Urethral trauma

Background

Female (a) and male (b) urethra.
The human male urethra laid open on its anterior (upper) surface.
Transverse section of the penis.
  • Commonly result of blunt trauma
  • Missed or inadequately managed injuries can result in strictures and recurrent urologic procedures

Types

  • Anterior
    • Located anterior to the membranous urethra
    • Straddle injuries, self-instrumentation
  • Posterior
    • Located in the membranous and prostatic urethra
    • Due to blunt trauma from massive deceleration[1]
    • Often accompanies pelvic fracture

Clinical Features

  • Hematuria, dysuria, inability to void, blood at meatus
  • Vaginal bleeding
  • Perineal or scrotal hematoma
  • High-riding or detached prostate
    • Associated with complete posterior urethral disruption
    • "ATLS ® -10 has now removed rectal examination for this purpose due to the poor sensitivity (2%) demonstrated for this maneuver." [2]

Differential Diagnosis

Genitourinary Trauma

Evaluation

  • Standard "trauma CT" is likely to miss urethral trauma[3]
  • Retrograde urethrogram
    • Must perform before catheterization to prevent further urethral injury; inflate balloon with 2-3ml of saline to minimize displacement
    • 20-60 mL of water soluble contrast in toomey syringe
      • Can mix contrast with lubricating jelly in 1:1 ratio to minimize leakage.[4]
    • Stretch penis perpendicularly across patient's thigh to unfold urethra.
    • Inject 20-60 cc slowly into urethra (to prevent venous intravasation) while putting pressure on the glans to prevent leakage, shoot KUB during last 10 mL
    • No bladder filling with extravasation - complete tear
    • Bladder filling with extravasation - partial tear

Management

  • Posterior urethral injury
    • Suprapubic cathether placement
    • Surgery is usually performed weeks later
  • Anterior urethral injury
    • Penetrating injuries require surgical exploration and repair

Disposition

See Also

References

  1. ↑ 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
  2. ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
  3. ↑ Lawson CM, Daley BJ, Ormsby CD, Enderson B. Missed injuries in the era of the trauma scan. J Trauma. Feb, 2011;70:452-6.
  4. ↑ https://www.emrap.org/episode/trauma-em-fundamentals/urogenital 12:40
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