Urethral Trauma Treatment & Management
- Author: James M Cummings, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm.
The traditional intervention for men with posterior urethral injury secondary to pelvic fracture is placement of a suprapubic catheter for bladder drainage and subsequent delayed repair. This is the safest approach because it establishes urinary drainage and does not require either urethral manipulation or entrance into the hematoma caused by the fracture of the pelvis. This allows a formal repair to be carried out several weeks later under controlled circumstances and after resolution of the hematoma. The suprapubic catheter can be safely placed either percutaneously or via an open approach with a small incision. Ultrasound guidance can aid in the percutaneous approach. Some advocate immediate realignment through a number of different techniques, although much controversy exists on this topic.
Ultimate repair of the posterior urethral injury can be performed 6-12 weeks after the event, after the pelvic hematoma has resolved and the patient's orthopedic injuries have stabilized. 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. To prevent tension on the anastomosis, the distal urethra can be mobilized to the penoscrotal junction. Further length can be achieved with division of the septum between the corpora cavernosa and with inferior pubectomy. A urethral catheter is left indwelling to stent the repair, and the suprapubic catheter may be removed. Transpubic approaches for this repair have also been described and may be useful in men with fistulous tracts complicating a membranous urethral injury. Combining a perineal and abdominal approach with pubectomy provides maximum exposure of the prostatic apex.[9, 10, 11, 12]
Early realignment of posterior urethral injuries is also a treatment option. This has been performed at the time of injury, using interlocking sounds or by passage of catheters from both retrograde and antegrade approaches. Also, direct suture repair has been attempted in the immediate postinjury period. Another approach could be careful insertion of a urethral catheter under fluoroscopic guidance by a urologist experienced in that approach. These approaches have the disadvantage of possible entrance into and contamination of the pelvic hematoma with ensuing hemorrhage and sepsis.
Early endoscopic realignment (within 1 week postinjury) using a combined transurethral and percutaneous transvesical approach may be safer. If performed 5-7 days postinjury, the pelvic hematoma has stabilized and hemorrhage is less of a concern. The patient's overall condition has usually improved by this time, and sepsis is less of a concern.[13, 7] Ultimate outcomes and benefits of this approach remain controversial.[14, 15]
Bulbar urethral injuries often manifest months to years following blunt perineal trauma. The presentation for these injuries is often that of decreased stream and voiding symptoms. The diagnosis of urethral stricture is then made with urethrography and cystoscopy. These strictures may be managed with excision of the stricture and end-to-end anastomosis via a perineal approach. Most are short (< 2 cm). Longer strictures may require flaps (penile fasciocutaneous) or grafts (buccal mucosa) to achieve a tensionless anastomosis.
Penetrating anterior urethral injuries should be explored. The area of injury should be examined, and devitalized tissue should be debrided carefully to minimize tissue loss. Defects of up to 2 cm in the bulbar urethra and up to 1.5 cm in the penile urethra can be repaired primarily via a direct anastomosis over a catheter with fine absorbable suture. This is the preferred method of repair for these injuries. Longer defects should never be repaired emergently; they should be reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue transfers required for the repair. Urinary diversion can be accomplished with a suprapubic catheter during this interval.
Female urethral injuries are uncommon but deserve special consideration. The mechanism involves shearing of the urethra away from the pubic symphysis by the pelvic fracture and can be associated with significant vaginal and bladder injury.
Blood is often found in the vaginal vault on pelvic examination, and passage of a urethral catheter is impossible or yields no urine. Urethrography is difficult to obtain; the diagnosis is often clinical. Concomitant bladder injury must often be ruled out with CT cystography. These women commonly have multiple injuries, and the management approach must reflect this.
Bladder drainage must be established; the easiest and fastest method is placement of a suprapubic catheter followed by delayed evaluation and reconstruction. If the patient is being explored for other injuries or if a percutaneous suprapubic catheter cannot be safely placed, cystotomy with antegrade urethral catheter may provide for early definitive repair and minimize further morbidity. Careful follow-up is needed to manage any resulting incontinence or gynecologic disturbance.
In all urethral injuries, the location of the injury should be localized with repeat urethrography, antegrade cystogram through the suprapubic tube, and cystoscopy, if needed. If an open perineal repair is performed, the patient should be positioned in an exaggerated lithotomy position with the legs well padded. Deep venous thrombosis prophylaxis with compression stockings is preferred. Access to the bladder via the indwelling suprapubic catheter is also useful.
If endoscopic realignment is contemplated, a more relaxed lithotomy position is better. A wide variety of endoscopes, graspers, and wires is needed. This procedure is often best performed using a C-arm for fluoroscopy because of the ease in obtaining oblique views.
Exploration for penile urethral injuries can be performed in the supine position, although lithotomy may also be helpful if dissection must be carried down into the scrotum. Flexible cystoscopy may also be of assistance during the procedure.
In open urethral reconstruction, careful dissection of the urethra is important. Anastomoses must be performed in a mucosa-to-mucosa fashion to ensure proper healing without further scarring. All anastomoses should be performed over a catheter for stenting purposes.
Excessive mobilization of the urethra must be avoided to prevent tethering of the penis. If a gap of more than 2 cm must be bridged, performing a flap procedure rather than placing the anastomosis under tension or tethering the penis, which causes curvature, is better. This should be performed as part of a delayed reconstruction and not in the acute setting.
Local flaps should be handled meticulously to avoid devascularization. Buccal mucosal grafts should be harvested from the inner cheek and carefully tubularized over a catheter. These may also be effectively used in an onlay fashion.
