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Urethral Injuries Ahmed S. Zugail Urology House Officer. Case: 26 year old  . Medically free. Sudanese. MVC (pedestrian). ER 16/11. Urethral meatus bleeding. Lower abdominal pain. Acute urinary retention. . No past medical or surgical history. Smoker. Jeddah. ABCDE.

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Urethral injuries ahmed s zugail urology house officer

Urethral InjuriesAhmed S. ZugailUrology House Officer


  • Case:

    • 26 year old .

    • Medically free.

    • Sudanese.

    • MVC (pedestrian).

    • ER 16/11.

    • Urethral meatus bleeding.

    • Lower abdominal pain.

    • Acute urinary retention.



  • CXR, Pelvic X-ray & CT.

  • Retrograde urethrogram.

  • Suprapubic catheter.

  • Admission on 16/10.

  • Passed clots with small amount of urine 17/10.


  • CT 19/10:

    • Cystogram.

    • Arterial phase.

    • Delayed phase.



Etiology:

  • Well-defined events.

  • Major blunt trauma 90%.1

  • Penetrating injuries.

  • Straddle injuries.

  • Iatrogenic injury.

1 Dixon CM. Diagnosis and acute management of posterior urethral disruptions. In: McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia, Pa: WB Saunders; 1996:347-55.




  • Iatrogenic injury to the urethra: to the bladder neck because of the rudimentary nature of the prostate (Devine et al, 1989; Al-Rifaei et al,

    • The majority of iatrogenic lesions are the result of improper or prolonged catheterization.

    • They are surprisingly common and account for 32% of urethral strictures. Of these, 52% affect the bulbar and/or prostatic urethra.2

2 Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral stricture: etiology and characteristics. Urology 2005 Jun;65(6):1055-8 (level of evidence 3).


  • Iatrogenic to the bladder neck because of the rudimentary nature of the prostate (Devine et al, 1989; Al-Rifaei et al, urethral trauma caused by transurethral surgery Transurethral procedures, especially transurethral resection of the prostate (TUR-P), are the second most common cause of iatrogenic urethral lesions.3

3 Vicente J, Rosales A, Montlleó M, Caffaratti J. Value of electrical dispersion as a cause of urethral stenosis after endoscopic surgery. Eur Urol 1992;21(4):280-3.


Frequency to the bladder neck because of the rudimentary nature of the prostate (Devine et al, 1989; Al-Rifaei et al, :

  • Posterior urethral injuries’ incidence is 5-10% associated with pelvic fracture with an annual rate of 20:100000.4

4 Dixon CM. Diagnosis and acute management of posterior urethral disruptions. In: McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia, Pa: WB Saunders; 1996:347-55.


5 Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996 Jun;77(6):876-80 (level of evidence: 2b).



Presentation: determine because they are seldom diagnosed emergently.

  • Blood at the meatus.

  • Inability to urinate.

  • Palpably full bladder.

  • High-riding prostate.

  • Perineal hematoma.

  • Vulvar edema.

  • Blood at the vaginal introitus.

  • Failure to pass a foley catheter.


6 Lim PH, Chng HC. Initial management of acute urethral injuries. Br J Urol 1989 Aug;64(2):165-8 (level

of evidence: 3).

7 McAninch JW. Traumatic injuries to the urethra. J Trauma 1981 Apr;21(4):291-7 (level of evidence: 3).


  • Blood at the vaginal posterior urethral injuryintroitus is present in more than 80% of female patients with pelvic fractures and co-existing urethral injuries.8


  • 8 Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol 1992 Jan;147(1):139-43 (level of evidence 2b).


Imaging Studies: catheterisation or use of instruments are:

1 - Retrograde urethrography: It is performed using gentle injection of 20-30 mL of contrast into the urethra. Examination is made for extravasation, which pinpoints the existence and location of the urethral tear.



  • 2 - Cystography: urethrography in females with suspected urethral injury (Perry and Husmann,

    • Exclude bladder injury in the acute setting (static cystography).

    • Voiding cystography (performed through the suprapubic catheter) demonstrates the bladder neck and prostatic urethral anatomy when a delayed repair is being considered and for surgical planning.


3 - Computerized tomography: may miss lower urinary tract injuries and thus missing the suspicion for further evaluating studies of urethral injuries.9

9Lawson CM, Daley BJ, Ormsby CD, Enderson B. Missed injuries in the era of the trauma scan. J Trauma. Feb, 2011;70:452-6.


4 - Magnetic Resonance Imaging: has been used successfully to define defect length

and to determine the extent and direction of urethral dislocation and the extent of prostatic displacement, and it may help in planning the surgical approach. (Dixon et al, 1992) and (Koraitim and Reda, 2007).


  • Diagnostic Procedure: to define defect length

  • Cystoscopy:

  • A valuable tool in the evaluation of a male urethral injury.

  • The feasibility of early endoscopic realignment can be determined especially in the acute setting.



Management down-o-gram” and cystoscopy gives a more accurate estimation of the stricture length which facilitates decisions in operative strategy.


Management of posterior urethral injuries in men down-o-gram” and cystoscopy gives a more accurate estimation of the stricture length which facilitates decisions in operative strategy.


Management of anterior urethral injuries in men down-o-gram” and cystoscopy gives a more accurate estimation of the stricture length which facilitates decisions in operative strategy.


Management of urethral injuries in women down-o-gram” and cystoscopy gives a more accurate estimation of the stricture length which facilitates decisions in operative strategy.


  • In cases of female urethral disruption related to pelvic fracture, most authorities suggest immediate primary repair, or at least urethral realignment over a catheter, to avoid subsequent urethrovaginal fistulas or urethral obliteration (Koraitim et al, 1996; Dorairajan et al, 2004, Black et al, 2006).


  • Incomplete urethral tears are best treated by stenting with a urethral catheter. The authors and others (Al-Ali and Husain, 1983; Mundy, 1991; Kotkin and Koch, 1996) have not seen any evidence that a gentle attempt to place a urethral catheter can convert an incomplete into a complete transection.


  • Complications: a urethral catheter. The authors and others (Al-Ali and Husain, 1983; Mundy, 1991; Kotkin and Koch, 1996)

    • Erectile Dysfunction.

    • Recurrent Stenosis/Stricture.

    • Incontinence.


  • Some degree of impotence is noted in up to 82% of patients with pelvic fracture and urethral distraction injury (Flynn et al, 2003).

  • Although the average reported rate is approximately 50% (Corriere et al, 1994; Routt et al, 1996; Elliott and Barrett, 1997; Asci et al, 1999; Koraitim, 2005).


  • The etiology is multifactorial with pelvic fracture and urethral distraction injury (Flynn et al, 2003).and variably attributed to cavernous nerve injury, arterial insufficiency, venous leak, and direct corporeal injury (Narumi et al, 1993; Munarriz et al, 1995; Shenfeld et al, 2003).



? about 5% and the rate of incontinence is about 4%.


Thank you about 5% and the rate of incontinence is about 4%.


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