Harvey's Garden

Urethral injuries

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  • Anatomical Classification
    • Posterior Urethra: Membranous (narrowest, most common site of injury) and Prostatic segments.
    • Anterior Urethra (Spongy urethra): Bulbar and Penile segments. t
  • Etiology
    • Posterior Urethral Injury:
      • Associated with pelvic fractures (e.g., MVA).
      • Shearing force at the prostatomembranous junction.
    • Anterior Urethral Injury:
      • Associated with straddle injuries (e.g., falling on a bicycle crossbar), direct perineal trauma, or instrumentation t .
      • Crushing of the bulbar urethra against the pubic symphysis.
  • Clinical Presentation
    • General Signs (both anterior & posterior):
      • Blood at the urethral meatus (most common and reliable sign).
      • Inability to void/urinate.
      • Distended bladder (palpable suprapubic mass).
    • Posterior Urethral Injury Specifics:
      • High-riding prostate on digital rectal exam (DRE) due to disruption of puboprostatic ligaments (poor sensitivity but highly tested). c
        • Also, the expanding pelvic hematoma physically pushes the detached bladder and prostate superiorly (cranially) into the pelvis
      • Pelvic instability/pain.
    • Anterior Urethral Injury Specifics:
      • Normal prostate on DRE.
      • “Butterfly” hematoma of the perineum, scrotum, and penis (extravasation of blood/urine limited by Colles’ fascia).
  • Diagnostics
    • Initial & Gold Standard: Retrograde urethrogram (RUG). c
      • Contrast injected into the distal urethra; extravasation of contrast confirms the tear (partial vs. complete).
    • Key Contraindication: Do NOT insert a Foley catheter before performing RUG if a urethral injury is suspected. c
      • Risk of converting a partial urethral tear into a complete transection and introducing infection.
    • Key Labs: Urinalysis (usually gross hematuria, though RUG is prioritized over UA).
  • Management
    1. Immediate Urinary Diversion (First-line):
      • Place a suprapubic catheter to decompress the bladder and divert urine away from the injured area.
      • Safe to perform when the bladder is palpable/distended.
    2. Surgical Intervention (Second-line/Definitive):
      • Delayed urethral reconstruction (urethroplasty) typically performed 3–6 months later after pelvic hematoma and inflammation resolve.
      • Immediate primary endoscopic realignment may be considered in select stable patients.
    3. Refractory/Late Stricture Management:
      • Endoscopic dilation or direct vision internal urethrotomy (DVIU) for short, focal strictures.

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