Urethral disruption may result from straddle injuries, fractures of the pelvis, blunt abdominal trauma instrumentation or surgery. Regions of vulnerability in the male urethra include the posterior urethra at the urogenital diaphragm and bulbous urethra.  Lower abdominal trauma may result in partial or complete vesicourethral avulsion. The ends of the urethra may remain in close apposition or be widely separated. Rarely females may rupture the vesicourethrovaginal septum.  Trauma to the bulbous urethra is usually a straddle injury against the inferior pubic ramus. Complete tears are infrequent, dorsal disruption is most common.

 

Patients present with inability to void, urethral pain and hematuria. A palpable mass may be present on rectal exam secondary to a hematoma and a high riding prostate may be detected.

 

Diagnosis is best established by retrograde urethrogram. Catheterization of the posterior urethra should be avoided in order to prevent further trauma. Contrast injection may be performed by hand demonstrating extravasation at the injury site. Suprapubic catheter placement allows performance of a voiding cystourethrogram which may allow assessment of the position and alignment of the urethral segments. With avulsion of the urethra, the base of the bladder is elevated and flattened. If a catheter has been already placed, retrograde contrast injection may still be performed by placement of an additional 5Fr feeding tube.

 

The site of injury determines management. Prostatomembranous injury requires immediate surgery with urethral re-alignment or limited exploration with suprapubic catheter placement and delayed repair. Stricture formation is seen in 70% of immediate repairs and 100% of delayed repairs. Impotence and incontinence are less common complications. Bulbar urethral injuries and secondary stricture may not be manifest for weeks or months after the injury. Strictures are usually managed by excision and end to end anastomosis.

 

 

 

 

1. Sty JR. Caffey’s Pediatric Diagnostic Imaging.  Tenth Edition. 2004; Elsivier Inc.  pp1803-1805

 

2. Dobrowolski ZF. Treatment of Posterior and anterior Urethral Trauma. BJU International (2002), 89, 752-754