urethral injury and management

1. Urethral injury and
urethral caruncle
Dr. Prakash Patel

2. INTRODUCTION
 10- 20 % of all poly trauma patients
 Life threatening injuries first but DON’T neglect GU
trauma.
 Long term morbidity
 Impotence
 Incontinence

3. CLASSIFIICATION
 Upper urinary tract
 Kidney
 Ureters
 Lower urinary tracts
 Bladder
 Urethra
 External genitalia

4. Urethral Trauma
 10% in male with pelvic fracture
 6% in female with pelvic fracture
 60% due to blunt trauma
 40% due to penetrating and itrogenic.

5. ANATOMY

6. ANATOMY

7. ANATOMY
 In males, the urethra is divided into the proximal
(posterior) segment and the distal (anterior) segment by
urogenital diaphragm.
 The posterior urethra is further divided into membranous
(sphincteric) and prostatic segments. About 3 cm long.

8. CLASSIFICATION
 Posterior urethral injuries>> most commonly related to
major blunt trauma and major falls, and most of such
cases are accompanied by pelvic fractures.
 Anterior urethral injuries>> most commonly related to
blunt trauma to the perineum( straddle injuries)

9.  Posterior urethra – fixed at both- urogenital diaphragm
and
puboprostatic ligament
 So bulbo membranous junction is more vulnerable to
injury

11. ETIOLOGY
 Blunt trauma
 Penetrating trauma
 Iatrogenic trauma (Difficult catheterisation)

12. EXAMINATION
 TRIANGLE OF –
Blood at meatus
Inability to urinate
Palpable full bladder
 Other findings – On Per rectal examinations
High riding of prostate
Butter fly perineal Haematoma
 First detected at emergency dept when a urethral catheter cannot be
placed.
 In female – Vulval oedema
Blood at vaginal introitus.

13. POSTERIOR URETHRAL INJURIES
 other Clinical Features :
Gross haematuria in 98%
Pelvic/ Supra pubic tenderness
Penile/ scrotal/perineal haematoma
ill- defined mass on rectal examination.

14. DIAGNOSIS
Retreograde Urethrogram

15. Retrograde Urethrogram
 When blood at meatus >> an immediate Retrograde
urethrogram >> to rule out urethral injury
 Pre test KUB film
 Supine position 30 degree ( oblique / lateral decubitus
position)
 Injection of 25ml of contrast medium
 X-ray when 10 ml left and after 25ml
 Post- voiding X- ray.

16. INTERPRETATION
 Contrast extravasation+ Contrast in bladder >>>>>
PARTIAL TEAR.
 Contrast extravasation only >>>>> COMPLETE TEAR.

17. Partial Tear

18. Complete tear

19. Urethroscopy
 Urethroscopy is done In female patient with suspected
urethral injury to direct inspection of urethra.

20. MANAGEMENT
 Initial Management
SUPRA PUBIC CYSTOSTOMY

21. Management
 IF patient is stable
 Partial tear
 Careful passage of 12-14Fr. Foley.
 If any resistance : Surgery
 Complete tear:
 Supra pubic catheter + Surgery.
 Surgery = Primary endoscopic alignment and delayed repair(10 -14
days) or late primary closure ( > 3 month )
 Early urethral repair is not recommended because of risk of
haemorrhage and infection.

22.  When urethral catheter is removed after 4-6 weeks after
surgery
keep supra pubic catheter in situ
because there is chances of development of
stricture at the site of anastomosis or injury .
 If patient voids satisfactorily through urethra >> supra
pubic catheter can be removed after 7-14 days .

23. URETHRAL STRICTURE
 Partial ( < 1cm ) – endoscopic repair (
Direct vision internal urethrotomy )
Complete ( long segment >1cm ) -
urethroplasty

24. COMPLEX INJURIES
 In case of female urethral disruption
Immediate primary repair OR
At least urethral re alignment over catheter
to avoid subsequent urethrovaginal fistuala
 Delayed reconstruction is difficult in female because-
too short urethra (4 cm )
Scarring makes surgery difficult.

