Approach to the patient with Urethral Trauma - a clinical approach to a trauma patient with urethral injury

1. Dr Awaneesh Katiyar
Senior Resident
Trauma Surgery and Critical Care
AIIMS Rishikesh
Approach to the Patients with
Urethral Trauma
1

2. Overview
Case based approach to Urethral Trauma
• Clinical presentation
• Introduction, clinical signs and symptoms
• Clinical diagnosis
• Classification and Investigations
• Management of PFUDD - Emergency/ Definitive management (primary/ delayed / deferred)
2

3. Case
A 25 years male patient, met with road traffic injury
• Patient was driving bike (30km/hr), hit a tractor - he fell on the ground and bike
overturn hip on the patient and rescued by bystanders.
• Patient arrived – within 1hr of trauma.
• On Arrival – P 112, BP 101/64, SpO2 98% at room air
• Airway- patent, shouting for hip pain
• Breathing – RR 24/min, CCT- negative, Bilateral air- entry equal
• Circulation – Tachycardia, with Normal BP, FAST-Negative , PCT – Positive
No long bone fracture, No external bleeding
3

4. • Disability – GCS- 15/15, Pupil B/L NSNR, No Focal Neurological deficit.
• History (AMPLE):
• No Allergy no the any drug.
• Patient did not received – primary care from other hospital
• No Past Medical history
• Last meal – 2 hours before
• Small pit on the road- leads to collision between the tractor and bike (LMV)
4

5. Primary Management and Secondary Survey
As per ATLS protocol
• Put on O2 Mask at 6/min
• 1liter warm RL – infused.
• Analgesics, anti-emetics given.
• Pelvis binder - after examination of pelvis
5
Life or Limb threatening injuries- should be addresses first

6. Secondary Survey
• Logroll – no spinal tenderness, abrasion or bruising
• Pelvis and perineum examination
• Pelvis compression test - positive
• Blood at meatus – noted ( no active bleeding)
, Bladder was not full on USG.
• Hematoma around scrotum
• No Laceration, abrasion – over genital and
perineum
6

7. Digital Rectal Examination
• No visible bleeding from outside
• Anal tone – normal
• Rectal mucosa – integrity maintained
• Prostate – high riding, mobile
• Coccyx – fixed
• Non-blood staining of finger.
7

8. Clinical diagnosis??
Pelvis fracture with suspected urethral injury
8

9. Anatomy
9
UpToDate,April 2020

10. Introduction
• 10% - Pelvis fracture - Urethral Injury (bulbomembranous)
• 72% posterior urethra)
• 20% urethral injury – associated with bladder injury.
• Anterior urethral injuries are - 33%
• Straddle injuries are common.
• Female – urethral injuries <6% in RTI
Ingram MD, Watson SG, Skippage PL, Patel U. Urethral injuries after pelvic trauma: evaluation with urethrography. Radiographics. 2008 Oct;28(6):1631-43.
10

11. Introduction
• Female urethral injury – 75% associated with vaginal , 33% with rectum injury
• High grade of pelvis fracture (Rami) associated with - urethral injury
• Posterior or lateral fracture - almost 0% urethral injury
• Isolated Injury to penis, scrotum, perineum – Anterior urethra
UpToDate April 2020
Ingram MD, Watson SG, Skippage PL, Patel U. Urethral injuries after pelvic trauma: evaluation with urethrography. Radiographics. 2008 Oct;28(6):1631-43.
11

12. Clinical Approach
Initial Assessment and Management
Suspected urethral injury
1. Perineal/ scrotal
hematoma
2. Blood at meatus
3. Unable to micturate
4. DRE- high prostate
5. Wound in vicinity to
urethra
1. RTI associated pelvis
fracture
2. Direct blow to the
perineum- straddle
3. Penile fracture
4. Penetrating injury
ExaminationHistory
life or limb-threatening injury
12

13. Types of Urethral Injury
Anterior Vs Posterior
1. Anterior ( Bulbous and penile)
• Direct blow
• Straddle
• Instrumental
• Penile fracture
2. Posterior (membranous and prostatic)
• Associated with pelvis fracture
• Penetrating injury
13

