0022-534 7/79 /1224-0560$02.00/0 Vol. 122, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
TRAUMATIC RUPTURE OF THE FEMALE URETHRA JACQUES J. BREDAEL, STEPHEN A. KRAMER, LAURENCE K. CLEEVE AND GEORGE D. WEBSTER From the Department of Surgery, Division of Urology, Duke University Medical Center, Durham, North Carolina
ABSTRACT
The clinical course of 4 female patients with complete traumatic rupture of the urethra was evaluated in an effort to propose guide lines for the investigation and initial management of this unusual injury. Treatment modalities are determined by the level of urethral injury and the subsequent effect on continence. We recommend a retropubic approach for bladder neck injuries, a transvaginal approach for proximal urethral ruptures with reanastomosis over a stenting catheter and acceptance of a hypospadiac neomeatus for distal urethral ruptures. Female urethral injuries are associated most commonly with instrumentation, vaginal operations and obstetric complications. 1' 2 Complete rupture of the female urethra occurs infrequently after pelvic trauma and in a review of the literature only isolated case reports were found. 3- 10 A series of 381 patients with traumatic rupture of the urethra included only 7 female subjects, each of whom had incomplete tears. 11 Williams has reported his experience with the late management of female urethral ruptures in children. 12 Herein we review the clinical course of 4 female patients with complete traumatic rupture of the urethra in an effort to propose guide lines for the investigation and initial management of this unusual injury. CASE REPORTS
Case 1. A. N., an 8-year-old girl, was involved in a motor vehicle accident and sustained multiple pelvic fractures, including fractures of both pubic rami. Pelvic examination revealed a deep laceration of the anterior vaginal wall and complete transection of the urethra at the level of the bladder neck. A bladder flap urethroplasty was done through a retropubic approach. Re-exploration was necessary 6 weeks postoperatively because of wound infection and purulent urethral discharge. Intraoperative findings revealed complete slough of the urethra and a new flap was developed. After removal of the urethral catheter the patient failed to void spontaneously and was referred to us for further evaluation. Cystourethroscopy revealed complete obliteration of the neourethra. A suprapubic cystostomy was done, which will be maintained until pubescence, when a transpubic bladder flap urethroplasty will be undertaken. Considering the young age of this patient and the history of 2 unsuccessful reconstructions, it is believed that further tissue maturation will increase the chance of a successful repair. Case 2. H. D., a 7-year-old girl, was hit by a bus and admitted to a local hospital with multiple pelvic fractures and complete transection of the proximal urethra. Retropubic exploration revealed that the proximal two-thirds of the urethra was crushed completely. Primary urethral anastomosis was not possible and a diverting suprapubic cystostomy was done. The patient was referred to us for further evaluation and a bladder flap urethroplasty was done 3 months after the initial injury. Followup 1 year postoperatively revealed that the patient was regaining some degree of bladder control. Case 3. E. W., a 27-year-old woman, sustained multiple pelvic fractures during a motor vehicle accident. Pelvic examination revealed a deep laceration of the anterior vaginal wall and attempted urethral catheterization was unsuccessful. Excretory urography (IVP) was normal. Vaginal exploration revealed complete transection of the proximal urethra. The proximal and distal portions of the urethra were identified and a primary Accepted for publication January 19, 1979.
