DISCUSS URETHRAL INJURY

DR BASSEY, A E

OUTLINE• INTRODUCTION

– DEFINITION– STATEMENT OF SURGICAL IMPORTANCE– EPIDEMIOLOGY

• RELEVANT ANATOMY• CLASSIFICATION

– SITE– TYPE OF INJURY

• AETIOPATHOGENESIS• MANAGEMENT

– RESUSCITATION– HISTORY– EXAMINATION– INVESTIGATION– TREATMENT– COMPLICATIONS

• FOLLOW UP/PROGNOSIS• FUTURE TRENDS• CONCLUSION• REFERENCES

INTRODUCTION

• URETHRAL INJURY IS A BREACH IN THE STRUCTURAL INTEGRITY OF THE URETHRA RESULTING FROM EXCESSIVE TRAUMA

• WITH INCREASING INDUSTRIALIZATION, HIGH-SPEED COMMUTE, HUMAN CONFLICT AS WELL AS ADVANCES IN SURGICAL SCIENCE THE INCIDENCE OF URETHRAL INJURY IS ON THE RISE. TIMELY AND ACCURATE DIAGNOSIS ARE NECESSARY FOR APPROPRIATE ACUTE MANAGEMENT AND REDUCTION OF LONG TERM MORBIDITY

INTRODUCTION

• EPIDEMIOLOGY– IT IS THE COMMONEST CAUSE OF URETHRAL

STRICTURE IN NIGERIA1,2

– MAKES UP MAJORITY OF GU INJURIES4,5

– 10% OF PELVIC FRACTURES ASSOC WITH URETHRAL INJURY6

RELEVANT ANATOMY

CLASSIFICATION

• SITE– POSTERIOR URETHRAL INJURY– ANTERIOR URETHRAL INJURY

• TYPE OF INJURY– CONTUSION– PARTIAL RUPTURE– COMPLETE RUPTURE

AETIOPATHOGENESIS• POSTERIOR URETHRAL INJURY– PELVIC FRACTURE

– 10% ASSOC WITH URETHRAL INJURY. ALMOST ALL PU INJURY 2O BLUNT TRAUMA HAVE ASSOC PELVIC FRACTURE7

– RTA COMMONEST CAUSE OF PELVIC FRACTURE8

– INJURY OCCURS IN MEMBRANOUS URETHRA– 3 MECHANISMS– OFTEN ASSOC WITH MULTIPLE ORGAN TRAUMA

– IATROGENIC– CATHETER-RELATED– BOUGINAGE– ENDOSCOPY – MECHANICAL OR ELECTRICAL– SURGERY – RADICAL PROSTATECTOMY

AETIOPATHOGENESIS

– FOREIGN BODY– CALCULUS

– PENETRATING INJURY– THIS IS RARE

AETIOPATHOGENESIS• ANTERIOR URETHRAL INJURY (USU. ISOLATED)– STRADDLE INJURY

– INJURY OCCURS IN BULBAR URETHRA

– IATROGENIC– CATHETER-RELATED– BOUGINAGE– ENDOSCOPY – MECHANICAL OR ELECTRICAL– CIRCUMCISION

– PENETRATING INJURY– GUNSHOT

– PENILE FRACTURE– SELF-MUTILATION

– MENTALLY ILL– SEXUAL GRATIFICATION

AETIOPATHOGENESIS

• FEMALE URETHRA– PELVIC FRACTURE– VAGINAL SURGERY

MANAGEMENT

• RESUSCITATION– PARTICULARLY OF IMPORTANCE IN PU INJURY

DUE TO PELVIC FRACTURE– LIFE-THREATENING CONDITIONS TAKE

PRECEDENCE OVER URETHRAL INJURY AND MUST BE AMELIORATED FIRST !!!

MANAGEMENT

• HISTORY– INABILITY TO PASS URINE DESPITE THE URGE– HAEMATURIA– PAINFUL MICTURITION– URETHRAL BLEEDING– HISTORY OF THE AETIOLOGIC EVENT

EXAMINATION• GENERAL EXAMINATION NOT SPECIFICALLY

CONTRIBUTORY TO DIAGNOSIS OF URETHRAL INJURY

• ABDOMEN – ECCHYMOSIS– DISTENDED URINARY BLADDER

• EXT. GENITALIA– BLOOD AT MEATUS– ANY SURGERY OR PENETRATING INJURY?– PENILE OR PERINEAL ECCHYMOSIS – FOREIGN BODY IN URETHRA MAY BE FOUND

EXAMINATION – URETHRAL BLEEDING

EXAMINATION – PENILE FRACTURE

EXAMINATION• DIGITAL RECTAL EXAM

– BOGGINESS – HIGH RIDING OR ABSENT PROSTATE

• VAGINAL EXAM– BLEEDING– VAGINAL LACERATION

• MUSCULOSKELETAL– POSITIVE PELVIC COMPRESSION AND DISTRACTION TESTS

INVESTIGATION

• TO CONFIRM DIAGNOSIS– RETROGRADE URETHROGRAPHY• CONFIRMS INJURY• TYPE• LOCATION• PRESENCE OF FOREIGN BODY• ASSOC INJURY e.g. BLADDER

