LOWER UROGENITAL TRAUMA Yehya Elshebiny Adan Hospital

Bladder. Urethra. Genital.

Bladder Injuries External trauma (82%) RTA Falls, industrial trauma , blows to lower abdomen . Penetrating injury 60-90 % have associated pelvic fracture . 44% have associated intra-abdominal injury . Only 3.5% of pelvic fracture have associated bladder Injuries . Types : Extraperitoneal (50-70% ) . almost always with fracture pelvis . ? Sharp bone edges . Intraperitoneal ( 25-40%). Combined (10-15%) .

External : Obstetric and gynaecologic procedures. Internal : TURB. Iatrogenic trauma (17%) External : Obstetric and gynaecologic procedures. General surgical and urologic interventions. Internal : TURB.

Risk factors : Intra-peritoneal : driving under the influence of alcohol Extra peritoneal : disruptions of the pelvic circle Iatrogenic : Previous CS . Previous pelvic surgery . Malignancy . Endometriosis . Sling procedures retropubic route .

Presentation : External trauma : bladder injury might be blurred by associated pelvic fracture and visceral injuries . The cardinal sign of bladder injury is gross haematuria . the classic combination of pelvic fracture and gross haematuria constitutes an absolute indication for further imaging of the bladder Isolated gross haematuria or pelvic fracture, decision for further imaging should be based on the presence of other clinical signs and symptoms .

Other signs and symptoms : Abdominal tenderness . Abdominal distension . Inability to void . Extravasation of urine : extraperitoneal . uraemia .

Iatrogenic trauma . During open surgery : methylene blue . During TURB . Postoperative : urine leakage from the wound.

Cystography (conventional or CT) . Imaging : Cystography (conventional or CT) . Look for signs of associated urethral injury before catheter insertion .

Cystoscopy Routine postoperative cystoscopy after gynaecological procedures remains controversial. It is recommended for all procedures where bladder injury is suspected . ex. suburethral sling operations by retropubic route .

Ultrasound alone is insufficient . Excretory phase of CT or IVP ??? Insufficient .

catheter drainage alone Treatment External injury : Blunt trauma: extraperitoneal rupture catheter drainage alone However : Open surgery #Orthopaedic surgery . # Surgical exploration for other injuries . # Bladder neck involvement, the presence of bone fragments in the bladder wall, concomitant rectal injury .

laparoscopic suturing Blunt trauma: intraperitoneal rupture surgical repair laparoscopic suturing Penetrating injuries : emergency exploration

Perforations recognised intraoperatively are primarely closed Iatrogenic injuries : Perforations recognised intraoperatively are primarely closed IF not recognised : Extraperitoneal injuries : Bladder drainage and antibiotic prophylaxis. Intraperitoneal injuries surgical exploration with repair . In selected cases : continuous bladder drainage , antibiotic, and intraperitoneal drain . If after TURB : Immediate intravesical instillation with chemotherapeutic agents should not be performed . Meticulous bowel inspection is required to rule out concomitant injury .

Postoperative management Bladder catheter is maintained for 7-14 days Postoperative management Bladder catheter is maintained for 7-14 days. Cystography upon removal of the catheter is advised .

In Conclusion : Extraperitoneal bladder perforations are more frequent than intraperitoneal perforations, mostly associated with pelvic fractures due to an RTA . The combination of pelvic fracture and gross haematuria is highly suggestive of bladder injury , is a strong indication for Cystography . Requires drainage with antibiotics . Intraperitoneal bladder injuries require exploration and repair.

URETHRAL TRAUMA Anterior urethral injuries : Blunt trauma Accounts for more than 90% ‘Fall-astride’ or ‘straddle’ injury Penile fracture : 20% have associated urethral injury . Constriction device : ischaemic injuries . Penetrating injuries Iatrogenic urethral injuries caused by instruments are by far the most common cause of urethral trauma

Posterior urethral injuries : Occurs in 4-19% of pelvic-fracture in males . Found 0-6% in females ; Short and mobile, without any significant attachments to the pubic bone.

Diagnosis : Bleeding per urethra and voiding difficulty …. suspicion of urethral trauma, although their absence does not rule out urethral injury. Other signs : Haematuria Pain on urination - Dysuria Inability to void Haematoma Swelling ‘High-riding’ or “absent” prostate Blood at the vaginal introitus .

Retrograde urethrography Is the gold standard for evaluating urethral injury. Ultrasonograph : Suprapubic catheter insertion . Tunica albuginea ruptures . CT , MRI , and urethroscopy : have no place in the initial assessment of urethral injuries However, in females , urethroscopy helps in identification and staging of urethral injuries .

Management : The management of urethral injuries remains controversial because of the variety of injury patterns, associated injuries and treatment options available.

Anterior urethral injuries Blunt : suprapubic diversion Acute or early urethroplasty is not Indicated. Delayed management at 3-6 months : # Optical urethrotomy or urethral dilatation . # Anastomotic urethroplasty . # Flap/graft urethroplasty.

Fracture penis with urethral injury open repair .

Penetrating anterior urethral injuries : Immediate exploration and end-to-end anastomosis Urethral debridement should be kept to a minimum since the spongiosum is well vascularised and so usually heals well. Peri-operative antimicrobial cover. There is no role for acute placement of a graft or flap in the initial management of any urethral injury Delayed management : If defect is > 1-1.5 cm in length, two-stage urethral repair.

Posterior urethral injuries Blunt injury : Partial tear Acute management suprapubic or urethral catheter Delayed Management # Urethral dilatation # Optical urethrotomy # Anastomotic urethroplasty

In complete urethral ruptures : The gap betweenthe disrupted end of the urethra retract and fibrous tissue fills the space between them. There is no urethral wall in the scarred space, and any lumen represents merely a fistulous tract between the urethral stumps .