end-to-end anastomosis was done over a stenting urethral catheter. Postoperatively, an anastomotic stricture developed but has responded to urethral dilation. The patient remains continent and voids without difficulty. Case 4. D. G., a 19-year-old woman, was involved in a motor vehicle accident and sustained multiple extremity fractures and a non-displaced right acetabular fracture. Pelvic examination revealed a large perineal hematoma, a deep laceration of the anterior vaginal wall and left labia majora, and complete transection of the distal urethra. After evacuation of the vaginal hematoma a urethral catheter was inserted into the proximal urethral stump. IVP and cystography were normal. The vaginal laceration was closed primarily and the urethral catheter was removed 10 days postoperatively. The patient remains continent and voids without difficulty through the neomeatus. DISCUSSION
A pelvic fracture in the male patient commonly results in injury to the prostatomembranous urethra owing to rigid fixation of the prostate to the pubis by the puboprostatic ligaments and the lack of mobility of the membranous urethra. However, in female patients the short course of the urethra behind the osseous pubic arch and its mobility in the pelvic floor afford adequate protection from pelvic trauma. Traumatic urethral rupture may occur after blunt perineal or straddle injury with compression of the urethra against the posteroinferior border of the pubic symphysis and blunt trauma to the anterior aspect of the bony pelvis with posterior displacement of the pubic symphysis and avulsion of the urethra. Rupture of the female urethra should be suspected in the clinical setting of pelvic fractures, deep vaginal lacerations, inability to void or after unsuccessful attempts at catheterization. Failure of catheterization should be followed by retrograde urethrography. IVP and, when possible, cystography are necessary to evaluate potential concomitant urologic injury. The implications of injury on subsequent continence are determined by the level of urethral rupture. The primary mechanism of continence in the female subject is the bladder neck, while secondary continence is maintained by the intrinsic urethral mechanism and the striated external urethral sphincter. 13 Surgical repair is directed at restoration of urethral continuity and preservation of continence. This is accomplished most easily transvaginally, recognizing the limitations imposed by associated injury to the pelvic girdle and lower extremities. Urethral rupture may be incomplete or complete. Partial urethral rupture may be repaired by layered closure of the vagina over a stenting urethral catheter. There are 2 types of complete ruptures and initial management is dependent upon the level of injury. Rupture of the proximal urethra is 1 type, which is managed ideally through a transvaginal approach with debridement and end-to-end anastomosis over a stenting urethral catheter. A
560
TRAUMATIC RUPTURE OF FEMALE URETHRA
layered closure of the overlying vaginal laceration is accomplished. Associated bladder neck disruption requires retropubic exploration with attempted anatomic reconstruction of the bladder neck over a stenting catheter. Immediate attempts at reconstruction of the urethra with bladder flap procedures have significant morbidity in the fractured and unstable pelvis as demonstrated in case 1. The second type is rupture of the distal urethra in which the continence mechanism is not at risk and surgical repair is directed at establishing an adequate external meatus by either of 2 methods: catheterization of the proximal urethral stump with closure of the vaginal laceration around the neomeatus or urethral advancement and development of a neomeatus. Postoperative complications may include an anastomotic stricture, fistula or incontinence. A urethral stricture has been managed easily with infrequent dilations. Vaginal hypospadias or a urethrovaginal fistula below the distal urethral sphincteric mechanism will not effect continence provided that the bladder neck remains competent. An incompetent bladder neck associated with injury to the urethral sphincter will result in incontinence and may require cystourethral suspensions, bladder neck plications and/or bladder flap urethroplasties. These procedures should be postponed until 3 to 6 months after the initial injury. REFERENCES
1. Persky, L. and Hoch, W. H.: Genitourinary tract trauma. Curr.
561
Prob. Surg., pp. 1-64, September 1972. 2. Hamm, F. C. and Waterhouse, K.: Injuries to the genital tract. In: Urology. Edited by M. F. Campbell. Philadelphia: W. B. Saunders Co., vol. 2, p. 878, 1963. 3. Bolgar, G. C., Duncan, R. E. and Evans, A. T.: Primary repair of completely transected female urethra by advancement. J. Urol., 118: 118, 1977. 4. Buxton, R. A.: Rupture of the urethra in a female child with a fractured pelvis: a case report. Injury, 9: 209, 1977. 5. Casselman, R. C. and Schillinger, J. F.: Fractured pelvis with avulsion of the female urethra. J. Urol., 117: 385, 1977. 6. Chatelain, C., Giuli, R., Farge, C. and Kiiss, R.: Rupture traumatique de l'urethre feminin associee a une fracture du bassin interessant le bloc pubo-symphysaire. J. Urol. Nephrol., 76: 108, 1970. 7. Jung, F. and Jung, A.: Rupture accidentelle de l'uretre feminin. J. Urol. Nephrol., 72: 709, 1966. 8. Shah, N. S. and Shah, H. N.: Accidental avulsion of the female urethra. J. Ind. Med. Ass., 52: 434, 1969. 9. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. 10. Tank, E. S., Eraklis, A. J. and Gross, R. E.: Blunt abdominal trauma in infancy and childhood. J. Trauma, 8: 439, 1968. 11. Simpson-Smith, A.: Traumatic rupture of the urethra: eight personal cases with a review of 381 recorded ruptures. Brit. J. Surg., 24: 309, 1936. 12. Williams, D. I.: Rupture of the female urethra in childhood. Eur. Urol., 1: 129, 1975. 13. Lapides, J .: Structure and function of the intemal vesical sphincter. J. Urol., 80: 341, 1958.
