Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXI: Wounds and Injuries of the Genitourinary Tract

Wounds of the Urethra

United States Department of Defense

Injuries to the male urethra should always be suspect in patients. With blood at the urethral meatus. Urethral catheterization is contraindicated until integrity has been established by retrograde urethrography, After sterile prepping of the penis, retrograde urethrography is performed by inserting the end of a cathetertip syringe into the urethral meatus with gentle retrograde instillation of 15-20cc of a water-soluble contrast medium. An X-ray is taken during injection. Urethral injury will be represented by extravasation of the contrast material. Contrast must be seen flowing into the bladder to ascertain urethral integrity proximal to the urogenital diaphragm.

The urethra is divided into anterior and posterior (prostatic) segments by the urogenital diaphragm. Posterior urethral disruption commonly occurs following pelvic fracture injuries. Rectal examination reveals the prostate to have been avulsed at the apex. Improved continence and potency rates are attained when suprapubic tube cystostomy is used as the initial management. No attempt at reapproximation of the urethral edges should be made, as such attempts increase the risk of impotency, release the tamponade of the pelvic hematoma, and too often result in an infected hematoma. With expectant observation virtually all these injuries will heal with an obliterative prostatomembranous urethral stricture, which can be repaired secondarily in 4-6 months after reabsorption of the pelvic hematoma. Initial exploration of the pelvic hematoma is strictly reserved for patients with concomitant transmural rectal injury.

Anterior urethral injuries may result from blunt trauma, such as results from falls astride an object (straddle), or from penetrating injuries. Blunt trauma resulting in minor nondisruptive urethral injuries may be managed by gentle insertion of a 16 French foley catheter for 7-10 days. If any difficulty in passing the catheter is encountered, or if the blunt trauma has an associated perineal or penile hematoma indicating more than a minor mucosal injury, the urethra is not instrumented and suprapubic tube cystostomy is performed. Suprapubic urinary diversion is maintained for 10-14 days and urethral integrity is confirmed radiographically prior to removal of the suprapubic tube. Healing may occur without stricture formation. If a stricture develops, it is readily managed by direct vision urethrotomy or open urethroplasty at a later procedure.

Penetrating wounds of the anterior urethra should be managed by exploration and debridement. Small, clean lacerations of the urethra may be repaired primarily by reapproximation of the urethral edges using interrupted 4-0 chromic catgut sutures. Most penetrating urethral injuries, however, will be associated with devitalized margins requiring debridement. One should refrain from the temptation to mobilize the entire urethra for a primary anastomosis, as the shortened urethral length in the pendulous, urethra will invariably result in ventral chordee and an anastomosis under tension. Instead, the injured urethral segment should be marsupialized by suturing the skin edges to the cut edges of the urethra. Marsupialization should be performed, until healthy urethra is encountered both proximally and distally. Closure of the marsupialized urethra is subsequently performed at six months to reestablish urethral continuity.

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Operational Medicine 2001

Health Care in Military Settings

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