In males, the urethra is divided into the proximal
(posterior) segment and the distal (anterior) segment by
The posterior urethra is further divided into membranous
(sphincteric) and prostatic segments. About 3 cm long.
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)
Posterior urethra – fixed at both- urogenital diaphragm
So bulbo membranous junction is more vulnerable to
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
In female – Vulval oedema
Blood at vaginal introitus.
POSTERIOR URETHRAL INJURIES
other Clinical Features :
Gross haematuria in 98%
Pelvic/ Supra pubic tenderness
Penile/ scrotal/perineal haematoma
ill- defined mass on rectal examination.
When blood at meatus >> an immediate Retrograde
urethrogram >> to rule out urethral injury
Pre test KUB film
Supine position 30 degree ( oblique / lateral decubitus
Injection of 25ml of contrast medium
X-ray when 10 ml left and after 25ml
Post- voiding X- ray.
IF patient is stable
Careful passage of 12-14Fr. Foley.
If any resistance : Surgery
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.
When urethral catheter is removed after 4-6 weeks after
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 .
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.
Prior to reconstruction – Retrograde urethrogram
to define length of obliterated urethra
Cysto urethroscopy also done
Reconstruction surgery - Posterior urethroplasty through
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
In those cases, further reconstruction may be
compromised and recurrent stricture rates rise.
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
ANY coloured urine other than yellow >>>> It’s BLOOD
until proven otherwise.
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
Benign, distal urethral lesion.
Most commonly found in post menopausal women
Resembles various urethral lesions like
Periurethral gland abscess
Originates from posterior lip of urethra.
Fleshy outgrowth of distal urethral mucosa
Usually small but can be grow to 1cm or more in diameter
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
Prolapse may occur in any age but caruncle almost
exclusively in post menopausal women
Female urethra 4-5 cm long
Distally -Lined by non keratinised stratified squamous
Proximally – Transitional epithelium
Outer layer –smooth muscle fibres and vasculature.
Postmenopausal women >> Oestrogen deficiency
>> Urogenital atrophy >> Distal urethral Prolapse
>> Development of urethral caruncle >> chronic
irritation of exposed urethral mucosa >> growth ,
Haemorrhage , necrosis of lesion.
Incidentally noted on pelvic examination
May be painful and associated with dysuria.
May be present with bleeding per urethra.
Pink or reddish exophytic lesion at urethral meatus
Sometime purple or black due to secondary thrombosis
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
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
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.