Fortunately urethral injuries are uncommon. But injuries can occur as a result of straddle- type falls or pelvic fractures. The following information should help explain why timely evaluation and proper management of these injuries are critical for the best outcomes.
What happens under normal conditions?
The urethra is a tube-like organ whose only function is to transport urine and seminal fluid from the bladder to outside the body. In males, the urethra begins at the bladder and then extends through the prostate gland, perineum and the entire length of the penis. In females, the urethra is much shorter and extends from the bladder to just in front of the vagina outside the body. Normally, urine flow can be controlled, the stream is strong, the urine is clear and there is never any visible blood in the urine.
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Urethral Trauma can affect two different parts of the urethra. Anterior Urethral Trauma is usually the result of straddle-like injuries. This trauma occurs when a person sustains blunt injury to the perineum since the urethra is located near the skin in this area. This injury can occur, for example, when a child forcefully straddles a bicycle seat or a fence. Posterior Urethral Trauma affects the part of the urethra that travels inside the body. This type of trauma almost always occurs as a result of pelvic fractures following automobile accidents or falls from significant heights. In males, posterior Urethral Trauma usually results in the urethra being completely torn just below the prostate.
What are the symptoms of Urethral Trauma?
Trauma to the urethra can cause significant problems. Injury can cause leakage of urine into surrounding tissues and result in swelling, inflammation, infection and abdominal pain. Urethral Trauma can also cause the inability to urinate, retention of urine in the bladder and blood in the urine (hematuria). For males, the most common sign of a problem is blood — even a drop — at the tip of the penis. Swelling and bruising of the penis, scrotum and perineum may also occur, along with pain in the affected area. For females, urethral injury may include cuts, tears, bruises and/or pain in the vaginal area.
How is Urethral Trauma diagnosed?
Individuals who have blood at the end of the penis or in the urine or who cannot urinate following an injury to the urethral area should see a physician immediately so that an appropriate evaluation (including X-rays) can be performed.
In any patient who suffers a pelvic fracture, an X-ray of the urethra is routinely performed because of the high incidence of urethral injury (about 10 percent) associated with such injuries. This X-ray is performed by injecting contrast dye into the opening of the urethra. X-rays are taken to see if any of the dye leaks out of the urethra, which indicates an injury.
How is Urethral Trauma treated?
The treatment options for Urethral Trauma depend on the severity and location of the injury. Some partial urethral injuries can be treated with the insertion of a catheter, which is usually left in place for 14 to 21 days to allow the urethra to mend, and then an X-ray is performed to confirm that the injury has healed.
In the case of an anterior urethral injury, an X-ray of the urethra is repeated after the catheter has been in place for two to three weeks. If the injury has healed, the catheter can be removed in the doctor's office.
In general, if serious Urethral Trauma is seen on the X-ray, urine should be diverted away from the injured area to prevent leakage of urine and subsequent swelling, inflammation, infection and scarring. In the case of complete urethral breakage, urine must be drained from the bladder by performing a suprapubic cystostomy. This procedure diverts urine away from the injured area by placing a catheter into the bladder through the skin just above the pubic bone in the lower abdomen. This can be done at the time of abdominal surgery for other associated injuries or through a small puncture wound with the aid of X-ray to be sure that the catheter is placed in the bladder.
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The treatment of posterior urethral injuries is more complicated. Most urologists leave the catheter placed in the bladder at the time of injury for three to six months to allow for the bleeding from the pelvic fracture to reabsorb. It is also easier to repair the injury after the swelling in the tissues from the injury has subsided. Most posterior urethral injuries require an operation to repair the injury and to create continuity of the urethra. This operation is usually performed through an incision in the perineum and continuity of the urethra is reestablished by suturing the two ends of the urethra together. Occasionally the procedure may need to be performed with an abdominal incision for technical reasons. In certain circumstances, some urologists prefer to repair the urethra immediately after the injury.
After the urethra has been repaired and continuity restored, a catheter exiting from the lower abdomen and a second catheter placed through the penis into the bladder are left for about three weeks after the operation to allow healing of the urethra. After three weeks, X-rays are performed to be sure that the urethra has healed. If healing has taken place, the catheters are removed. If the X-ray shows persistent leakage, the catheters are left for a while longer.
What can be expected after treatment for Urethral Trauma?
If a surgical procedure for a urethral injury is performed, catheters are left in the bladder and can be uncomfortable. In addition, pain from unwanted bladder contractions may occur because the bladder is chronically irritated by the catheters.
Once the catheters have been removed, symptoms usually rapidly improve. Although blood in the urine can occur because of irritation from the catheters, it usually disappears after they are removed. Scarring in the area of the urethral repair is the most common and most significant complication. Significant scarring usually causes a decrease in the strength and size of the urine stream and can cause the patient to strain during urination. This can usually be fixed by expanding the scarring with instruments placed up the urethra. However, sometimes the surgical urethral procedure needs to be repeated to prevent further blockage of urine flow.
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Following my operation for a posterior urethral disruption, what are the chances that I will require further surgery?
Most patients do not require further surgery or expansion of urethral scarring following repair.
Will the injury or the surgery cause me to leak urine?
small number of patients (2 to 5 percent) have problems with incontinence following repair of posterior Urethral Trauma. The reason for this is thought to be damage to nerves that control the bladder outlet at the time of the initial injury and not from the surgery.
Will the injury or the surgery result in sexual problems?
Some men (approximately 10 to 20 percent) do have problems with penile erection after the surgery and catheter removal. Like incontinence, the primary cause of this problem is thought to be nerve damage related to the initial injury.