14. Clinical Signs and Symptoms
H/O-Injury to the penis, scrotum, peritoneum, or the lower abdomen, either blunt or penetrating
Blood at the urethral
meatus
37–93% -posterior urethral injury,
75% -an anterior urethral injury.
Avoid urethral instrumentation
Haematuria or blood at
vaginal introitus Present in more than 80% of female patients with pelvic fractures
Inability to void / painful
urination
Either symptom suggest urethral disruption
Perineal hematoma /
scrotal / labial
14

15. 1. I: Stretching of the posterior urethra due to disruption of
puboprostatic ligaments, though the urethra is intact
2. II: Posterior urethral injury above urogenital diaphragm
3. III: Injury to the membranous urethra, extending into the proximal
bulbous urethra (i.e. with laceration of the urogenital diaphragm)
4. IV: Bladder base injury involving bladder neck extending into the
proximal urethra
• Internal sphincter is injured, hence the potential for
incontinence
5. IVa: Bladder base injury, not involving bladder neck (cannot be
differentiated from type IV radiologically)
6. V: Anterior urethral injury (isolated)
Goldman Colapinto classification
15

16. AAST grading of urethral Injury Grade
16

17. Grade Description Appearance Management
I Contusion Blood at the urethral meatus;
no extravasation on urethrography
No treatment required
II Stretch injury Elongation of the urethra without
extravasation on urethrography
Grades II and III can be
managed conservatively with
suprapubic cystostomy or
urethral catheterization
III Partial disruption Extravasation of contrast at injury site with
contrast visualized in the proximal urethra
or bladder
IV Complete disruption Extravasation of contrast at injury site
without visualization of proximal urethra or
anterior
urethra or bladder
Suprapubic cystostomy and
delayed repair or primary
endoscopic realignment in
selected patients, delayed
repair Primary open repair
V Associated with tear of bladder
Neck, rectum or vagina
Extravasation of contrast at urethral injury
site , blood in the vaginal introitus
Extravasation of contrast at bladder neck
during suprapubic cystography, rectal or
vaginal filling with contrast material
Management According to the Grade of Injury
17

18. Clinical Diagnosis
Blood at meatus
painful to void
First void hematuria
Inability of void
Full bladder
Blood at vagina
or rectum
Straddle
Direct injury – kicks
Sit on sharp object
Penile fracture
Foreign body insertion
High index of suspicion
RTI – pelvis fracture /penetrating
Suspect Posterior
Suspect Anterior
May be Partial
May be Complete18

19. Partial posterior urethral injury
Urethrography, 2 weekly
Managed on – SPC or PUC
Healed without scarring Healed with scarring
(Non obliterating)
Complete obstruction
Continue follow up
Internal urethrotomy urethroplastyfailed
19

20. Complete posterior urethral injury
Isolated urethral injury Associated
1. Bladder neck disruption
2. Vaginal or rectal tear
3. Bladder perforation
Immediate re-alignment
• Endoscopic preferred
• Prevent – stricture rate
Immediate repair
Bladder neck, rectum, vagina or
diversion colostomy
20

21. Management
Suspected Urethral injury
Isolated Polytrauma
Stable Unstable
Retrograde urethrography
No intervention Gentle attempt with expert hand
SPC and delayed/ deferred TtGr I
Gr II & III
Gr IV & V
Failed
Urethrography 2 weekly
Partial
complete
21

22. Normal study
RGU
22
Investigation
Ascending or descending urethrogram
CT Urography ( Polytrauma)

23. Grade II urethral injury
Contrast extravasation at posterior
urethra, intact diaphragm
Grade I urethral injury
no evidence of contrast material
extravasation
23

24. Grade III urethral injury
contrast material extravasation
Membranous Urethra
24

25. Grade IV injury
Complete transection of the posterior
urethra with contrast material extravasation
into the perineal soft tissues
25

26. Grade V
Distal dye length can’t be
assessed- complete
26

27. 27
Management
EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018
Algorithm Posterior Urethra

28. 28EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018

29. 29
EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018
Anterior Urethra

