Urethral trauma V. COLAPINTO, MD, B SC (MED), FAGS, FRCS[C]
The male urethra can be divided into two portions - anterior and posterior. The anterior urethra is a relatively simple tube extending from the external urethral meatus to the surface of the urogenital diphragm. As with any tubular conduit in the body, the consequences of rupture of the anterior urethra are twofold: first, extravasation of urine when the patient voids and, second, stricture (stenosis) of the urethra by fibrous tissue as healing occurs. The posterior urethra is much more complex. It comprises the membranous urethra, which passes through the urogenital diaphragm to the apex of the prostate, and the prostatic urethra, which passes to the bladder neck. The smooth muscle sphincters that control passive urinary continence are in the posterior urethra, one at the bladder neck (internal sphincter) and the other at the membranous urethra (intrinsic sphincter) (Fig. 1). The posterior urethra is intimately related to the autonomic nerves that govern penile erection. Consequently, when the posterior urethra is injured, in addition to extravasation and stricture sexual impotence and incontinence may result. Classification and management
Injury via the urethral lumen By far the most common urethral injuries are those sustained via the urethral lumen. Most are iatrogenic and the usual result is urethral stricture. Indwelling catheters: These may cause infection in the urethral wall and pressure necrosis, particularly at the penoscrotal junction. Transurethral surgery: The anterior urethra may be injured by large instruments that cause ischemia and pressure necrosis of the urethral wall. Posterior urethral injury may occur during prostatectomy, and if both sphincters are injured incontinence may result. Self-inflicted: A small percentage of urethral injuries are self-inflicted by the insertion into the urethra of various household articles for erotic purposes. Chemical: Fortunately chemical instillations are no longer given as treatment of urethral diseases. In the past considerable damage was inflicted to the urethra by such treatment. Penetrating wounds Urethral injury due to penetrating wounds is rare in peace time. With a Reprint requests to: Dr. V. Colapinto, 170 St. George St., Ste. 724, Toronto, Ont. M5R 2M8
penetrating wound of the external genitalia it is necessary to determine whether the urethra has been injured. Blood discharging from the external urethral meatus is the most important clinical finding. Retrograde urethrography will demonstrate extravasion if the urethra is ruptured, or irregularity of the wall if the urethra has only been contused. D.bridement and primary repair are then carried out. The urinary stream must be diverted from the site of injury for 10 to 14 days, ideally by suprapubic cystostomy. Most penetrating wounds of the urethra occur in the anterior portion. Those of the posterior urethra are usually caused by an object's being thrust upwards through the perineum. It is almost impossible for the posterior urethra to be damaged by means of an abdominal wound because of the protection afforded by the pubis. Penetrating injuries to the posterior urethra via the perineum are frequently accompanied by injuries to bowel, bladder and rectum and require skilful diagnosis and management. Blunt trauma Straddle injury: This injury occurs when an individual falls astride a rigid object, thereby crushing the bulbus urethrae against the underside of the bony pubic arch. The lesion varies from contusion to complete severance of the urethra. Diagnosis depends on the history and the finding of blood at the external urethral meatus. Retrograde urethrography will demonstrate extravasation if rupture has occurred. If the rupture is minor a urethral catheter will usually pass into the bladder; 7 to 10 days' drainage with the catheter is sufficient treatment. However, a more serious rupture will prevent passage of a cath-
FIG. 1-Sphincters of posterior urethra. (From "Urological Radiology of the Adult Male Lower Urinary Tract"1 with permission of coauthor and publisher.)
