URETHROPLASTY
                                                          It is performed in the patients who have formed a bad
DEFINITIVE TREATMENT                                      and blind structure. Open surgery is performed. The
It is the treatment given to keep the urethral lumen      perineal approach is used urethra is exposed.
patent and free distal urinary flow. The essence of       Fibrous stricture is completely excised and end to
treatment of urethral disruption is to avoid the          end anastomosis of urethra is performed. It may
complications. It is performed 3-6 months after injury    require internal urethrotomy or dilatation at a later
when swelling has settled.                                stage. The rate of complications with this procedure
                                                                           11
                                                          is relatively low .
The problems involved in the definitive surgery for
urethral disruption should never be under                 COMBINATION OF THESE
         7
estimated .                                                PROCEDURES
                                                          A combination of these procedures may be required
Commonly used methods are ;                               to achieve satisfactory results.

DELAYED PRIMARY ENDOSCOPIC                                TREATMENT OF COMPLICATIONS
 REALIGNMENT OF URETHRA                                   This is the treatment of effects and complications of
It is endscopic alignment performed within 3-10 days      the urethral injury. Most important complication is
after urethral injury. The initial injury is managed by   stricture urethra which is treated by urethral
urinary diversion as an emergency. The initial edema      dilatation, urethrotomy or urethroplasty or a
has settled and fibrous stricture formation has not       combination of all or some of these procedures.
occurred yet. The morbidity is relatively less and
complications are less.                                   TREATMENT OF ASSOCIATED
                                                          INJURIES
DELAYED ENDOSCOPIC OPTICAL                                Associated injuries are treated according to their
URETHROTOMY.                                              severity. Head injuries, chest injuries, abdominal
The optical internal urethrotomy is performed three       injuries and pelvic fracture all are more serious than
to six months later when all the injuries have settled.   rupture urethra and require treatment on priority
The optical urethrotomy is used to cut the structure      basis. Urinary diversion takes care of the urethral
under vision. It is less traumatic but repeated           disruption during emergency period.




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                                                                                           URETHRAL TRAUMA 09



REFERENCES
1.   Carter CT. Schafer N. Incidence of urethral disruption in   8-   Gundogdu H. Tanyel FC. Buynk pamuk Primary
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     journal of emergency medicine. 1993 May. [JC:aa2) 11(3):         British journal of urology. 1990 Jun. [JC:b3k] 65(6): 650-2.
     218-20.

2-   Dickmann- Guiroy B. Young DH. Female urethral injury        9-   Herschorn S. Thussen A. Radomski BB. The value of
     secondary to blunt pelvic trauma. Annals of                      immediate or early catheterization of the traumatized
     emergency medicine. 1991 Dec. [JC: 427] 20(12): 1376-            posterior urethra. Journal of urology. 1992 Nov. [JC:Kc7]
     8.                                                               148 (5): 428- 31.

3-   Perry MO. Husmann DA. Urethral injuries in female           10- WU YA. Huang Ch. Liu JH. Endoscopic management for
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     1992 Jan. [JC: Kc7] 147(1) : 139-43.                            medical journal Peking. 1992Nov. [JC: d3b] 105 (11): 940-
                                                                     3.
4-   Guille F. Cpolla B. Leveque JM et al. Early
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     urology. 1991Aug. [HC:b3k] 68(2): 178-80.                       approach. Experience with 74 cases. J Urol. 1991.
                                                                     145:744.
5-   Spirnak JP. Smith EM Elder JS. Posterior urethral
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     urology. 1993 Apr. [JC: Kc7) 149(4): 766-8.                     Trauma. European Association of Urology. Feb. 2003.

6-   Koraitum MM. Pelvic fracture urethral injuries              13. L. Martinez- Pinero, N Djakovic, N Plas, Y Mor, RA
                                                                     Santucci, E. Eerafetimdis. EAU Guidelines on urethral
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                                                                     trauma. EurUrol(2010) doj:10.1016/J.euuro.
     J. Urol. 156: 1288.
                                                                     2010.01.013.
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SURGERY - UROLOGICAL PROBLEMS                                                                                                 219

				
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