Editing AUA: Urotrauma (2020) (section)

===== '''Urethral trauma''' =====

* '''Background'''
** '''Urethral injuries may be partial or complete disruption of the urethra'''
** '''Male urethral injuries are classified as posterior (at or above the membranous urethra) vs.''' '''anterior urethra (penile or bulbar urethra)'''
* '''Pathogenesis'''
** '''Posterior injuries'''
*** '''Almost exclusively associated with pelvic fractures'''
**** '''In females, urethral injuries occur almost exclusively as a result of pelvic fracture'''
** '''Anterior injuries'''
*** '''May be blunt''' (e.g., straddle injuries, where the urethra is crushed between the pubic bones and a fixed object) '''or penetrating''', and the urethra may be lacerated, crushed, or disrupted.
*** '''Most commonly involves bulbar urethra''' since it is most susceptible to compressive injury due to its fixed location beneath the pubis
* '''Diagnosis and Evaluation'''
** '''History and physical exam'''
*** '''Indicators of urethral trauma (5):'''
***# '''Blood at the urethral meatus (most common finding)'''
***# '''Inability to urinate'''
***# '''Perineal/genital ecchymosis'''
***# '''In males, high-riding prostate on physical exam'''
***# '''In females, labial edema and/or blood in the vaginal vault'''

** '''Imaging'''
*** '''Modality: retrograde urethrogram (RUG)'''
**** See figure of retograde urethrogram of traumatic proximal urethral injury
**** '''Should be performed immediately when urethral injury is suspected'''

***** May demonstrate partial or complete urethral disruption, providing guidance for how to best manage bladder drainage in the acute setting
***** '''Blind catheter passage prior to RUG should be avoided, unless exceptional circumstances indicate an attempt at emergent catheter drainage for monitoring'''
****** Patients with pelvic fracture urethral injury (PFUI) are often unable to urinate due to their injuries. Trauma resuscitations typically involve aggressive hydration and a critical need to closely monitor patient volume status
****** In the acute setting of a partial urethral disruption, a single attempt with a well-lubricated catheter may be attempted by an experienced team member.
**** '''Technique'''
****# '''Position the patient obliquely with the bottom leg flexed at the knee and the top leg kept straight'''
****#* If severe pelvic or spine fractures are present, leaving the patient supine and placing the penis on stretch to acquire the image is appropriate.
****# '''Introduce a catheter tipped syringe or a 12Fr Foley catheter into the fossa navicularis'''
****# '''Place the penis on gentle traction'''
****# '''Inject 20-25 mL undiluted water-soluble contrast material and capture images'''
**** '''Occasionally a Foley catheter has been placed before evaluating the urethra'''
***** '''If no meatal blood is present and suspicion of injury is low, further imaging is not warranted.'''
***** '''If blood is present, a pericatheter RUG should be performed to identify potential missed urethral injury.'''
****** A pericatheter RUG can be done by injecting contrast material through a 3Fr catheter or angiocatheter held in the fossa navicularis to distend the urethra and prevent contrast leak per meatus.
* '''Management'''
** '''Regardless of the type of injury, securing catheter drainage of the bladder is the immediate goal of treatment'''.
** '''Male'''
*** '''Posterior injuries'''
**** '''Pelvic fracture urethral injury: immediate suprapubic tube (pecutaneous or open) with delayed repair'''
***** '''SPT remains the gold standard for urinary drainage.'''
***** '''Attempts at immediate sutured repair of posterior urethral injury are associated with unacceptably high rates of erectile dysfunction and urinary incontinence.'''
***** If the bladder is displaced due to pelvic hematoma, bladder localization techniques such as aspiration with an 18 G spinal needle or imaging with ultrasound or fluoroscopy may facilitate percutaneous SPT insertion.
***** 14 Fr or larger Foley catheter is preferred
***** '''May be placed in patients undergoing open reduction internal fixation (ORIF) for pelvic fracture'''
****** No evidence to indicate that SPT insertion increases the risk of orthopedic hardware infection.
***** '''Most PFUI patients will develop obliterative strictures which are amenable to open posterior urethroplasty''' 
***** '''Primary realignment vs. suprapubic tube'''
****** '''Primary realignment refers to advancing a urinary catheter across the ruptured urethra'''
******* The technique of PR may require two urologists to navigate the urethra simultaneously from above and below with multiple flexible or rigid cystoscopes, video monitors, and fluoroscopy.
******* The Emergency Department setting is inappropriate for primary realignment of most PFUI.
******* '''Prolonged attempts at endoscopic realignment in patients with PFUI should be avoided.'''
****** May be associated with less severe urethral strictures compared to patients undergoing suprapubic tube alone; however, has been associated with a longer clinical course due to multiple procedures required for recurrent obstruction over an extended timeline.
****** Even if primary alignment successful, patients with pelvic fracture associated urethral injury are at high risk for developing urethral stricture, and suprapubic tube trainage should be maintained while awaiting resolution of PFUI.
***** '''Complications of posterior urethral injury and it's repair (3):'''
*****# '''Urethral stricture'''
*****# '''Erectile dysfunction'''
*****# '''Incontinence'''
****** '''Patients should be followed for at least 1 year following urethral injury to monitor for development of complications'''
******* Surveillance strategies for stricture recommended for the first year after injury include uroflowmetry, retrograde urethrogram, cystoscopy, or some combination of methods.
******* Stricture can be treated with urethroplasty or direct vision internal urethrotomy
****** Impotence and incontinence are generally considered to be caused by the pelvic fracture itself rather than contemporary interventions for PFUI.
*** '''Anterior injuries'''
**** '''Straddle injury to the anterior urethra: prompt urinary drainage (SPT or PR) with delayed repair'''
***** '''With straddle injury, immediate operative intervention with to repair or debride the injured urethra is contraindicated due to the indistinct nature of the injury border.'''
***** For major straddle injuries involving the urethra, initial SPT is the standard of care; however, PR has shown promising results with respect to stricture rate and erectile dysfunction in patients with straddle injuries of lesser magnitude.
***** '''Stricture formation after straddle injury is very high and thus all patients require follow-up surveillance using uroflowmetry, retrograde urethrogram and/or cystoscopy.'''
**** '''Penetrating trauma: prompt surgical repairs should be performed in patients with uncomplicated penetrating (including gunshot) trauma of the anterior urethra'''
***** '''Spatulated primary repair of uncomplicated injuries in the acute setting offers superior outcomes to delayed reconstruction'''.
***** Surgical repair should not be undertaken if the patient is unstable, the surgeon lacks expertise in urethral surgery or in the setting of extensive tissue destruction or loss