Urethral injuries usually occur in men. Most major urethral injuries are due to blunt trauma. Penetrating urethral trauma is less common, occurring mainly as a result of gunshot wounds, or, alternatively, due to inserting objects into the urethra during sexual activity or because of psychiatric illness.
Urethral injuries are classified as contusions, partial disruptions, or complete disruptions, and they may involve the posterior urethra (membranous and prostatic) or anterior urethra (bulbous and penile urethra). Posterior urethral injuries occur almost exclusively with pelvic fractures. Anterior urethral injuries are often consequences of a perineal blow, motor vehicle crash, or perineal straddle injury due to a fall. Iatrogenic injuries occur during transurethral instrumentation (eg, catheter placement or removal, cystoscopy).
Complications include infection, incontinence, erectile dysfunction, and stricture or stenosis ("stenosis" is narrowing of the posterior urethra whereas "stricture" refers exclusively to the anterior urethra).
Symptoms of urethral injuries include pain with voiding or inability to void. Blood at the urethral meatus is the most important sign of a urethral injury. Additional signs include perineal, scrotal, penile, and labial ecchymosis, edema, or both. Abnormal location of the prostate on rectal examination (so-called high-riding prostate) is an inaccurate indicator of a urethral injury. Blood on digital, rectal, or vaginal examination requires thorough evaluation.
Any male patient with symptoms or signs suggestive of a urethral injury should undergo retrograde urethrography. This procedure should always precede catheterization. Urethral catheterization in a male with an undetected significant urethral injury may potentiate urethral disruption (eg, convert a partial disruption to a complete disruption). Female patients require prompt cystoscopy and a thorough vaginal examination. CT alone is inadequate to diagnose and evaluate urethral trauma.
Contusions can be safely treated with an indwelling transurethral catheter for about 5 to 7 days. Partial disruptions are best treated with bladder drainage via a suprapubic cystostomy. In select cases of posterior partial disruptions, primary urethral realignment (endoscopic or open) may be attempted; if successful, this approach may limit subsequent urethral stenosis.
The simplest and safest option for most patients with complete disruption is bladder drainage via a suprapubic cystostomy. Definitive surgery is deferred for about 8 to 12 weeks until the urethral scar tissue has stabilized and the patient has recovered from any accompanying injuries.
Immediate open repair of urethral injuries is limited to those associated with penile fractures, penetrating injuries, and all injuries in females.
Most posterior urethral injuries are associated with pelvic fractures. Anterior injuries are usually from a blunt mechanism; urethral injuries with penile fractures or from penetrating trauma occur less frequently.
Consider urethral injuries particularly in patients who have pelvic fractures or straddle injuries and who have blood at the urethral meatus or difficulty voiding.
In males, do retrograde urethrography before urethral catheterization.
In females, do cystoscopy and a thorough vaginal examination.
Treat contusions with urethral catheterization and most urethral disruptions initially with a suprapubic cystostomy; consider primary realignment in select cases.
Delay surgical reconstruction except in select injuries (ie, penile fractures, penetrating injuries, and female urethral injuries).