DIAGNOSIS AND MANAGEMENT OF URETHRAL TRAUMA

ANATOMY The male urethra is divided into the anterior and posterior sections by the urogenital diaphragm Only the posterior urethra exists in the female Hohenfellner, Markus. Emergencies in Urology. Springer-Verlag. 2007

CLASSIFICATION Anterior urethral injuries Posterior urethral injuries

ANTERIOR URETHRAL INJURIES

POSTERIOR URETHRAL INJURIES Injuries to the posterior urethra occur with pelvic fractures The male posterior urethra is concomitantly injured in approximately 3.5%–19% The female urethra in 0%–6% in all pelvic fractures

CLINICAL ASSESSMENT Primary survey (ABCD) Complete history and physical examination : Blood at the meatus Blood at the vaginal introitus Hematuria Pain on urination or inability to void Hematoma High-riding prostate Inability to pass a urethral catheter Hohenfellner, Markus. Emergencies in Urology. Springer-Verlag. 2007

GRADING

MANAGEMENT Primary survey (ABCD) + stabilization Order specific diagnostic imaging Blunt trauma : Urinary diversion  Definitive repair by timing : Immediate : < 48 hours after injury Delayed primary : 2 days – 14 days after injury Deferred : > 3 months after injury Penetrating trauma : Immediate exploration N.D Kitrey et al. EAU Guideines : Urological Trauma. 2017

Radiographic Examination Retrograde urethrography / Bipolar urethrocystography Hohenfellner, Markus. Emergencies in Urology. Springer-Verlag. 2007

Early urinary diversion for three main reasons : To monitor urinary output, since this is a valuable sign of the haemodynamic condition and the renal function of the patient; To treat symptomatic retention if the patient is still conscious; To minimise urinary extravasation and its secondary effects, such as infection and fibrosis.

Management algorithm of anterior urethral injuries

Management of posterior urethral injuries

Treatment of iatrogenic urethral injury caused by improper insertion of a catheter

PENILE FRACTURE

DEFINITION Rupture of the tunica albuginea of the erect penis (i.e. rupture of one or both corpora cavernosa with or without rupture of the corpus spongiosum with rupture of the urethra) Traumatic injuries to the penis are rare, with variable etiology. Reynard, John. Oxford Handbook of Urology : Penile Injuries. Oxford Medical Publications. 2017

EPIDEMIOLOGY & ETIOLOGY Penile fracture usually occurs in men between the age of 30–40 most commonly occurs during sexual intercourse, masturbation, rolling over in bed, and kneading the penis to achieve detumescence

CLINICAL PRESENTATION The patient usually reports a sudden ‘snapping’ or ‘popping’ sound and/or sensation with sudden penile pain and detumescence of the erection Inability to erect after the incidence If Buck’s fascia has ruptured, bruising extends onto the lower abdominal wall and into the perineum and scrotum Eggplant sign If the urethra is damaged, there may be blood at the meatus or haematuria (dipstick/ microscopic or macroscopic) and pain on voiding or urinary retention

Case Presentation Man 39 years old Blunt injury during masturbation and overbanding of the penile On physical examination, there was subcutaneous hematoma on the right proximal penile shaft. meatal bleeding Urethrography investigation showed a leakage of the contrast in the pendulous part of urethra So we diagnose this patient with Penile Fracture and Partial Rupture of the Urethra

Management Patient underwent emergency surgery Degloving the penile Hematoma evacuation Repair defect of tunica albuginea Repair partial rupture of urethra Artificial Erection

Result Hospitalised for 3 days with no complication after discharge Follow up : The silicone catheter was removed after 3 weeks with bladder training prior to removal. No voiding symptoms with IPSS score was 3 No pain on erection, satisfying erection with IIEF-5 score was 22 and EHS score was 5. Urethrography was performed 3 months after surgery. Neither leakage of the contrast nor narrowing of the urethra was found

MANAGEMENT SUMMARY Perform retrograde urethrography Conservative: application of cold compresses to the penis; analgesics and anti-inflammatory drugs; abstinence from sexual activity for 6–8 weeks to allow healing Complication : Could perform penile abcess and penile curvature Immediate Surgical Exploration : expose the fracture site in the tunica albuginea, evacuate the haematoma, and close the defect in the tunica.

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