DISCUSS URETHRAL

INJURY
DR BASSEY, A E

INTRODUCTION

OUTLINE

DEFINITION
STATEMENT OF SURGICAL IMPORTANCE
EPIDEMIOLOGY

RELEVANT ANATOMY
CLASSIFICATION
SITE
TYPE OF INJURY

AETIOPATHOGENESIS
MANAGEMENT

RESUSCITATION
HISTORY
EXAMINATION
INVESTIGATION
TREATMENT
COMPLICATIONS

FOLLOW UP/PROGNOSIS
FUTURE TRENDS
CONCLUSION
REFERENCES

INTRODUCTION
URETHRAL INJURY IS A BREACH IN THE
STRUCTURAL INTEGRITY OF THE URETHRA
RESULTING FROM EXCESSIVE TRAUMA
WITH INCREASING INDUSTRIALIZATION, HIGHSPEED COMMUTE, HUMAN CONFLICT AS WELL
AS ADVANCES IN SURGICAL SCIENCE THE
INCIDENCE OF URETHRAL INJURY IS ON THE
RISE. TIMELY AND ACCURATE DIAGNOSIS ARE
NECESSARY FOR APPROPRIATE ACUTE
MANAGEMENT AND REDUCTION OF LONG
TERM MORBIDITY

INTRODUCTION
EPIDEMIOLOGY
IT IS THE COMMONEST CAUSE OF
URETHRAL STRICTURE IN NIGERIA1,2
MAKES UP MAJORITY OF GU INJURIES4,5
10% OF PELVIC FRACTURES ASSOC WITH
URETHRAL INJURY6

RELEVANT ANATOMY

CLASSIFICATION
SITE
POSTERIOR URETHRAL INJURY
ANTERIOR URETHRAL INJURY

TYPE OF INJURY
CONTUSION
PARTIAL RUPTURE
COMPLETE RUPTURE

AETIOPATHOGENESIS
POSTERIOR URETHRAL INJURY
PELVIC FRACTURE
10% ASSOC WITH URETHRAL INJURY. ALMOST ALL
PU INJURY 2O BLUNT TRAUMA HAVE ASSOC PELVIC
FRACTURE7
RTA COMMONEST CAUSE OF PELVIC FRACTURE8
INJURY OCCURS IN MEMBRANOUS URETHRA
3 MECHANISMS
OFTEN ASSOC WITH MULTIPLE ORGAN TRAUMA

IATROGENIC

CATHETER-RELATED
BOUGINAGE
ENDOSCOPY MECHANICAL OR ELECTRICAL
SURGERY RADICAL PROSTATECTOMY

AETIOPATHOGENESIS
FOREIGN BODY
CALCULUS

PENETRATING INJURY
THIS IS RARE

AETIOPATHOGENESIS

ANTERIOR URETHRAL INJURY (USU.

ISOLATED)
STRADDLE INJURY
INJURY OCCURS IN BULBAR URETHRA

IATROGENIC

CATHETER-RELATED
BOUGINAGE
ENDOSCOPY MECHANICAL OR ELECTRICAL
CIRCUMCISION

PENETRATING INJURY
GUNSHOT

PENILE FRACTURE
SELF-MUTILATION
MENTALLY ILL
SEXUAL GRATIFICATION

AETIOPATHOGENESIS
FEMALE URETHRA
PELVIC FRACTURE
VAGINAL SURGERY

MANAGEMENT
RESUSCITATION
PARTICULARLY OF IMPORTANCE IN PU
INJURY DUE TO PELVIC FRACTURE
LIFE-THREATENING CONDITIONS TAKE
PRECEDENCE OVER URETHRAL INJURY
AND MUST BE AMELIORATED FIRST !!!

MANAGEMENT
HISTORY
INABILITY TO PASS URINE DESPITE THE
URGE
HAEMATURIA
PAINFUL MICTURITION
URETHRAL BLEEDING
HISTORY OF THE AETIOLOGIC EVENT

