RUPTUR URETRARUPTUR URETRAAndharu Primayudha InfantriAndharu Primayudha Infantri

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Pembimbing : dr. Hendra Herman, Sp.UPembimbing : dr. Hendra Herman, Sp.U

About 10% of all injuries seen in the emergency room involve the genitourinary system to some extent.

Fractures of the lower ribs are often associated with renal injuries, and pelvic fractures often accompany bladder and urethral injuries.

Urethral injuries are uncommon and occur most often in men, usually associated with pelvic fractures or straddle- type falls.

Early diagnosis is essential to prevent serious complications.

The urethra can be separated into 2 broad anatomic divisions:

the posterior urethra : consisting of the prostatic and membranous portions

the anterior urethra : consisting of the bulbous and pendulous portions.

INJURIES TO THE POSTERIOR URETHRA

When pelvic fractures occur from

blunt trauma, the membranous

urethra is sheared from the

prostatic apex at the

prostatomembranous junction.

The American Asosiasi for Surgery Trauma (AAST)

Sign and SymptomsSign and Symptoms

Blood at the urethral meatus

Suprapubic tenderness

Inability to urinate

lower abdominal pain

A history of crushing injury to the pelvis

The presence of pelvic fracture are noted on physical examination

A large developing pelvic hematoma may be palpated

X-RAY FINDINGS A urethrogram (using 20–30 mL of water-soluble contrast material) shows the site of extravasation at the prostatomembranous junction.

Treatment

EMERGENCY MEASURES :

Shock and hemorrhage should be treated.

SURGICAL MEASURES :

1. Immediate management

2. Delayed urethral reconstruction

3. Immediate urethral realignment

1. Immediate management

Initial management should consist of suprapubic cystostomy to provide urinary drainage.

The suprapubic cystostomy is maintained in place for about 3 months.

incomplete laceration of the posterior urethra heals spontaneously, and the suprapubic cystostomy can be removed within 2–3 weeks.

The cystostomy tube should not be removed before voiding cystourethrography shows that no extravasation persists.

2. Delayed urethral reconstruction

Reconstruction of the urethra after prostatic disruption can be undertaken within 3 months, assuming there is no pelvic abscess or other evidence of persistent pelvic infection.

The pre ferred approach is a single-stage reconstruction of the urethral rupture defect with direct excision of the strictured area and anastomosis of the bulbous urethra directly to the apex of the prostate.

A 16F silicone urethral catheter should be left in place along with a suprapubic cystostomy. Catheters are removed within a month, and the patient is then able to void

3. Immediate urethral realignment

Persistent bleeding and surrounding hematoma create technical problems.

The incidence of stricture, impotence, and incontinence appears to be higher than with immediate cystostomy and delayed reconstruction.

ComplicationsComplications

Stricture

Impotent

Incontinence

INJURIES TO THE ANTERIOR URETHRA

Classification based on Classification based on radiologyradiology

ContusioContusio

Incomplete disruptionIncomplete disruption

Complete disruptionComplete disruption

Pathogenesis & Pathology

A. CONTUSION

Contusion of the urethra is a sign of crush injury without urethral disruption. Perineal hematoma usually resolves without complications.

B. LACERATION

A severe straddle injury may result in laceration of part of the urethral wall, allowing extravasation of urine. If the extravasation is unrecognized, it may extend into the scro- tum, along the penile shaft, and up to the abdominal wall. It is limited only by Colles’ fascia and often results in sep- sis, infection, and serious morbidity.

Sign and SimptomsSign and Simptoms

There is usually a history of a fall, and in some cases a his- tory of instrumentation.

Bleeding from the urethra

There is local pain into the perineum and sometimes massive perineal hematoma.

If voiding has occurred and extravasation is noted, sudden swelling in the area will be present.

X-RAY FINDINGS

A urethrogram, with instillation of 15–20 mL of water-sol- uble contrast material, demonstrates extravasation and the location of injury. A contused urethra shows no evidence of extravasation.

Treatment

1. Urethral contusion

The patient with urethral contusion shows no evidence of extravasation, and the urethra remains intact. After urethrography, the patient is allowed to void; and if the voiding occurs normally, without pain or bleeding, no additional treatment is necessary. If bleeding persists, urethral catheter drainage can be done.

2. Urethral lacerations

suprapubic cystostomy tube can be inserted, allowing complete urinary diversion while the urethral laceration heals.

If only minor extravasation is noted on the urethrogram, a voiding study can be performed within 7 days after suprapubic catheter drainage to search for extravasation

Healing at the site of injury may result in stricture formation

Daftar PustakaDaftar PustakaBlair, Meg. 2011. Overview of genitourinary trauma. Diakses pada mei 2015. Diunduh dari URL: http://www.medscape.com/viewarticle/746075

Purnomo, Basuki B. 2003. Dasar-dasar urologi. Edisi 3. Jakarta : Sagung Seto

Schenkman, Noah S. 2013. Male Urethra Anatomy. Diakses pada mei 2015. Diunduh dari URL: http://emedicine.medscape.com/article/1972482-overview#showall

Snell, Richard S. 2006. Anatomi klinik untuk mahasiswa kedokteran. Ed. 6. EGC: Jakarta

Hansen, John T. 2005. Netter’s clinical anatomy. 2nd Edition. Philadelpia : Elseivers Sanders

Pineiro, L. Martinez. 2007. Urethral trauma. Diakses pada mei 2015. Diunduh dari URL: http://www.springer.com/978-3-540-48603-9.pdf

Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Campbell-walsh urology. 9 th Edition. Philadelphia : Saunders elsevier; 2007

Cummings, James M. 2013. Urethral trauma. Diakses pada mei 2015. Diunduh dari URL: http://emedicine.medscape.com/ article/451797-workup#showall

Pineiro LM, Djakov M, Plas E, et al. 2010. EAU guidelines on urethral trauma. European Urology 57 (2010) 79-803.

Rosenstein, Daniel I, Alsikafi NF. 2006. Diagnosis and clasification of uretrhal injuries. Urologic Clinic of North America. 33 (2006) 73-85.

Sjamsuhidayat R, Jong W. 2005. Buku ajar ilmu bedah. Ed.2. EGC: Jakarta.

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