Urethral Trauma

Incidence

Urethral injuries are classified based upon whether they involve the posterior or the anterior urethra.

The posterior urethra extends from the bladder neck to the bulbous urethra (Image 8.11).

Injuries to this area are generally the result of severe blunt trauma. Posterior urethral injuries are found in 5% of males with pelvic fractures and 10-30% of these patients also have bladder ruptures. Isolated bulbar urethral injuries are usually caused by straddle trauma.

Anterior urethral injuries are most often associated with genital injuries.

Presentation

Children with urethral injuries are unable to void and are often seen with a distended bladder. Frequently, blood is noted at the external urinary meatus. In posterior urethral injuries, rectal examination may reveal a pelvic hematoma or upward displacement of a distended bladder. Anterior urethral injuries are frequently associated with a perineal or scrotal swelling hematoma.

Diagnosis

Urethral injuries are evaluated with retrograde urethrocystography. In boys, the urethra is not instrumented if an injury is identified. In females, the urethra and the bladder neck are best evaluated by cystoscopy.

Management

In children, partial tears of the urethra heal better if permitted to do so spontaneously. A suprapubic cathether is inserted to drain the urinary bladder and antibiotics are administered. After 7 to 10 days a voiding cystourethrogram is carried out by instilling contrast through the suprapubic catheter. If the wound has healed, the catheter is clamped and the child is permitted to void. If no voiding problems are noted, the suprapubic catheter is removed.

If required, urethral reconstruction is generally delayed until the acute inflammatory process and hematoma have resolved.

Complications of urethral injuries include stricture, incontinence and impotence.