25. Delayed Reconstruction.
 Prior to reconstruction – Retrograde urethrogram
Voiding cystourethrogram
to define length of obliterated urethra
 Cysto urethroscopy also done
 Reconstruction surgery - Posterior urethroplasty through
perineal approach

26. COMPLICATIONS
 Stricture
 Incontinance
 Impotence

27. Outcome and Prognosis
 Men with urethral injuries have an excellent prognosis
when managed correctly.
 Problems arise if urethral injury is unrecognised and the
urethra is further damaged by attempts at blind
catheterisation.
 In those cases, further reconstruction may be
compromised and recurrent stricture rates rise.

28. Foley Catheter
 NO if you suspect a urethral injury
 When to suspect urethral injuries:
Pelvic # or Gross haematuria
 Danger to convert partial into complete
 NEVER REMOVE A FOLEY WHEN YOU SUSPECT A PARTIAL
TEAR AFTERWARDS.
 ANY coloured urine other than yellow >>>> It’s BLOOD
until proven otherwise.

29. Anterior Urethra
 More common than posterior
 Bulbous injury is the most common urethral injury.
 Direct trauma ( Straddle –type)
 Usually NO pelvic #
 Blood at meatus
 Unable to micturate
 Penile / Scrotal / Perineal
Contusion
Haematoma
Fluid collection.

30. Anterior Urethral Rupture

31. Sleeve Haematoma

32. Butterfly Haematoma

33. MANAGEMENT
 NO Foley if injury suspected
 Retrograde Urethrogram
 Surgical treatment

34. Urethral caruncle

35. URETHRAL CARUNCLE
 Benign, distal urethral lesion.
 Most commonly found in post menopausal women
 Resembles various urethral lesions like
Carcinoma
Urethral diverticulum
Urethral Prolapse
Periurethral gland abscess

36.  Originates from posterior lip of urethra.
 Fleshy outgrowth of distal urethral mucosa
 Usually small but can be grow to 1cm or more in diameter

37. Epidemiology
 Common in elderly post menopausal women
 Rare in pre and peri menopausal women
 Urethral prolapse is similar in appearance
 But prolapse is circumferential while caruncles are focal
lesion
 Prolapse may occur in any age but caruncle almost
exclusively in post menopausal women

38. Relevant Anatomy
 Female urethra 4-5 cm long
 Distally -Lined by non keratinised stratified squamous
epithelium
 Proximally – Transitional epithelium
 Outer layer –smooth muscle fibres and vasculature.

39. Pathophysiology
 Postmenopausal women >> Oestrogen deficiency
>> Urogenital atrophy >> Distal urethral Prolapse
>> Development of urethral caruncle >> chronic
irritation of exposed urethral mucosa >> growth ,
Haemorrhage , necrosis of lesion.

40. PRESENTATION
 Mostly asymptomatic
 Incidentally noted on pelvic examination
 May be painful and associated with dysuria.
 May be present with bleeding per urethra.
ON EXAMINATION
 Pink or reddish exophytic lesion at urethral meatus
 Sometime purple or black due to secondary thrombosis

42. MANAGEMENT
CONSERVATIVE
 Hot sitz bath
 Topical estrogen ointments
 Topical anti inflammatory drugs
SURGICAL - Excixion and biopsy
 In patient with large symptomatic lesions
 In whom conservative therapy fails
 Uncertain diagnosis

43. Laboratory Examinations
 Urine R/M – To rule out UTI
 Histopahtological examination if diagnosis is uncertain

44.  CYSTOSCOPY – to rule out another causes of haematuria
To rule out urinary bladder pathology

45. HISTOLOGIC FINDINGS
 Microscopically – Bed of granulation tissue covered by
either squamous or transitional epithelium.
Inflammatory infiltrate is common.

46. Intraoperative Details
 Excision and Biopsy
 First perform cystourethroscopy to rule out urinary
bladder and urethral abnormalities
 Place Foley catheter.
 Use stay sutures in the epithelium to prevent mucosal
retraction and meatal stenosis.
 Excise the lesion.
 Oversew the edges with 3-0 or 4-0 absorbable sutures

47. ALTERNATIVE TECHNIQUE
 developed by Park and Cho
 Base of the caruncle is ligated , allowing it to slough off
after 1-2 weeks
 technique requires neither anaesthesia nor analgesia.

48. POSTOPERATIVE
 A Foley catheter may be left in place for 1-2 days to allow
healing of urethral mucosa.

49. COMPLICATIONS
 Meatal stenosis
 Urethral stricture.

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