1. DIAGNOSIS AND MANAGEMENT OF URETHRAL TRAUMA

2. 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

3. CLASSIFICATION
Anterior urethral injuries
Posterior urethral injuries

4. ANTERIOR URETHRAL INJURIES

5. 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

6. 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

7. GRADING

8. 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

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

10. 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.

11. Management algorithm of anterior urethral injuries

13. Management of posterior urethral injuries

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

17. PENILE FRACTURE

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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.

25. THANK YOU