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Posterior Urethral Injury

Definition

Posterior urethral injuries are most commonly an avulsion of the membranous urethra from the prostate as part of a pelvic ring fracture (Brandes et al., 2001) (Machtens et al., 2000). EAU guideline: Urological Trauma.

Etiology

Due to the fixed connection between the membranous urethra and the pelvic bone, pelvic fractures and the resulting force can lead to avulsion between the mobile prostate and the fixed urethra. The injury results in a pelvic hematoma and urinoma, which displaces the prostate further cranially.

Signs and Symptoms of Posterior Urethral Injury

Patients present with pelvic fracture, no urine output, bloody secretion from meatus, cranial displacement of the prostate on rectal examination, and urinary phlegmon in the absence of timely diagnosis.

Diagnosis of Posterior Urethral Injury

Retrograde urethrogram [fig. Urethrogram of posterior urethral injury], pelvic and abdominal CT.

Urethrogram of posterior urethral injury in a patient with a pelvic fracture: the contrasted bladder (from CT) demonstrates cranial displacement of the prostatic urethra. With kind permission, Dr. G. Antes, Kempten.

Treatment of Posterior Urethral Injury

Gentle trial of a transurethral catheter:

An option for patients with incomplete urethral tear in imaging. It is best done with the help of a hydrophile guide wire and X-ray control of the correct catheter position.

Suprapubic catheter:

Suprapubic catheter for posterior urethral injury is indicated for unstable patients (not able to undergo anesthesia, other urgent surgical procedures necessary) and if the trial of a transurethral catheter has failed.

Primary realignment with a transurethral catheter:

Suitable for stable patients (able to undergo anesthesia, no other urgent surgical indications). Under X-ray and visual control (retrograde and antegrade cystoscopy), a guidewire, and afterward, with the Seldinger technique, a 20 CH irrigation catheter is placed into the bladder. The catheter is removed after 2–3 weeks, there is a chance of primary recovery without further surgery. Impotence rates of 20–40% are more favorable than in patients with immediate or delayed surgical management. Short-distance strictures can be treated with endoscopic urethrotomy.

Immediate surgical treatment:

If the pelvic fracture has to be treated by open surgery, the suprapubic approach can be used for an end-to-end anastomosis of the membranous urethra. The advantage is the chance of a fast, definitive healing. Disadvantages are the high risk of bleeding, nerve injury with impotence (56%), and incontinence (21%) due to complex dissection in a bloody surgical field. Alternatively (with poor overview), the approach is used to place a transurethral catheter securely.

Delayed surgical treatment:

Definitive surgical treatment is sought after three months of healing. Patients with minor bladder dislocation may present with a short urethral stricture, which is treated with endoscopic urethrotomy. If a long urethral stricture develops, perineal access to the membranous urethra, excision of the stricture, and end-to-end anastomosis are performed.

Complications of Posterior Urethral Injury:

Stress incontinence (10–20%), erectile dysfunction (20–60%), recurrent urethral stricture (30–60%).

References

EAU Guidelines: Urological Trauma

Brandes und Borrelli 2001 BRANDES, S. ; BORRELLI, Jr.: Pelvic fracture and associated urologic injuries.
In: World J Surg
25 (2001), Nr. 12, S. 1578–87

Koraitim 1999 KORAITIM, M. M.: Pelvic fracture urethral injuries: the unresolved controversy.
In: J Urol
161 (1999), Nr. 5, S. 1433–41

Machtens u.a. 2000 MACHTENS, S.. ; STIEF, C. G. ; HAGEMANN, J. ; PFINGST, G. ; GäNSSLEN, A. ; POHLEMANN, T. ; TRUSS, M. C. ; KUCZYK, M. A. ; BECKER, A. J. ; JONAS, U.: Management traumatischer Läsionen von Harnblase und Urethra.
In: Urologe B
40 (2000), S. 560–571

  Deutsche Version: Verletzung der hinteren Harnröhre