Injury to the posterior urethra is most likely to occur with unstable pelvic fractures : Bilateral ischiopubic rami fractures (‘straddle fracture’), Symphysis pubis diastasis. The combination of straddle fractures with diastasis of the sacroiliac joint has the highest risk of urethral injury .

Never life-threatening . Strictures, Incontinence and Erectile dysfunction. Erectile dysfunction occurs in 20-60% of cases . Bilateral pubic rami fractures are the most frequent cause of impotence. Neurogenic, due to bilateral damage of the cavernous nerves at the prostatomembranous urethra behind the symphysis pubis .

suprapubic catheter is the primary treatment. Management Complete posterior urethral rupture : suprapubic catheter is the primary treatment. Further treatment depends on the patients comorbidity and co-existing injuries .

When urethral trauma is suspected ,urethrogram is done then an attempt of urethral catheterisation should be carried. It is extremely unlikely that gentle passage of a urethral catheter will do any additional damage . Although it has been suggested that passing a catheter may convert a partial tear Into a complete one , there are no convincing data indicating that there is a higher rate of infection or urethral stricture after a single attempt at catheterisation . In an unstable patient, an attempt to pass a urethral catheter should be performed, but if there is any difficulty, a suprapubic catheter should be placed using US guidance .

Acute treatment options : after position of the suprapubic catheter include:

Immediate open urethroplasty, ???? experimental . Open realignment has been described , but it should be performed only in patients who undergo open abdominal or pelvic surgery for associated injuries like bladder neck or rectal injuries or for internal bone fixation . Immediate repair of bladder neck and rectal injury aims at : # Reduction of incontinence and infection of the pelvic fractures # Reduction of sepsis and fistulae due to rectal injury.

Primary (endoscopic) realignment : Usually within 7 days . The proposed benefits of primary alignment are: A lower stricture rate Easier urethroplasty However, there is the disadvantage of a higher incidence of Impotence and incontinence.

Primary realignment techniques include: # Simple passage of a catheter across the defect . # Catheter realignment using flexible /rigid endoscopes and fluoroscopy . # Interlocking sounds (‘railroading’) # Pelvic haematoma evacuation and dissection of the prostatic apex to resume continuity of urethra over a catheter (with or without suture anastomosis). # catheter traction or perineal traction sutures to pull the prostate back to its normal location.

Delayed management of posterior urethral injuries : Delayed primary urethroplasty within 2 weeks after injury : is mainly indicated in female. Delayed formal urethroplasty at 3 months after injury is the gold standard approach .

stricture incontinence impotence Primary suturing 49% 21% 56% Suprapubic divertion 97% 4% 19% Delayed urethroplasty 10% - 5%

Delayed endoscopic optical incision : cut-to-the-light technique aided with C-arm fluoroscopy. failure is common ( up to 95% ) . Indicated for short strictures only .

Penetrating posterior urethral injuries Open repair . If unstable : suprapubic cystostomy.

GENITAL TRAUMA Of all genito-urinary injuries : 1/3rd to 2/3rds involve the external genitalia Mostly males . Blunt injury in 80% of cases. Majority of open trauma due blast injury .

Management In genital trauma, a urinalysis should be performed. The presence of macro- and or microhaematuria : Males : retrograde urethrogram . Females : cystoscopy to exclude urethral and bladder injury.

Escherichia coli,Streptococcus viridans, Staphylococcus aureus . Gunshot wounds : high–velocity missiles . Animal bites : 50% Pasturella Multicida Escherichia coli,Streptococcus viridans, Staphylococcus aureus . Treatment : Amoxiclavulanic Rabies vaccination Human rabies immunoglobulin Human bites : hepatitis B vaccine immunoglobulin HIV

Penile Fracture : Trauma to the erect penis . Rupture of the tunica albuginea , and urethral injury in about 20% of cases The thickness of the tunica albuginea in the flaccid state (approximately 2 mm) decreases during erection to < 0.5mm, making it more vulnerable to traumatic injury .

Sudden cracking or popping sound, pain and immediate detumescence. Swelling of the penile shaft develops quickly . Extend to the lower abdominal wall if Buck’s fascia is also ruptured.

Early surgical intervention through circumferential , or local longitudinal incisions to close the tunica albuginea . Postoperative complications (mainly wound infection ) in 9%, and impotence in 1%.

Conservative management of penile fracture is not recommended as It increases complications (as penile abscess, missed urethral disruption, penile curvature, and persistent haematoma ) in 35% and impotence in up to 62% of cases .

Penile avulsion injuries and amputation : Self-inflicted , industrial accidents or assault Microsurgical re-implantation .

Scrotal Trauma : Haematocoele Conservative management is recommended in haematoceles smaller than three times the size of the contralateral testis . In large haematoceles, non-operative management often fails .

Testicular Rupture : About 50% of cases of blunt scrotal trauma . Sensitivity of US in differentiation of testicular rupture or haematocele ??? . Testicular CT or MRI may be helpful . In doubtful cases , surgical exploration is done to close the tunica albuginea with running absorbable sutures (such as 3/0 vicryl ).

In conclusion : Anterior urethral injury is mostly due to direct trauma to perineum ( falling astride ) where as posterior urethral injury occurs in association with pelvic fractures. Bleeding per urethra in the hallmark of urethral injury , mandates ascending urethrogram followed by urinary diversion . Short strictures can be treated with optical urethrotomy . Urethroplasty at 3-6 months is the gold standard treatment for denser strictures .

Exploration and repair is needed in cases of Penile fracture Scrotal injury with large hematocele or in doubtful testicular rupture.

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