eter; perineal exploration should be done and simple lesions repaired primarily. In either situation the risk of subsequent stricture formation is high, and follow-up urethrography 12 months later is recommended in all cases. Extensive rupture is best treated initially by exteriorizing the wound by firststage urethroplasty for later closure. Fractured pelvis: With these fractures urethral lesions occur in the posterior urethra, most commonly in the membranous urethral segment. The shearing forces that develop as the pubic bones move during these severe crushing injuries tend to rupture the membranous urethra and the urogenital diaphragm, which surrounds it. The adjacent bulbus urethrae is often injured as well. If the puboprostatic ligaments are also torn the prostate becomes freely mobile and may be dislocated in any direction. These fractures usually result in very heavy retroperitoneal bleeding leading to a large but concealed intrapelvic hematoma. The attending physician must be aware of the potential blood loss and be prepared for rapid transfusion. The hematoma may elevate the dislocated prostate high into the pelvis. Diagnosis of posterior urethral injury in a patient with a fractured pelvis is based on the following findings: (a) blood at the external urethral meatus, (b) inability of the patient to void and (c) hypermobility or elevation of the prostate above its normal position as assessed from rectal examination. Experience has demonstrated that these signs taken together indicate, with a high degree of accuracy, injury to the posterior urethra in patients with a fractured pelvis. However, the degree and exact site of injury cannot accurately be determined without retrograde urethrography, a procedure done easily in any emergency department. A small Foley catheter balloon is inflated just inside the urethral meatus with 2 mL of fluid. Contrast medium is then injected in 10-mL increments while films are exposed; thus a dynamic study is obtained. We have found this technique to be valuable in the diagnosis and classification of posterior urethral injury in patients with a fractured pelvis (Fig. 2).1 Attempting to pass a urethral catheter into the bladder in these patients, with or without radiographic control, is to be condemned. Not only is the practice potentially injurious, but also the information obtained is usually confusing or misleading.
CMA JOURNAL/OCTOBER 8, 1977/VOL. 117 791
tion relieved only by suprapubic cystostomy; (d) chronic prostatitis; (e) bladder stones and diverticula; (f) ascending infection resulting in pyelonephritis, renal stones and chronic renal failure; (g) periurethral abscess and perineal urinary fistulas; (h) periurethral phiegmon; and (i) squamous carcinoma of the urethra.
ATASOL
Non-ASA AnalgesiclAntipyretic With or Without Codeine Acetaminophen INDICATIONS For the relief of mild to moderate pain of various causes as in: headache, migraine, dental pain, dysmenorrhea, myalgias and neuralgias. Also useful as an antipyretic when fever accompanies painful conditions. CONTRAINDICATIONS Repeated administration to patients with anemia or with cardiac, pulmonary, renal or hepatic disease is contraindicated. PRECAUTIONS It has been reported that acetaminophen potentiates the action of warfarin-type anticoagulants if administered several times daily over a two-week period. This should be borne in mind if the two drugs are administered concurrently. Renal damage has not been reported following the use of acetaminophen in therapeutic doses, but the chemical relationship of this drug to phenacetin cautions against its use in large amounts over protracted periods of time. Although tolerance and addiction to codeine are rare, * Atasol-iS and* Atasol-30 should be prescribed cautiously to addiction-prone individuals. The drug should be administered with caution since the depressant effects of codeine may be enhanced by concurrent administration of sedatives and tranquilizers. ADVERSE REACTIONS These are usually mild and rare. GI. upset, usually rarer than after salicylate administration, and skin reactions are known, and anemia has been reported after chronic ingestion. Usually after larger doses, codeine may cause g.i. symptoms of nausea, vomiting and constipation. DOSAGE AND ADMINISTRATION ATASOL TABLETS 325 mg acetaminophen 1-3 tablets daily Adults: Children: 10-14 years, one-half tablet, 3 times daily ATASOL FORTE TABLETS 500 mg acetaminophen 1-2 tablets as directed by a physician, up Adults: to a maximum of 5 tablets daily ATASOL LIQUID 108 mg acetaminophen/5 ml Children: 5-9 years, usual dose, 1 teaspoon 3 times daily or as directed by a physician to a maximum of 2 teaspoonsful 4 times daily 2-4 years, usual dose, one-half teaspoon 3 times daily or as directed by a physician up to a maximum of 1 teaspoon 4 times daily ATASOL DROPS 54 mg acetaminophen/0.6 ml Children: 2-4 years, usual dose 0.6 ml 3 times daily or as directed by a physician up to a maximum of 1.2 ml 4 times daily 1-2 years, as directed by a physician up to a maximum of 0.6 ml 4 times daily under 1 year, as directed by a physician up to a maximum of 0.3 ml 4 times daily * ATASOL-8 325 mg acetaminophen 8 mg codeine phosphate 30 mg caffeine citrate usual dose, 1 tablet 3 times daily or as Adults: directed by a physician up to a maximum of 2 tablets 4 times daily Children: 10-14 years, usual dose, one-half tablet 3 times daily or as directed by a physician up to a maximum of 1 tablet 4 times daily * ATASOL*15 325 mg acetaminophen 15 mg codeine phosphate 30 mg caffeine citrate 2 to 4 tablets daily or as directed by a Adults: physician * ATASOL-30 325 mg acetaminophen 30 mg codeine phosphate 30 mg caffeine citrate Adults: 2 to 4 tablets daily or as directed by a physician Full information available on request
OHORflER Montreal, Canada
44
NORMAL
TYPE II
j.