30. 30
EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018

31. 31
EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018
Iatrogenic

32. AUA guidelines 2018 - Recommendations
• Perform retrograde urethrography in patients with blood at the urethral meatus
after pelvic trauma. (Evidence Strength: Grade C)
• Prompt urinary drainage in patients with pelvic fracture associated urethral
injury(PFUI). (Evidence Strength: Grade C)
• May place suprapubic tubes in patients undergoing open reduction internal
fixation for pelvic fracture. (Expert Opinion)
• Primary realignment (PR) in hemodynamically stable patients with pelvic fracture
associated urethral injury (PFUI). (Evidence Strength: Grade C )
Morey AF, Brandes S, Dugi DD, Armstrong JH, Breyer BN, Broghammer JA, Erickson BA, Holzbeierlein J, Hudak SJ, Pruitt JH, Reston JT. Urotrauma: AUA
guideline. The Journal of urology. 2014 Aug;192(2):327-35.
32

33. AUA guidelines 2018 - Recommendations
• Should not perform prolonged attempts at endoscopic realignment in patients
with pelvic fracture associated urethral injury. (Clinical Principle)
• Monitor patients for complications (e.g., stricture formation, erectile dysfunction,
incontinence) for at least one year following urethral injury. (Grade C)
• Prompt surgical repair in patients with uncomplicated penetrating trauma of the
anterior urethra. (Expert Opinion)
• Prompt urinary drainage in patients with straddle injury to the anterior urethra.
(Grade C)
Morey AF, Brandes S, Dugi DD, Armstrong JH, Breyer BN, Broghammer JA, Erickson BA, Holzbeierlein J, Hudak SJ, Pruitt JH, Reston JT. Urotrauma: AUA
guideline. The Journal of urology. 2014 Aug;192(2):327-35.
33

34. Surgical Management
Pelvis fracture urethral distraction defects (PFUDD) repair
• Immediate (Primary) – first 48 hours
• Delayed ( delayed Primary)– 2 days to 2 weeks
• Deferred ( Delayed) – > 3 months
34
1. Primary, 2. delayed primary, 3. Delayed – few authors
EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018

35. Immediate management
Suspicion of urethral trauma
• Stabilize the patient – as per ATLS protocol
• Primary survey and initial management
Suspected Urethral Injury
Stable
Unstable SPC
Resuscitation
Ascending urethrogram (descending if possible)
CT Urography 35
Urinary diversion
1. Shock
2. Painful urinary retention – polytrauma
3. Extravasation of urine

36. Shock with urethral trauma
Required output monitoring
• In polytrauma patient – output monitoring is vital
• Gentle attempt of PUC – expert hands
Failed trial Bladder Full – SPC
Empty or partial filled – USG or Under vision SPC
FAST positive - suspected rupture
With contract leak/ ragged margin/empty
Consider – open repair
36
EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018

37. Immediate realignment
Passage of catheter – along the defect
• Flexible / rigid endoscopes with Biplanar fluoroscopy
• Interlocking sounds or magnetic catheters
• Endoscopic re-alignment – preferred
• Retrograde( P/U) and antegrade(S/P)
• Catheter kept for – (4- 8) weeks
• Open re-alignment – considered as suture anastomosis between prostatic
apex and membranous urethra – form of immediate urethroplasty.
37EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018

38. Immediate Urethroplasty
• Immediate urethroplasty cannot be recommended and should only be done
in experienced centres
• Difficult - inability to assess accurately - swelling and ecchymosis
• Risk of uncontrolled bleeding - the pelvic haematoma
• High rates of impotence (56%), incontinence (21%) and strictures (69%)
EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018
38

39. Delayed re-alignment
• When immediate realignment –not possible
• Delayed realignment – considered within 14 days ( before fibrosis begins)
•
• Benefits for Immediate and delayed urethral repair ( <14 days ) are same
• Endoscopic is preferred.
EAU guidelines - UROLOGICAL TRAUMA - LIMITED UPDATE MARCH 2018
39

40. Delayed urethroplasty
Within 14 days
• Stable patient
• Short distraction defects
• Who - fit for lithotomy position
• Immediate – failed re-alignment and urethroplasty – worse prognosis
40

41. Conclusion
Failed alignment and
Anastomosis – decrease
Success of subsequent
Anastomosis
Avoided in suboptimal
conditions
41

42. Deferred urethroplasty
After 3 months of initial urinary diversion
• Pelvic haematoma - resolved,
• Prostate descended - more normal position,
• Scar tissue - stabilised
• Stable - the lithotomy position
• Most posterior urethral distraction defects are short and can be treated using a
perineal anastomotic repair.
• Key objective - achieve a tension-free anastomosis between two healthy
urethral ends
42