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
TRAUMATIC RUPTURE OF THE FEMALE URETHRA JACQUES J. BREDAEL, STEPHEN A. KRAMER, LAURENCE K. CLEEVE AND GEORGE D. WEBSTER From the Department of Surgery, Division of Urology, Duke University Medical Center, Durham, North Carolina
ABSTRACT
The clinical course of 4 female patients with complete traumatic rupture of the urethra was evaluated in an effort to propose guide lines for the investigation and initial management of this unusual injury. Treatment modalities are determined by the level of urethral injury and the subsequent effect on continence. We recommend a retropubic approach for bladder neck injuries, a transvaginal approach for proximal urethral ruptures with reanastomosis over a stenting catheter and acceptance of a hypospadiac neomeatus for distal urethral ruptures. Female urethral injuries are associated most commonly with instrumentation, vaginal operations and obstetric complications. 1' 2 Complete rupture of the female urethra occurs infrequently after pelvic trauma and in a review of the literature only isolated case reports were found. 3- 10 A series of 381 patients with traumatic rupture of the urethra included only 7 female subjects, each of whom had incomplete tears. 11 Williams has reported his experience with the late management of female urethral ruptures in children. 12 Herein we review the clinical course of 4 female patients with complete traumatic rupture of the urethra in an effort to propose guide lines for the investigation and initial management of this unusual injury. CASE REPORTS
Case 1. A. N., an 8-year-old girl, was involved in a motor vehicle accident and sustained multiple pelvic fractures, including fractures of both pubic rami. Pelvic examination revealed a deep laceration of the anterior vaginal wall and complete transection of the urethra at the level of the bladder neck. A bladder flap urethroplasty was done through a retropubic approach. Re-exploration was necessary 6 weeks postoperatively because of wound infection and purulent urethral discharge. Intraoperative findings revealed complete slough of the urethra and a new flap was developed. After removal of the urethral catheter the patient failed to void spontaneously and was referred to us for further evaluation. Cystourethroscopy revealed complete obliteration of the neourethra. A suprapubic cystostomy was done, which will be maintained until pubescence, when a transpubic bladder flap urethroplasty will be undertaken. Considering the young age of this patient and the history of 2 unsuccessful reconstructions, it is believed that further tissue maturation will increase the chance of a successful repair. Case 2. H. D., a 7-year-old girl, was hit by a bus and admitted to a local hospital with multiple pelvic fractures and complete transection of the proximal urethra. Retropubic exploration revealed that the proximal two-thirds of the urethra was crushed completely. Primary urethral anastomosis was not possible and a diverting suprapubic cystostomy was done. The patient was referred to us for further evaluation and a bladder flap urethroplasty was done 3 months after the initial injury. Followup 1 year postoperatively revealed that the patient was regaining some degree of bladder control. Case 3. E. W., a 27-year-old woman, sustained multiple pelvic fractures during a motor vehicle accident. Pelvic examination revealed a deep laceration of the anterior vaginal wall and attempted urethral catheterization was unsuccessful. Excretory urography (IVP) was normal. Vaginal exploration revealed complete transection of the proximal urethra. The proximal and distal portions of the urethra were identified and a primary Accepted for publication January 19, 1979.
