Hydronephrosis

Urethral trauma is divided into:

Anterior urethral injury

Usually affects bulbar or penile urethra.

Typical causes:

• Straddle trauma
• Penile fracture
• Catheter injury
• Penetrating trauma

Posterior urethral injury

Usually associated with pelvic ring disruption in men.

Modern terminology often describes this as pelvic fracture urethral injury.

Injury may be:

• Contusion
• Partial disruption
• Complete disruption

Suggestive findings include:

• Blood at urethral meatus
• Inability to void
• Perineal bruising
• Scrotal haematoma
• Pelvic fracture
• Difficult traumatic catheterisation

Do not rely on a \"high riding prostate\" because it is an insensitive examination finding.

In a stable male patient:

Retrograde urethrography is the standard assessment.

Flexible cystourethroscopy is an alternative or complementary investigation. Current trauma guidance supports either modality for male urethral injury assessment.

In female urethral trauma, use:

• Cystourethroscopy
• Vaginoscopy

Partial blunt anterior injury

Establish urinary diversion using:

• Carefully placed urethral catheter

or

• Suprapubic catheter

Partial disruptions can heal with catheter drainage.

Complete blunt anterior injury

Initial suprapubic diversion followed by definitive reconstruction is appropriate in many cases.

Immediate urethroplasty after blunt injury should be performed only by an experienced reconstructive urethral surgeon.

Penile fracture associated urethral injury

Repair the urethral injury at the same operation as tunical repair.

Small lacerations can be closed primarily.

Complete disruptions without significant tissue loss undergo tension free anastomotic repair.

Male pelvic fracture urethral injury

Prioritise:

• Trauma resuscitation
• Pelvic haemorrhage control
• Urinary drainage

Options include:

Suprapubic catheterisation

or

Early endoscopic realignment

when expertise and circumstances permit.

Do not repeatedly attempt endoscopic realignment after failure.

Definitive posterior urethroplasty is generally delayed until:

• Pelvic injuries have healed
• Haematoma has resolved
• Urethral distraction defect can be accurately defined

commonly after approximately 3 months.

The standard operation is posterior anastomotic urethroplasty with excision of scar and tension free bulboprostatic anastomosis.

Long term complications include:

• Urethral stricture
• Erectile dysfunction
• Urinary incontinence