43. Type of Urethroplasty
• <2 cm – simple perineal urethroplasty*
• 2-5cm – elaborated perineal urethroplasty #
• > 5cm - substitution / augmented urethroplasty&
43
& Aggarwal SK, Sinha SK, Kumar A, Pant N, Borkar NK, Dhua A. Traumatic strictures of the posterior urethra in boys with special reference to recurrent strictures.
Journal of pediatric urology. 2011 Jun 1;7(3):356-62.
# Webster GD, Peterson AC. Simple perineal and elaborated perineal posterior urethroplasty. Arab journal of urology. 2015 Mar 1;13(1):17-23.
* Singh SK, Pawar DS, Khandelwal AK. Transperineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect and
role of ancillary maneuver: A retrospective study in 172 patients. Urology annals. 2010 May;2(2):53.

44. 44
Exaggerated lithotomy position
Position

45. Simple perineal urethroplasty
45
• Uses- Urethral mobilization alone-
• < 2cm defect
• Success rate – 90-95%
Singh SK, Pawar DS, Khandelwal AK. Transperineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect and
role of ancillary maneuver: A retrospective study in 172 patients. Urology annals. 2010 May;2(2):53.

46. 46
Simple perineal
urethroplasty
Y- shaped or vertical

47. Elaborated perineal urethroplasty
elaborating procedures
47
1. Bulbo-urethral mobilisation
2. Corporal body separation
3. Inferior wedge pubectomy
4. Supra-crural urethral re-routing
• Webster -Perineal approach
• Turner-Warwick (Perineo- Abdominal
Progressive Approach)
• Waterhouse Approach - pubectomy
Webster GD, Peterson AC. Simple perineal and elaborated perineal posterior urethroplasty. Arab journal of urology. 2015 Mar 1;13(1):17-23.

48. Length gain - in elaboration
3cm – Bulbo-urethral mobilisation
2cm - Corporal body separation
2cm - Inferior wedge pubectomy
2cm - Supra-crural urethral re-routing
48
End to End Anastomosis
4-5 cm defect – membranous urethra
or bulbar urethra
2-3 cm defect – penile urethra
7-9cm can also be repair – Associated with increased failure rate, Results are better with experienced hands
Webster GD, Peterson AC. Simple perineal and elaborated perineal posterior urethroplasty. Arab journal of urology. 2015 Mar 1;13(1):17-23.
Singh SK, Pawar DS, Khandelwal AK. Transperineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect and
role of ancillary maneuver: A retrospective study in 172 patients. Urology annals. 2010 May;2(2):53.

49. 49
Elaborated Urethroplasty
Exposure
1. Urethral mobilization
Urethral mobilization
Surgical Atlas -Anastomotic urethroplasty

50. 50
Elaborated Urethroplasty 2. Corporal body separation
Surgical Atlas -Anastomotic urethroplasty

51. 51
Elaborated Urethroplasty 3. Inferior pubectomy
Surgical Atlas -Anastomotic urethroplasty

52. 52
Elaborated Urethroplasty 4. Supra-Crural Re-routing
Surgical Atlas -Anastomotic urethroplasty

53. Substitutional / Augmented urethroplasty
53
• Augmented urethroplasty
• Buccal Mucosa graft
• Preputial skin graft
• Omental patch
• Substitutional Urethroplasty
• Pedicled Appendix
• Monti-Ileum Buccal mucosa
Thompson C, Trail M, Alhasso A. Urethroplasty: a review of indications, techniques and outcomes,2018. Surgical Atlas -Anastomotic urethroplasty

54. 54
Aggarwal SK, Sinha SK, Kumar A, Pant N, Borkar NK, Dhua A. Traumatic strictures of the posterior urethra in boys with special reference to recurrent strictures. Journal of
pediatric urology. 2011 Jun 1;7(3):356-62.

55. 55
301 – total
263- Success
38- failed
Primary – 89.3
CBS- 86.5
IP- 84.2
Re-routing-85.7

56. Summary & Recommedation: EAU 2018
56

57. Female Urethral Injury
Brief
• Immediate primary repair – mid or proximal urethral injury
• Retropubic or trans-vaginal routes
• Distal urethral injuries can be left - if they are not involving sphincter
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Chapple, C., et al. Consensus statement on urethral trauma. BJU Int, 2004. 93: 1195.

58. 58
Thank You