Urethral injury

1. DISCUSS URETHRAL INJURY
DR BASSEY, A E

2. OUTLINE
•INTRODUCTION
–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

3. INTRODUCTION
•URETHRAL INJURY IS A BREACH IN THE STRUCTURAL
INTEGRITY OF THE URETHRA RESULTING FROM
EXCESSIVE TRAUMA
•WITH INCREASING INDUSTRIALIZATION, HIGH-SPEED
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

4. INTRODUCTION
•EPIDEMIOLOGY
–IT IS THE COMMONEST CAUSE OF URETHRAL
STRICTURE IN NIGERIA
1,2
–MAKES UP MAJORITY OF GU INJURIES
4,5
–10% OF PELVIC FRACTURES ASSOC WITH
URETHRAL INJURY
6

5. RELEVANT ANATOMY

6. CLASSIFICATION
•SITE
–POSTERIOR URETHRAL INJURY
–ANTERIOR URETHRAL INJURY
•TYPE OF INJURY
–CONTUSION
–PARTIAL RUPTURE
–COMPLETE RUPTURE

7. AETIOPATHOGENESIS
•POSTERIOR URETHRAL INJURY
–PELVIC FRACTURE
–10% ASSOC WITH URETHRAL INJURY. ALMOST ALL PU INJURY
2
O
BLUNT TRAUMA HAVE ASSOC PELVIC FRACTURE
7
–RTA COMMONEST CAUSE OF PELVIC FRACTURE
8
–INJURY OCCURS IN MEMBRANOUS URETHRA
–3 MECHANISMS
–OFTEN ASSOC WITH MULTIPLE ORGAN TRAUMA
–IATROGENIC
–CATHETER-RELATED
–BOUGINAGE
–ENDOSCOPY – MECHANICAL OR ELECTRICAL
–SURGERY – RADICAL PROSTATECTOMY

8. AETIOPATHOGENESIS
–FOREIGN BODY
–CALCULUS
–PENETRATING INJURY
–THIS IS RARE

9. 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

10. AETIOPATHOGENESIS
•FEMALE URETHRA
–PELVIC FRACTURE
–VAGINAL SURGERY

11. 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 !!!

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

13. 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

14. EXAMINATION – URETHRAL BLEEDING

15. EXAMINATION – PENILE FRACTURE

16. EXAMINATION
•DIGITAL RECTAL EXAM
–BOGGINESS
–HIGH RIDING OR ABSENT PROSTATE
•VAGINAL EXAM
–BLEEDING
–VAGINAL LACERATION
•MUSCULOSKELETAL
–POSITIVE PELVIC COMPRESSION AND DISTRACTION TESTS

17. INVESTIGATION
•TO CONFIRM DIAGNOSIS
–RETROGRADE URETHROGRAPHY
•CONFIRMS INJURY
•TYPE
•LOCATION
•PRESENCE OF FOREIGN BODY
•ASSOC INJURY e.g. BLADDER

18. INVESTIGATION – URETHRAL CONTUSION

19. INVESTIGATION – PARTIAL URETHRAL
RUPTURE

20. INVESTIGATION – COMPLETE URETHRAL
RUPTURE

21. INVESTIGATION
•TO DETERMINE EXTENT OF DISEASE
–PELVIC XRAY
–IMAGING FOR INVOLVED ORGAN SYSTEMS
•TO SUPPORT MANAGEMENT
–FBC
–EUCr
–URINALYSIS
–CXR
–ECG

22. 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

23. 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

24. 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
•IT’S THE OPTION BEEN FAVOURED BY UROLOGISTS IN
THE PAST 25 YEARS

25. TREATMENT
•CATHETERS LEFT IN SITU FOR 4 WEEKS
•PERICATHETER RUG DONE AND CATHETER
REMOVED IF NO EXTRAVASATION NOTED
•PATIENT’S VOIDING ABILITY NOTED

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

27. FOLLOW-UP
•FOLLOW-UP SHOULD BE LIFELONG
6
•AT EACH CLINIC VISIT, NOTE PATIENT’S
VOIDING HISTORY. IF LUTS DEVELOP, RUG
SHOULD BE DONE
•NOTE ALSO PATIENT’S CONTINENCE STATUS
AND ERECTILE FUNCTION

28. PROGNOSIS
•WITH PROPER MGT PROGNOSIS IS EXCELLENT
6
•UNRECOGNIZED URETHRAL INJURY HOWEVER
LEADS TO HIGHER INCIDENCE OF
COMPLICATIONS

29. FUTURE TRENDS
•USE OF MAGNETIC CATHETERS FOR EARLY
REALIGNMENT OF THE URETHRA

30. 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.

31. THANK YOU

32. 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):50-54
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 OCT-DEC;3(4):311 -
3
5.PRINCIPLES & PRACTICE OF SURGERY INCLUDING
PATHOLOGY IN THE TROPICS, 4
TH
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;130:712–4.

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