11CT 19/10: Cystogram. Arterial phase. Delayed phase. ----- Meeting Notes (12/18/11 08:19) -----hemoglobin drop 11.5 to 9 vitally normal and no evidence of bleeding exept that he was passing clotsnurses bed sheets twice a day
21Etiology: Well-defined events. Major blunt trauma 90%.1 Penetrating injuries.Straddle injuries.Iatrogenic injury.1 Dixon CM. Diagnosis and acute management of posterior urethral disruptions. In: McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia, Pa: WB Saunders; 1996:
22The Bulbomembranous junction is more vulnerable to injury during pelvic fracture than is the prostatomembranous junction (Colapinto and McCallum, 1977; Brandes and Borelli, 2001).
23In children, injuries are more likely to extend proximally to the bladder neck because of the rudimentary nature of the prostate (Devine et al, 1989; Al-Rifaei et al, 1991; Boone et al, 1992).
24Iatrogenic injury to the urethra: The majority of iatrogenic lesions are the result of improper or prolonged catheterization.They are surprisingly common and account for 32% of urethral strictures. Of these, 52% affect the bulbar and/or prostatic urethra.22 Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral stricture: etiology and characteristics. Urology 2005 Jun;65(6): (level of evidence 3).
25Iatrogenic urethral trauma caused by transurethral surgery Transurethral procedures, especially transurethral resection of the prostate (TUR-P), are the second most common cause of iatrogenic urethral lesions.33 Vicente J, Rosales A, Montlleó M, Caffaratti J. Value of electrical dispersion as a cause of urethral stenosis after endoscopic surgery. Eur Urol 1992;21(4):280-3.
26Frequency:Posterior urethral injuries’ incidence is 5-10% associated with pelvic fracture with an annual rate of 20:4 Dixon CM. Diagnosis and acute management of posterior urethral disruptions. In: McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia, Pa: WB Saunders; 1996:
27The male posterior urethra is injured in 4-19% and the female urethra in 0-6% of all pelvic fractures.55 Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996 Jun;77(6): (level of evidence: 2b).
28Anterior urethral injuries actual incidence is difficult to determine because they are seldom diagnosed emergently.Penetrating injury to the urethra is rare.
29Presentation: Blood at the meatus. Inability to urinate. Palpably full bladder.High-riding prostate.Perineal hematoma.Vulvar edema.Blood at the vaginal introitus.Failure to pass a foley catheter.-Classic findings such as a “high-riding” prostate or a “butterfly” perineal hematoma may frequently be absent (Sandler and Corriere, 1989).-Vulvar edema, Blood at the vaginal introitus.(Perry and Husmann, 1992).
30Blood at the meatus is present in 37-93% of patients with posterior urethral injury6, and in at least 75% of patients with anterior urethral injury.76 Lim PH, Chng HC. Initial management of acute urethral injuries. Br J Urol 1989 Aug;64(2):165-8 (levelof evidence: 3).7 McAninch JW. Traumatic injuries to the urethra. J Trauma 1981 Apr;21(4):291-7 (level of evidence: 3).
31Blood at the vaginal introitus is present in more than 80% of female patients with pelvic fractures and co-existing urethral injuries.8
32• Penile and/or perineal pain (100%) • Urethral bleeding (86%).8 The symptoms of urethral injury caused by improper catheterisation or use of instruments are:• Penile and/or perineal pain (100%)• Urethral bleeding (86%).88 Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol 1992 Jan;147(1): (level of evidence 2b).
33Imaging Studies:1 - Retrograde urethrography: It is performed using gentle injection of mL of contrast into the urethra. Examination is made for extravasation, which pinpoints the existence and location of the urethral tear.
34Direct inspection by urethroscopy is suggested in lieu of urethrography in females with suspected urethral injury (Perry and Husmann, 1992; Koraitim, 1999).
352 - Cystography:Exclude bladder injury in the acute setting (static cystography).Voiding cystography (performed through the suprapubic catheter) demonstrates the bladder neck and prostatic urethral anatomy when a delayed repair is being considered and for surgical planning.
363 - Computerized tomography: may miss lower urinary tract injuries and thus missing the suspicion for further evaluating studies of urethral injuries.99Lawson CM, Daley BJ, Ormsby CD, Enderson B. Missed injuries in the era of the trauma scan. J Trauma. Feb, 2011;70:452-6.
374 - Magnetic Resonance Imaging: has been used successfully to define defect length and to determine the extent and direction of urethral dislocation and the extent of prostatic displacement, and it may help in planning the surgical approach. (Dixon et al, 1992) and (Koraitim and Reda, 2007).
47In cases of female urethral disruption related to pelvic fracture, most authorities suggest immediate primary repair, or at least urethral realignment over a catheter, to avoid subsequent urethrovaginal fistulas or urethral obliteration (Koraitim et al, 1996; Dorairajan et al, 2004, Black et al, 2006).
48Incomplete urethral tears are best treated by stenting with a urethral catheter. The authors and others (Al-Ali and Husain, 1983; Mundy, 1991; Kotkin and Koch, 1996) have not seen any evidence that a gentle attempt to place a urethral catheter can convert an incomplete into a complete transection.
50Some degree of impotence is noted in up to 82% of patients with pelvic fracture and urethral distraction injury (Flynn et al, 2003).Although the average reported rate is approximately 50% (Corriere et al, 1994; Routt et al, 1996; Elliott and Barrett, 1997; Asci et al, 1999; Koraitim, 2005).
51The etiology is multifactorial and variably attributed to cavernous nerve injury, arterial insufficiency, venous leak, and direct corporeal injury (Narumi et al, 1993; Munarriz et al, 1995; Shenfeld et al, 2003).
52The risk of impotence caused by delayed urethroplasty is about 5% and the rate of incontinence is about 4%.