EXAMINATION

GENERAL EXAMINATION NOT

SPECIFICALLY CONTRIBUTORY TO
DIAGNOSIS OF URETHRAL INJURY
ABDOMEN
ECCHYMOSIS
DISTENDED URINARY BLADDER

EXT. GENITALIA

BLOOD AT MEATUS
ANY SURGERY OR PENETRATING INJURY?
PENILE OR PERINEAL ECCHYMOSIS
FOREIGN BODY IN URETHRA MAY BE FOUND

EXAMINATION URETHRAL
BLEEDING

EXAMINATION PENILE
FRACTURE

EXAMINATION

DIGITAL RECTAL EXAM

BOGGINESS
HIGH RIDING OR ABSENT PROSTATE

VAGINAL EXAM
BLEEDING
VAGINAL LACERATION

MUSCULOSKELETAL
POSITIVE PELVIC COMPRESSION AND
DISTRACTION TESTS

INVESTIGATION
TO CONFIRM DIAGNOSIS
RETROGRADE URETHROGRAPHY

CONFIRMS INJURY
TYPE
LOCATION
PRESENCE OF FOREIGN BODY
ASSOC INJURY e.g. BLADDER

INVESTIGATION URETHRAL
CONTUSION

INVESTIGATION PARTIAL
URETHRAL RUPTURE

INVESTIGATION COMPLETE
URETHRAL RUPTURE

INVESTIGATION
TO DETERMINE EXTENT OF DISEASE
PELVIC XRAY
IMAGING FOR INVOLVED ORGAN SYSTEMS

TO SUPPORT MANAGEMENT
FBC
EUCr
URINALYSIS
CXR
ECG

TREATMENT
AIM IS TO HAVE A CONTINENT PATIENT
WITH SATISFACTORY VOIDING AND
SEXUAL FUNCTION
PATIENT IS GIVEN ANALGESIA AND
ANTIBIOTICS
AVOID REPEATED ATTEMPTS AT BLIND
CATHETERIZATION
PENETRATING INJURY IS JUDICIOUSLY
DEBRIDED
DEFINITIVE TREATMENT IS ACHIEVED BY
EARLY REPAIR OR
DELAYED REPAIR

TREATMENT
EARLY REPAIR
DONE WITHIN ONE WEEK OF INJURY
URINE DIVERSION VIA SUPRAPUBIC
CYSTOSTOMY
MODALITIES INCLUDE
USE OF INTERLOCKING URETHRAL SOUNDS
(RAILROADING)
ENDOSCOPIC REALIGNMENT
OPEN SURGERY AND REPAIR OVER A CATHETER

IT IS FRAUGHT WITH COMPLICATIONS SUCH AS

INFECTION OF HAEMATOMA
STRICTURE 70%5
ERECTILE DYSFUNCTION 45%5
INCONTINENCE 20%5

TREATMENT
DELAYED REPAIR
URINE DIVERSION BY SUPRAPUBIC
CYSTOSTOMY
AT 12 WEEKS POSTINJURY RUG IS DONE TO
ASSESS URETHRAL STRICTURE
REPAIR OF STRICTURE IS CARRIED OUT
COMPLICATION RISK
STRICTURE 50%5
ERECTILE DYSFUNCTION 12%5
INCONTINENCE 2%5

ITS THE OPTION BEEN FAVOURED BY

UROLOGISTS IN THE PAST 25 YEARS

TREATMENT
CATHETERS LEFT IN SITU FOR 4
WEEKS
PERICATHETER RUG DONE AND
CATHETER REMOVED IF NO
EXTRAVASATION NOTED
PATIENTS VOIDING ABILITY NOTED

COMPLICATIONS
EXTRAVASATION OF URINE
NECROTIZING INFECTION OF PENILE
AND PERINEAL SKIN
URETHRAL STRICTURE
ERECTILE DYSFUNCTION
URINARY INCONTINENCE

FOLLOW-UP
FOLLOW-UP SHOULD BE LIFELONG6
AT EACH CLINIC VISIT, NOTE
PATIENTS VOIDING HISTORY. IF LUTS
DEVELOP, RUG SHOULD BE DONE
NOTE ALSO PATIENTS CONTINENCE
STATUS AND ERECTILE FUNCTION

PROGNOSIS
WITH PROPER MGT PROGNOSIS IS
EXCELLENT6
UNRECOGNIZED URETHRAL INJURY
HOWEVER LEADS TO HIGHER
INCIDENCE OF COMPLICATIONS

FUTURE TRENDS
USE OF MAGNETIC CATHETERS FOR
EARLY REALIGNMENT OF THE
URETHRA

CONCLUSION
RECOGNITION OF CARDINAL SIGNS AND
SYMPTOMS OF URETHRAL INJURY
FACILITATES TIMELY RADIOGRAPHIC
DIAGNOSIS AND EARLY
COMMENCEMENT OF APPROPRIATE
INITIAL MANAGEMENT.
THE ASTUTE CLINICIAN MUST
MAINTAIN A HIGH INDEX OF SUSPICION,
AS THESE INJURIES ARE FREQUENTLY
OVERSHADOWED BY MULTISYSTEM
TRAUMA.

THANK YOU

REFERENCES
1. THE NEW PATTERN OF URETHRAL STRICTURE DISEASE IN
LAGOS, NIGERIA.
NIGER POSTGRAD MED J 2009 JUN;16(2):162-5
2. THE CHANGING PATTERN OF URETHRAL STRICTURE
DISEASE IN MIDWESTERN NIGERIA.
J MED BIOMED RESEARCH 2006 DEC;5(2):5054
3. DIAGNOSIS & CLASSIFICATION OF URETHRAL INJURIES.
UROL CLIN N AM
(2006) 73 85
4. TRAUMATIC UROLOGIC INJURIES IN ILE-IFE, NIGERIA
J EMERG TRAUMA SHOCK 2010 OCTDEC;3(4):311 - 3
5. PRINCIPLES & PRACTICE OF SURGERY INCLUDING
PATHOLOGY IN THE TROPICS, 4TH Ed, 2009:185 7
6. EMEDICINE.MEDSCAPE.COM/ARTICLE/451797
7. DIAGNOSIS AND INITIAL MANAGEMENT OF UROLOGICAL
INJURIES ASSOCIATEDWITH 200 CONSECUTIVE PELVIC
FRACTURES.
J UROL 1983;130:7124.

REFERENCES
8. POST-TRAUMATIC POSTERIOR
URETHRAL STRICTURES IN
CHILDREN: A 20 YEAR EXPERIENCE.
J UROL
1997;157:641.