Urethral injuries

Key points

Management

Full ATLS/APLS assessment

CT Abdo/pelvis for pelvic fractures

Consult Urologist early

Can attempt urethral catherisation as suitably qualified

If fails, theatre for re-attempt, then cystoscopy if failed +/- suprapubic catheter (SPC)

Place cystoscope in SPC tract and do antegrade wiring - pass catheter over wire - ‘urethral realignment’

This has a high failure rate

Fourniers gangrene (Necrotising fasciitis) is a potential complication of any urethral injury

Male

Classify anterior/posterior

Anterior: Bulbar + Penile - straddle injuries

Posterior: Membranous + Prostatic - pelvic fracture and rupture of puboprostatic ligaments and prostatomembranous junction

Anterior urethrocutaneous injury: immediate exploration with Urologist + repair similar to a Hypospadias

Bladder neck or prostate injury (rare): immediate exploration to minimise incontinence

All other injuries: SPC then MCUG + delayed repair at 6-8 weeks

Bulboprostatic anastomotic urethroplasty (BPA) - Mundy

Perineal incision

Spatulated end-to end anastomoses over catheter - PDS

Can split corpora or remove part of public symphysis to decrease distance

Penile fracture

Better outcomes with exploration and evacuation of haematoma and repair

Female

Rare, usually involve other tissues +/- bladder neck

Management:

Primary washout and repair of vulval lacerations

Urethral catheterisation - if fails - SPC

If bladder neck injury - immediate exploration to minimise incontinence

References

Reidy, Rosemary E. "Urethral Injury." Pediatric Surgery NaT, American Pediatric Surgical Association, 2020. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829099/all/Urethral_Injury.

Andrich DE, Greenwell TJ, Mundy AR. Treatment of pelvic fracture-related urethral trauma: a survey of current practice in the UK. BJU Int. 2005 Jul;96(1):127-30. doi: 10.1111/j.1464-410X.2005.05580.x. PMID: 15963134.