INVESTIGATION – URETHRAL CONTUSION

INVESTIGATION – PARTIAL URETHRAL RUPTURE

INVESTIGATION – COMPLETE URETHRAL RUPTURE

INVESTIGATION• TO DETERMINE EXTENT OF DISEASE– PELVIC XRAY– IMAGING FOR INVOLVED ORGAN SYSTEMS

• TO SUPPORT MANAGEMENT– FBC– EUCr– URINALYSIS– CXR– ECG

TREATMENT• AIM IS TO HAVE A CONTINENT PATIENT WITH

SATISFACTORY VOIDING AND SEXUAL FUNCTION

• PATIENT IS GIVEN ANALGESIA AND ANTIBIOTICS• AVOID REPEATED ATTEMPTS AT BLIND

CATHETERIZATION• PENETRATING INJURY IS JUDICIOUSLY

DEBRIDED• DEFINITIVE TREATMENT IS ACHIEVED BY– EARLY REPAIR OR– DELAYED REPAIR

TREATMENT• EARLY REPAIR

• DONE WITHIN ONE WEEK OF INJURY• URINE DIVERSION VIA SUPRAPUBIC CYSTOSTOMY• MODALITIES INCLUDE

– USE OF INTERLOCKING URETHRAL SOUNDS (‘RAILROADING’)– ENDOSCOPIC REALIGNMENT– OPEN SURGERY AND REPAIR OVER A CATHETER

• IT IS FRAUGHT WITH COMPLICATIONS SUCH AS– INFECTION OF HAEMATOMA– STRICTURE – 70%5

– ERECTILE DYSFUNCTION – 45%5

– INCONTINENCE – 20%5

TREATMENT• DELAYED REPAIR

• URINE DIVERSION BY SUPRAPUBIC CYSTOSTOMY• AT 12 WEEKS POSTINJURY RUG IS DONE TO ASSESS

URETHRAL STRICTURE• REPAIR OF STRICTURE IS CARRIED OUT• COMPLICATION RISK

– STRICTURE – 50%5

– ERECTILE DYSFUNCTION – 12%5

– INCONTINENCE – 2%5

• IT’S THE OPTION BEEN FAVOURED BY UROLOGISTS IN THE PAST 25 YEARS

TREATMENT

• CATHETERS LEFT IN SITU FOR 4 WEEKS• PERICATHETER RUG DONE AND CATHETER

REMOVED IF NO EXTRAVASATION NOTED• PATIENT’S VOIDING ABILITY NOTED

COMPLICATIONS

• EXTRAVASATION OF URINE NECROTIZING INFECTION OF PENILE AND PERINEAL SKIN

• URETHRAL STRICTURE• ERECTILE DYSFUNCTION• URINARY INCONTINENCE

FOLLOW-UP

• FOLLOW-UP SHOULD BE LIFELONG6

• AT EACH CLINIC VISIT, NOTE PATIENT’S VOIDING HISTORY. IF LUTS DEVELOP, RUG SHOULD BE DONE

• NOTE ALSO PATIENT’S CONTINENCE STATUS AND ERECTILE FUNCTION

PROGNOSIS

• WITH PROPER MGT PROGNOSIS IS EXCELLENT6

• UNRECOGNIZED URETHRAL INJURY HOWEVER LEADS TO HIGHER INCIDENCE OF COMPLICATIONS

FUTURE TRENDS

• USE OF MAGNETIC CATHETERS FOR EARLY REALIGNMENT OF THE URETHRA

CONCLUSION

RECOGNITION OF CARDINAL SIGNS AND SYMPTOMS OF URETHRAL INJURY FACILITATES TIMELY RADIOGRAPHIC DIAGNOSIS AND EARLY COMMENCEMENT OF APPROPRIATE INITIAL MANAGEMENT. THE ASTUTE CLINICIAN MUST MAINTAIN A HIGH INDEX OF SUSPICION, AS THESE INJURIES ARE FREQUENTLY OVERSHADOWED BY MULTISYSTEM TRAUMA.

THANK YOU

REFERENCES1. THE NEW PATTERN OF URETHRAL STRICTURE DISEASE IN

LAGOS, NIGERIA. NIGER POSTGRAD MED J 2009 JUN;16(2):162-5

2. THE CHANGING PATTERN OF URETHRAL STRICTURE DISEASE IN MIDWESTERN NIGERIA. J MED BIOMED RESEARCH 2006 DEC;5(2):50-54

3. DIAGNOSIS & CLASSIFICATION OF URETHRAL INJURIES. UROL CLIN N AM (2006) 73 – 85

4. TRAUMATIC UROLOGIC INJURIES IN ILE-IFE, NIGERIA J EMERG TRAUMA SHOCK 2010 OCT-DEC;3(4):311 - 3

5. PRINCIPLES & PRACTICE OF SURGERY INCLUDING PATHOLOGY IN THE TROPICS, 4TH Ed, 2009:185 – 7

6. EMEDICINE.MEDSCAPE.COM/ARTICLE/4517977. DIAGNOSIS AND INITIAL MANAGEMENT OF UROLOGICAL

INJURIES ASSOCIATEDWITH 200 CONSECUTIVE PELVIC FRACTURES. J UROL 1983;130:712–4.

REFERENCES8. POST-TRAUMATIC POSTERIOR URETHRAL

STRICTURES IN CHILDREN: A 20 YEAR EXPERIENCE. J UROL 1997;157:641.