.FYPE
TYPEIII
FIG. 2-Classification of membranous urethral injury in patients with fractured pelvis. (From "Urological Radiology of the Adult Male Lower Urinary Tract"' with permission of coauthor and publisher.) The prime requisite in management
is diversion of the urinary stream by suprapubic cystostomy. If the surgeon is experienced in treating these injuries he should try to re-establish urethral continuity over a urethral catheter but must take great care not to damage the bladder neck (internal sphincter). Complications
Extravasation of urine Small quantities of extravasated urine may be reabsorbed by the body with little tissue damage. However, large quantities of urine (200 mL or more) can result in tissue necrosis and suppuration even when the extravasated urine is sterile initially. If the extravasated urine is infected, rapidly spreading cellulitis, gangrene of the skin and fatal septicemia may occur (periurethral phlegmon). Urethral stricture The end result of every urethral injury, if inadequately treated, is urethral stricture. It is a common lesion and generally regarded casually by the medical profession, but urologists are aware of its potential serious complications: (a) difficulty in voiding, requiring dilatation several times a year for an indefinite period; (b) painful, difficult dilatations causing further scarring, false passages, bleeding, bacteremia or septicemia; (c) episodes of acute reten-
792 CMA JOURNAL/OCTOBER 8, 1977/VOL. 117
Complications specific to posterior urethral rupture Impotence: The incidence of sexual impotence is high (approximately 40%) in patients with rupture of the posterior urethra.2 The patients are unable to obtain a functional erection, presumably owing to injury of the parasympathetic nervi erigentes as they traverse the prostate and urogenital diaphragm. Incontinence of urine: Rupture of the membranous urethra invariably damages the intrinsic urethral sphincter (Fig. 1). However, passive urinary continence will be preserved unless the internal sphincter (bladder neck) is also damaged by the accident or by subsequent surgical interference. Conclusion The diagnosis of urethral injury requires knowledge of urethral anatomy, modes of injury, clinical signs and urethrographic appearance of the lesions. Management is founded on diverting the urinary stream from the site of injury with a urethral catheter or cystostomy tube or exteriorization by urethroplasty. Awareness of the possible complications is essential to intelligent management. References 1. MccALLUM RW, COLAPINTO V: Urological Radiology of the Adult Male Lower Urinary Tract, Springfield, IL, CC Thomas, 1976 2. GIBsoN GR: Impotence following fractured pelvis and ruptured urethra. Br .! Urol 42: 86, 1970
Correction In the r6sum6 of "Coronary artery surgery. 2. Results, indications and recommendations" (Can Med A ssoc 1 117: 455, 1977) a line was omitted inadvertently by the printer in the last stage of production. The sentence (with the missing portion in italics) should read: "La grande majorit. des etudes rapport.es portant sur le traitement de malades par pontage aortocoronarien n'ont pas 6t6 des 6preuves cliniques avec partitions al6atoires des sujets entre le traitement medical et le traitement chirurgical ."