end-to-end anastomosis was done over a stenting urethral catheter. Postoperatively, an anastomotic stricture developed but has responded to urethral dilation. The patient remains continent and voids without difficulty. Case 4. D. G., a 19-year-old woman, was involved in a motor vehicle accident and sustained multiple extremity fractures and a non-displaced right acetabular fracture. Pelvic examination revealed a large perineal hematoma, a deep laceration of the anterior vaginal wall and left labia majora, and complete transection of the distal urethra. After evacuation of the vaginal hematoma a urethral catheter was inserted into the proximal urethral stump. IVP and cystography were normal. The vaginal laceration was closed primarily and the urethral catheter was removed 10 days postoperatively. The patient remains continent and voids without difficulty through the neomeatus. DISCUSSION
A pelvic fracture in the male patient commonly results in injury to the prostatomembranous urethra owing to rigid fixation of the prostate to the pubis by the puboprostatic ligaments and the lack of mobility of the membranous urethra. However, in female patients the short course of the urethra behind the osseous pubic arch and its mobility in the pelvic floor afford adequate protection from pelvic trauma. Traumatic urethral rupture may occur after blunt perineal or straddle injury with compression of the urethra against the posteroinferior border of the pubic symphysis and blunt trauma to the anterior aspect of the bony pelvis with posterior displacement of the pubic symphysis and avulsion of the urethra. Rupture of the female urethra should be suspected in the clinical setting of pelvic fractures, deep vaginal lacerations, inability to void or after unsuccessful attempts at catheterization. Failure of catheterization should be followed by retrograde urethrography. IVP and, when possible, cystography are necessary to evaluate potential concomitant urologic injury. The implications of injury on subsequent continence are determined by the level of urethral rupture. The primary mechanism of continence in the female subject is the bladder neck, while secondary continence is maintained by the intrinsic urethral mechanism and the striated external urethral sphincter. 13 Surgical repair is directed at restoration of urethral continuity and preservation of continence. This is accomplished most easily transvaginally, recognizing the limitations imposed by associated injury to the pelvic girdle and lower extremities. Urethral rupture may be incomplete or complete. Partial urethral rupture may be repaired by layered closure of the vagina over a stenting urethral catheter. There are 2 types of complete ruptures and initial management is dependent upon the level of injury. Rupture of the proximal urethra is 1 type, which is managed ideally through a transvaginal approach with debridement and end-to-end anastomosis over a stenting urethral catheter. A
560
TRAUMATIC RUPTURE OF FEMALE URETHRA
layered closure of the overlying vaginal laceration is accomplished. Associated bladder neck disruption requires retropubic exploration with attempted anatomic reconstruction of the bladder neck over a stenting catheter. Immediate attempts at reconstruction of the urethra with bladder flap procedures have significant morbidity in the fractured and unstable pelvis as demonstrated in case 1. The second type is rupture of the distal urethra in which the continence mechanism is not at risk and surgical repair is directed at establishing an adequate external meatus by either of 2 methods: catheterization of the proximal urethral stump with closure of the vaginal laceration around the neomeatus or urethral advancement and development of a neomeatus. Postoperative complications may include an anastomotic stricture, fistula or incontinence. A urethral stricture has been managed easily with infrequent dilations. Vaginal hypospadias or a urethrovaginal fistula below the distal urethral sphincteric mechanism will not effect continence provided that the bladder neck remains competent. An incompetent bladder neck associated with injury to the urethral sphincter will result in incontinence and may require cystourethral suspensions, bladder neck plications and/or bladder flap urethroplasties. These procedures should be postponed until 3 to 6 months after the initial injury. REFERENCES
1. Persky, L. and Hoch, W. H.: Genitourinary tract trauma. Curr.
561
Prob. Surg., pp. 1-64, September 1972. 2. Hamm, F. C. and Waterhouse, K.: Injuries to the genital tract. In: Urology. Edited by M. F. Campbell. Philadelphia: W. B. Saunders Co., vol. 2, p. 878, 1963. 3. Bolgar, G. C., Duncan, R. E. and Evans, A. T.: Primary repair of completely transected female urethra by advancement. J. Urol., 118: 118, 1977. 4. Buxton, R. A.: Rupture of the urethra in a female child with a fractured pelvis: a case report. Injury, 9: 209, 1977. 5. Casselman, R. C. and Schillinger, J. F.: Fractured pelvis with avulsion of the female urethra. J. Urol., 117: 385, 1977. 6. Chatelain, C., Giuli, R., Farge, C. and Kiiss, R.: Rupture traumatique de l'urethre feminin associee a une fracture du bassin interessant le bloc pubo-symphysaire. J. Urol. Nephrol., 76: 108, 1970. 7. Jung, F. and Jung, A.: Rupture accidentelle de l'uretre feminin. J. Urol. Nephrol., 72: 709, 1966. 8. Shah, N. S. and Shah, H. N.: Accidental avulsion of the female urethra. J. Ind. Med. Ass., 52: 434, 1969. 9. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. 10. Tank, E. S., Eraklis, A. J. and Gross, R. E.: Blunt abdominal trauma in infancy and childhood. J. Trauma, 8: 439, 1968. 11. Simpson-Smith, A.: Traumatic rupture of the urethra: eight personal cases with a review of 381 recorded ruptures. Brit. J. Surg., 24: 309, 1936. 12. Williams, D. I.: Rupture of the female urethra in childhood. Eur. Urol., 1: 129, 1975. 13. Lapides, J .: Structure and function of the intemal vesical sphincter. J. Urol., 80: 341, 1958.
