- Management is controversial and often confusing
- In multiply injured patient there are the conflicting priorities of:
- Monitoring urine output with a urethral catheter
- Preventing exacerbation of a urethral injury
- Lower urinary tract injury should be suspected if the following are seen:
- Blood from urethral meatus
- Perineal bruising
- High riding prostate on rectal examination
- Potentially useful investigations include IVU, ascending urethrogram or cystogram
Bladder injury
- Often associated with pelvic fractures
- Also seen following direct blow to abdomen with a full bladder
- Rupture can either intraperitoneal or extraperitoneal
- Clinical features include lower abdominal peritonism and inability to pass urine
- IVU may show urine extravasation
- Diagnosis can be confirmed by cystography
- Intraperitoneal rupture requires laparotomy, bladder repair, urethral and suprapubic drainage
- Extraperitoneal rupture can be treated conservatively with urethral drainage
- Prophylactic antibiotics should be given
Bulbar urethral injury
- Is the commonest type of urethral injury
- Usually the result of direct trauma causes by falling astride an object
- Clinical features include blood from meatus and perineal bruising
- If unable to pass urine a urethral catheter should not be passed
- Can convert a partial tear into a complete urethral injury
- If catheter is required it should be inserted via the suprapubic route
- Diagnosis can be confirmed by ascending urethrogram
- Prophylactic antibiotics should be given
- Complications include a urethral stricture
Membranous urethral injury
- Often occur in multiply injured patient and unless suspected can be missed
- 10% of men with pelvic fracture have a membranous urethral injury
- Tear can be either partial or complete
- Partial injuries present with urethral bleeding and perineal bruising
- Complete injuries present with inability to pass urine
- On rectal examination the bladder and prostate is displaced upwards
- If injury suspected a urethral catheter should not be passed
- Diagnosis can be confirmed by ascending urethrogram
- Treatment is with suprapubic catheter
- Urethroplasty may be required
- Complications include stricture, impotence and incontinence
Bibliography
Chapple C R. Urethral injury. BJU Int 2000; 86: 318-326
Dreitlein D A, Suner S, Basler J. Genitourinary trauma. Emerg Med Clin North Am
2001; 19: 569-590.
Hernandez J, Morey A F. Anterior urethral injury. World J Urol 1999; 17:
96-100.
Mundy A R. Pelvic fracture injuries of the posterior urethra. World J Urol 1999;
17: 90-95 |