The male urethra can be divided into two portions - anterior and posterior. The anterior urethra is a relatively simple tube extending from the external urethral meatus to the surface of the urogenital diphragm. As with any tubular conduit in the body, the consequences of rupture of the anterior urethra are twofold: first, extravasation of urine when the patient voids and, second, stricture (stenosis) of the urethra by fibrous tissue as healing occurs. The posterior urethra is much more complex. It comprises the membranous urethra, which passes through the urogenital diaphragm to the apex of the prostate, and the prostatic urethra, which passes to the bladder neck. The smooth muscle sphincters that control passive urinary continence are in the posterior urethra, one at the bladder neck (internal sphincter) and the other at the membranous urethra (intrinsic sphincter) (Fig. 1). The posterior urethra is intimately related to the autonomic nerves that govern penile erection. Consequently, when the posterior urethra is injured, in addition to extravasation and stricture sexual impotence and incontinence may result. Classification and management
Injury via the urethral lumen By far the most common urethral injuries are those sustained via the urethral lumen. Most are iatrogenic and the usual result is urethral stricture. Indwelling catheters: These may cause infection in the urethral wall and pressure necrosis, particularly at the penoscrotal junction. Transurethral surgery: The anterior urethra may be injured by large instruments that cause ischemia and pressure necrosis of the urethral wall. Posterior urethral injury may occur during prostatectomy, and if both sphincters are injured incontinence may result. Self-inflicted: A small percentage of urethral injuries are self-inflicted by the insertion into the urethra of various household articles for erotic purposes. Chemical: Fortunately chemical instillations are no longer given as treatment of urethral diseases. In the past considerable damage was inflicted to the urethra by such treatment. Penetrating wounds Urethral injury due to penetrating wounds is rare in peace time. With a Reprint requests to: Dr. V. Colapinto, 170 St. George St., Ste. 724, Toronto, Ont. M5R 2M8
penetrating wound of the external genitalia it is necessary to determine whether the urethra has been injured. Blood discharging from the external urethral meatus is the most important clinical finding. Retrograde urethrography will demonstrate extravasion if the urethra is ruptured, or irregularity of the wall if the urethra has only been contused. D.bridement and primary repair are then carried out. The urinary stream must be diverted from the site of injury for 10 to 14 days, ideally by suprapubic cystostomy. Most penetrating wounds of the urethra occur in the anterior portion. Those of the posterior urethra are usually caused by an object's being thrust upwards through the perineum. It is almost impossible for the posterior urethra to be damaged by means of an abdominal wound because of the protection afforded by the pubis. Penetrating injuries to the posterior urethra via the perineum are frequently accompanied by injuries to bowel, bladder and rectum and require skilful diagnosis and management. Blunt trauma Straddle injury: This injury occurs when an individual falls astride a rigid object, thereby crushing the bulbus urethrae against the underside of the bony pubic arch. The lesion varies from contusion to complete severance of the urethra. Diagnosis depends on the history and the finding of blood at the external urethral meatus. Retrograde urethrography will demonstrate extravasation if rupture has occurred. If the rupture is minor a urethral catheter will usually pass into the bladder; 7 to 10 days' drainage with the catheter is sufficient treatment. However, a more serious rupture will prevent passage of a cath-
FIG. 1-Sphincters of posterior urethra. (From "Urological Radiology of the Adult Male Lower Urinary Tract"1 with permission of coauthor and publisher.)
eter; perineal exploration should be done and simple lesions repaired primarily. In either situation the risk of subsequent stricture formation is high, and follow-up urethrography 12 months later is recommended in all cases. Extensive rupture is best treated initially by exteriorizing the wound by firststage urethroplasty for later closure. Fractured pelvis: With these fractures urethral lesions occur in the posterior urethra, most commonly in the membranous urethral segment. The shearing forces that develop as the pubic bones move during these severe crushing injuries tend to rupture the membranous urethra and the urogenital diaphragm, which surrounds it. The adjacent bulbus urethrae is often injured as well. If the puboprostatic ligaments are also torn the prostate becomes freely mobile and may be dislocated in any direction. These fractures usually result in very heavy retroperitoneal bleeding leading to a large but concealed intrapelvic hematoma. The attending physician must be aware of the potential blood loss and be prepared for rapid transfusion. The hematoma may elevate the dislocated prostate high into the pelvis. Diagnosis of posterior urethral injury in a patient with a fractured pelvis is based on the following findings: (a) blood at the external urethral meatus, (b) inability of the patient to void and (c) hypermobility or elevation of the prostate above its normal position as assessed from rectal examination. Experience has demonstrated that these signs taken together indicate, with a high degree of accuracy, injury to the posterior urethra in patients with a fractured pelvis. However, the degree and exact site of injury cannot accurately be determined without retrograde urethrography, a procedure done easily in any emergency department. A small Foley catheter balloon is inflated just inside the urethral meatus with 2 mL of fluid. Contrast medium is then injected in 10-mL increments while films are exposed; thus a dynamic study is obtained. We have found this technique to be valuable in the diagnosis and classification of posterior urethral injury in patients with a fractured pelvis (Fig. 2).1 Attempting to pass a urethral catheter into the bladder in these patients, with or without radiographic control, is to be condemned. Not only is the practice potentially injurious, but also the information obtained is usually confusing or misleading.
