CASE REPORT trauma, blunt pelvic; urethral injury

Female Urethral Injury Secondary to Blunt Pelvic Trauma Urethral injury after blunt pelvic trauma is rare in women. We report a case of urethral injury and vaginal laceration secondary to blunt pelvic trauma. Pelvic examination should be performed in any female patient who has sustained blunt pelvic trauma to avoid the morbidity associated with delayed diagnosis of urethral injury. [Diekmann-Guiroy B, Young DH: Female urethral injury secondary to blunt pelvic trauma. Ann Emerg Med December 1991;20:1376-1378.] INTRODUCTION Previous studies have indicated that urethral injury in female trauma victims is rare and have suggested that for practical purposes it may be dismissed.I, ~ Others have noted that it does occur, 3 but infrequently.4, 5 Many reported cases of female urethral injury resulting from blunt trauma of the pelvis have been diagnosed only after the delayed sequelae of the injury have been manifested. 6 These sequelae include urinary incontinence, urinary hydrocolpos, stricture with urinary retention, ureterovaginal fistulas, urethral diverticula with dyspareunia, hematuria, abscess, recurrent urethritis and cystitis, and dysmenorrheaff, 8 We report a case of urethral injury in a woman diagnosed early by pelvic examination.

Bernadette Diekmann-Guiroy, MD David H Young, MD Wilmington, Delaware From the Department of Surgery, The Medical Center of Delaware, Wilmington. Received for publication March 25, 1991. Accepted for publication June 7, 1991. Address for reprints: Bernadette Diekmann-Guiroy, MD, % Karen McFadden, Suite 128, Medical Arts Pavilion, 4745 Stanton-Ogletown Road, Newark, Delaware 19713.

CASE REPORT A 19-year-old unrestrained driver was injured when her automobile was struck on the driver's side. She complained of pain in the right flank and left thigh. On arrival in the emergency department, the patient was alert but anxious, with a Glasgow Coma Score of 15. Her initial blood pressure was 140/60 m m Hg; pulse, 104; and respirations, 20. After initial assessment, stabilization, and rectal examination, a Foley urethral catheter was inserted; however, the patient complained of persistent need to void and only 5 mL of grossly bloody fluid drained from the Foley catheter. A suprapubic mass and tenderness in the right lower quadrant and the right flank were noted. Pain was elicited in the right inguinal area with hip rotation. Because of the initial clinical suspicion of a pelvic fracture, a pelvic radiograph was obtained and a pelvic examination was performed. There was a bloody vaginal discharge, and the urethral catheter tip and balloon were found to be located intravaginally, although the catheter passed through the urethral meatus appropriately (Figure 1). The urethral catheter was withdrawn, and a new 14F Foley catheter was passed into the bladder, guided with a finger supporting the anterior wall of the vagina, thus preventing the catheter from leaving the urethra. Then, 800 mL of urine were drained from the bladder, and the abdominal signs and suprapubic mass disappeared. Once stabilized, the patient was placed under sedation and, with local anesthesia, a 3-cm anterolateral vaginal laceration was identified and repaired. The urethral injury was not visualized. Laboratory findings were unremarkable, except for the urinalysis, which demonstrated large amounts of white and red blood cells. An anteroposterior film of the pelvis showed a comminuted fracture involving the lateral aspect of the left superior pubic ramus and suggested a fracture of the left inferior pubic ramus and the left side of the sacrum at the level of S1-2. Radiographs of the cervical spine and lower extremities

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FIGURE 1. A schematic representa-

tion of the sagittal view of the female pelvis shows the i n j u r y to the urethra and anterior wall of the vagina (long arrow) and the displaced urethral catheter (short arrow) in the vaginal canal. (Adapted with permission from Sobotta: Atlas of H u m a n Anatomy, Ilth English edition. Baltimore-Munich, Urban & Schwarzenberg, 1990.) FIGURE 2. Enhanced computed tomography scan of the axial plane of the pelvis demonstrates fluid collection (short arrows) surrounding the cervix (long arrow) in a 19-year-old female patient w~th an injury to the urethra and laceration of the anterior wall of the vagina associated with blunt pelvic trauma. appeared normal. The cystogram was within normal limits, except for displacement by a pelvic hematoma. A c o m p u t e d t o m o g r a p h y scan of the abdomen demonstrated a small amount of fluid in the posterior culde-sac and in the vaginal canal outlining the cervix (Figure 2). The urin a r y bladder, w h i c h was s h i f t e d slightly anteriorly and superiorly, appeared to distend normally. A Foley catheter was in place. A fracture was demonstrated running through the left sacral wing and the left pubic ramus. The left sacroiliac joint did not appear widened. A small hematoma was noted in the left obturator internus muscle. The vaginal l a c e r a t i o n was repaired under IV sedation and local anesthesia once the patient was stable. No genitourinary complications were noted during the patient's hospital stay. The pelvic fractures were 134/1377