In endoscopic realignment, having 2 urologists working simultaneously with fluoroscopy is preferable. One should pass a scope transurethrally and the other should work via the suprapubic tract. Often, injuries thought to be a complete disruption are found to be partial disruptions, and the intact mucosa can be followed into the bladder. If the scopes can meet and pass wires to one another, then a catheter may be placed transurethrally over the wire.
In open repairs, the suprapubic catheter may be removed immediately, leaving the urethral catheter for drainage and stenting. The patient may be mobilized on the day following surgery and discharged when tolerating a diet. Antibiotics are maintained for 2 weeks, and the catheter is removed after 4 weeks. A similar pattern is followed for the endoscopic procedure except that the urethral catheter is left indwelling for 6 weeks. After either type of procedure, retrograde urethrography may be indicated to ensure extravasation is not occurring prior to catheter removal. This is particularly true for patients with poor wound healing such as people with diabetes.
In all instances of urethral injury, follow-up should include assessment of the patient's voiding history, continence status, and potency. Undoubtedly, follow-up should be life-long, although in the trauma population this is often difficult to achieve. Repeat cystourethrography and cystoscopy should be used whenever changes occur following reconstruction.
The main complication following reconstruction 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 patients, although 10%-15% may require either dilation or incision of a short recurrence.
Endoscopic realignment by experienced physicians appears to produce similar results. When performed at 5-7 days postinjury, rare infectious complications occur despite the presence of the organized pelvic hematoma.
Continence rates approach 100% in all series, particularly if the bladder neck is not involved. Potency status is probably related to the extent of the injury itself rather than the management of the problem. Several series have demonstrated only a small group of men losing erectile capabilities following the urethroplasty when they are potent following the actual injury.
Complications of reconstruction of anterior urethral injuries are similar to those observed in posterior urethral repairs.
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 managed well, these men have an excellent chance of becoming totally rehabilitated from a urinary standpoint.
Dixon CM. Diagnosis and acute management of posterior urethral disruptions. McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia, Pa: WB Saunders; 1996. 347-55.
Andrich DE, Day AC, Mundy AR. Proposed mechanisms of lower urinary tract injury in fractures of the pelvic ring. BJU Int. Sept. 2007. 100:567-73. [Medline].
Siegel JA, Panda A, Tausch TJ, Meissner M, Klein A, Morey AF. Repeat Excision and Primary Anastomotic Urethroplasty for Salvage of Recurrent Bulbar Urethral Stricture. J Urol. 2015 Nov. 194 (5):1316-22. [Medline].
Mouraviev VB, Santucci RA. Cadaveric anatomy of pelvic fracture urethral distraction injury: most injuries are distal to the external urinary sphincter. J Urol. 2005 Mar. 173(3):869-72. [Medline].
Kellner DS, Fracchia JA, Armenakas NA. Ventral onlay buccal mucosal grafts for anterior urethral strictures: long-term followup. J Urol. 2004 Feb. 171(2 Pt 1):726-9. [Medline].
Lawson CM, Daley BJ, Ormsby CD, Enderson B. Missed injuries in the era of the trauma scan. J Trauma. Feb, 2011. 70:452-6. [Medline].
Kommu SS, Illahi I, Mumtaz F. Patterns of urethral injury and immediate management. Curr Opin Urol. 2007 Nov. 17(6):383-9. [Medline].
Lee MS, Kim SH, Kim BS, Choi GM, Huh JS. The Efficacy of Primary Interventional Urethral Realignment for the Treatment of Traumatic Urethral Injuries. J Vasc Interv Radiol. 2015 Sep 10. [Medline].
Mundy AR. The role of delayed primary repair in the acute management of pelvic fracture injuries of the urethra. Br J Urol. 1991 Sep. 68(3):273-6. [Medline].
Webster GD, Mathes GL, Selli C. Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management. J Urol. 1983 Nov. 130(5):898-902. [Medline].
Koraitim MM. On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol. 2005 Jan. 173(1):135-9. [Medline].
Cooperberg MR, McAninch JW, Alsikafi NF, Elliott SP. Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25-year experience. J Urol. 2007 Nov. 178(5):2006-10; discussion 2010. [Medline].
Jepson BR, Boullier JA, Moore RG, Parra RO. Traumatic posterior urethral injury and early primary endoscopic realignment: evaluation of long-term follow-up. Urology. 1999 Jun. 53(6):1205-10. [Medline].
Koraitim MM. Effect of early realignment on length and delayed repair of postpelvic fracture urethral injury. Urology. 2012 Apr. 79(4):912-5. [Medline].
Leddy LS, Vanni AJ, Wessells H, Voelzke BB. Outcomes of endoscopic realignment of pelvic fracture associated urethral injuries at a level 1 trauma center. J Urol. 2012 Jul. 188(1):174-8. [Medline]. [Full Text].
McAninch JW, Morey AF. Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures. J Urol. 1998 Apr. 159(4):1209-13. [Medline].
Morey AF, Hernandez J, McAninch JW. Reconstructive surgery for trauma of the lower urinary tract. Urol Clin North Am. 1999 Feb. 26(1):49-60, viii. [Medline].
Odoemene CA, Okere P. One-stage Anastomotic Urethroplasty for Traumatic Urethral Strictures. January 2004-January 2013. Niger J Surg. 2015 Jul-Dec. 21 (2):124-9. [Medline].
Tang CY, Fu Q, Cui RJ, Sun XJ. Erectile dysfunction in patients with traumatic urethral strictures treated with anastomotic urethroplasty: a single-factor analysis. Can J Urol. 2012 Dec. 19(6):6548-53. [Medline].