Urethral Trauma

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 the tube through which urine (and in males, semen) leaves 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. The anterior urethra goes from the tip of the penis through the perineum, the space between the scrotum and the anus. The posterior urethra is deep within the body. 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.

What is urethral trauma?

Urethral trauma can affect two different parts of the urethra. Trauma to the anterior urethra is usually the result of straddle-like injuries. This trauma occurs when a person sustains injury from a sharp blow 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 bar or a fence. Trauma to the anterior urethra can lead to scarring called a urethral stricture, scarring that can slow or block the flow of urine from the penis.

Trauma to the posterior urethra is almost always occurs as a result of severe injuries such as pelvic fractures following automobile accidents or falls from significant heights. In males, posterior urethral trauma may result in the urethra being completely torn just below the prostate. These severe injuries can also lead to scar tissue that slows or blocks the normal flow of urine. For females, urethral injuries are rare and almost always related to pelvic fractures or cuts, tears, or direct trauma to the vaginal area.

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.

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 x-ray 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, the injury may need to be repaired immediately with surgery. Minor injuries may be treated by diverting the urine away from the injury with a special tube inserted into the bladder (called a Foley catheter). Later, 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 tearing, urine must be drained from the bladder by placing a suprapubic catheter. This is a Foley catheter that goes directly through the skin just above the pubic bone in the lower abdomen into the bladder.. This is most common after severe posterior urethral injuries. 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. The doctor may also discuss a procedure to "realign" the torn urethra over a catheter, which may allow better healing.

The treatment of posterior urethral injuries is more complicated as they are almost always associated with other severe injuries. Because of these injuries, posterior urethral injuries cannot be definitively repaired at the time of injury. 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 reconnect the two torn edges 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.

After the urethra has been repaired, a suprapubic catheter and a Foley 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.

Frequently asked questions:

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 result in sexual problems?

The severe injuries that lead to posterior urethral injuries can also damage the delicate nerves that run alongside the urethra deep within the body and provide the signal to the penis to become erect for sexual activity. Approximately 50% of men who have urethral injuries from pelvic fractures will have some degree of erectile dysfunction once they recover. This may range from very mild to complete erectile dysfunction, but several treatment options do exist. Erectile dysfunction caused by the surgery to repair the urethra (rather than the injury itself) is uncommon.

Will the injury or the surgery cause me to leak urine?

A 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.