managed with gradual mobilization, and the patient was discharged with the Foley catheter still in place seven days after injury. Two weeks later, the Foley catheter was r e m o v e d by the p a t i e n t ' s urologist, and cystoscopy was performed, with no abnormal findings. DISCUSSION The anatomic characteristics of the female u r e t h r a usually p r o t e c t it from injury. It is short and not rigidly fixed on the pelvic floor because of the lack of attachment to the pubis, in c o n t r a s t to the m a l e u r e t h r a , which is long and fixed to the pubis by t h e p u b o p r o s t a t i c l i g a m e n t . 9 These differences, along with the fact that women have a much lower incidence of major trauma, make female urethral injury rare. The urethrogram, which is a mainstay in the diagnosis of male urethral injury, is difficult, if not impossible, to perform in women, and urethral injuries may be overlooked. Pelvic examination is an important part of physical diagnosis, but it is rarely performed in female patients with pelvic trauma. The performance of a pelvic e x a m i n a t i o n could increase the suspicion for urethral injury. The presence of blood during pelvic e x a m i n a t i o n i n d i c a t e s the need for further detailed vaginal examination using a speculum. A him a n u a l pelvic e x a m i n a t i o n w i t h evaluation of the external genitalia and urethral meatus should be a routine part of the secondary survey before placement of a Foley catheter in female patients who have sustained Annals of Emergency Medicine

blunt pelvic trauma. Hematuria is an important clinical and laboratory sign. Its presence is an indication of urinary tract injury and, in our patient, suggested that the injury was not in the upper urinary tract but rather was in the urethra and was due to a vaginal laceration. In addition to blunt trauma to the pelvis from motor vehicle accidents, falls, sporting accidents, or industrial crush injuries, the other major causes of injury to the female urethra are secondary to obstetric complications, vaginal surgery, rape, and introduction of foreign bodies, especially in children.lO-12 The increasingly active participation of women in sports is a factor that could raise the number of urethral injuries. 6 A retrospective study of 2,000 female patients reviewed for urethral injuries after blunt pelvic trauma found that 120 patients (6%) had urethral injury. 13 SUMMARY It is suggested that urethral injury should be suspected in any female patient with pelvic fractures because of the association of these fractures with urethral injury and vaginal laceration. A pelvic examination should be performed in all female patients who have suffered significant blunt pelvic trauma. REFERENCES l. Corriere JN Jr, Harris JD: The m a n a g e m e n t of urologic injuries in blunt pelvic trauma. Radiol C]Jn North A m 1981;19:187-i93. 2. Marshall V: The management of blunt injuries of the urinary tract. Aust N Z J Surg i977;47:548-551. 3. gpirnak |P: Pelvic fracture and injury to the lower urinary tract. &Irg Clin North Am 1988;68:1057-1069.

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4. McAninch JW: Injuries to the genitourinary tract, in Smith DR (ed): General Urology Los Altos, California, Lauge Medical Publishers, 1981, p 244-261. 5. Fallon B, Wendt JC, Hawtrey CE: Urological injury and assessment in patients with fractured pelvis. J UroI 1984;131:712-714. 6. Barach E, Martin G, Tomlanovich M, et al: Blunt pelvic trauma with urethral injury in the female: A case report and review of the literature. J Emerg Med

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1984;2:101-105.

rupture of the female urethra. J UroI 1979;122:560-561.

7. Williams DI: Rupture of the female urethra in childhood. Eur UroI 1978/1:129-130.

11. Buxton RA: Rupture of the urethra in a female child with a fractured pelvis. Injury 1976;9:209-211.

8. Patil U, Nesbitt R, Meyer R: Genitourinary tract injuries due to fracture of the pelvis in females: Sequelae and their management. Br J UroI 1982~54:32-38.

12. Parkhurst JD, Coker JE, Halverstadt DB: Traumatic avulsion of the lower urinary tract in the female child. J

9. Netto NR Jr, Ikari O, Zuppo VP: Traumatic rupture of female urethra. Urology 1983;22:601-603. 10. Bredael JJ, Kramer SA, Cleeve LK, et al: Traumatic

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Urol 1980;126:268-267. 13. Orkin LA: Trauma to the bladder, ureter and kidney, in 8ciarra D (ed): Gynecology and Obstetrics. Philadelphia, Harper & Row, 1983, vol 1, p 1-8.

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Female urethral injury secondary to blunt pelvic trauma.

Urethral injury after blunt pelvic trauma is rare in women. We report a case of urethral injury and vaginal laceration secondary to blunt pelvic traum...
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