CMA JOURNAL/OCTOBER 8, 1977/VOL. 117 791
tion relieved only by suprapubic cystostomy; (d) chronic prostatitis; (e) bladder stones and diverticula; (f) ascending infection resulting in pyelonephritis, renal stones and chronic renal failure; (g) periurethral abscess and perineal urinary fistulas; (h) periurethral phiegmon; and (i) squamous carcinoma of the urethra.
ATASOL
Non-ASA AnalgesiclAntipyretic With or Without Codeine Acetaminophen INDICATIONS For the relief of mild to moderate pain of various causes as in: headache, migraine, dental pain, dysmenorrhea, myalgias and neuralgias. Also useful as an antipyretic when fever accompanies painful conditions. CONTRAINDICATIONS Repeated administration to patients with anemia or with cardiac, pulmonary, renal or hepatic disease is contraindicated. PRECAUTIONS It has been reported that acetaminophen potentiates the action of warfarin-type anticoagulants if administered several times daily over a two-week period. This should be borne in mind if the two drugs are administered concurrently. Renal damage has not been reported following the use of acetaminophen in therapeutic doses, but the chemical relationship of this drug to phenacetin cautions against its use in large amounts over protracted periods of time. Although tolerance and addiction to codeine are rare, * Atasol-iS and* Atasol-30 should be prescribed cautiously to addiction-prone individuals. The drug should be administered with caution since the depressant effects of codeine may be enhanced by concurrent administration of sedatives and tranquilizers. ADVERSE REACTIONS These are usually mild and rare. GI. upset, usually rarer than after salicylate administration, and skin reactions are known, and anemia has been reported after chronic ingestion. Usually after larger doses, codeine may cause g.i. symptoms of nausea, vomiting and constipation. DOSAGE AND ADMINISTRATION ATASOL TABLETS 325 mg acetaminophen 1-3 tablets daily Adults: Children: 10-14 years, one-half tablet, 3 times daily ATASOL FORTE TABLETS 500 mg acetaminophen 1-2 tablets as directed by a physician, up Adults: to a maximum of 5 tablets daily ATASOL LIQUID 108 mg acetaminophen/5 ml Children: 5-9 years, usual dose, 1 teaspoon 3 times daily or as directed by a physician to a maximum of 2 teaspoonsful 4 times daily 2-4 years, usual dose, one-half teaspoon 3 times daily or as directed by a physician up to a maximum of 1 teaspoon 4 times daily ATASOL DROPS 54 mg acetaminophen/0.6 ml Children: 2-4 years, usual dose 0.6 ml 3 times daily or as directed by a physician up to a maximum of 1.2 ml 4 times daily 1-2 years, as directed by a physician up to a maximum of 0.6 ml 4 times daily under 1 year, as directed by a physician up to a maximum of 0.3 ml 4 times daily * ATASOL-8 325 mg acetaminophen 8 mg codeine phosphate 30 mg caffeine citrate usual dose, 1 tablet 3 times daily or as Adults: directed by a physician up to a maximum of 2 tablets 4 times daily Children: 10-14 years, usual dose, one-half tablet 3 times daily or as directed by a physician up to a maximum of 1 tablet 4 times daily * ATASOL*15 325 mg acetaminophen 15 mg codeine phosphate 30 mg caffeine citrate 2 to 4 tablets daily or as directed by a Adults: physician * ATASOL-30 325 mg acetaminophen 30 mg codeine phosphate 30 mg caffeine citrate Adults: 2 to 4 tablets daily or as directed by a physician Full information available on request
OHORflER Montreal, Canada
44
NORMAL
TYPE II
j.
.FYPE
TYPEIII
FIG. 2-Classification of membranous urethral injury in patients with fractured pelvis. (From "Urological Radiology of the Adult Male Lower Urinary Tract"' with permission of coauthor and publisher.) The prime requisite in management
is diversion of the urinary stream by suprapubic cystostomy. If the surgeon is experienced in treating these injuries he should try to re-establish urethral continuity over a urethral catheter but must take great care not to damage the bladder neck (internal sphincter). Complications
Extravasation of urine Small quantities of extravasated urine may be reabsorbed by the body with little tissue damage. However, large quantities of urine (200 mL or more) can result in tissue necrosis and suppuration even when the extravasated urine is sterile initially. If the extravasated urine is infected, rapidly spreading cellulitis, gangrene of the skin and fatal septicemia may occur (periurethral phlegmon). Urethral stricture The end result of every urethral injury, if inadequately treated, is urethral stricture. It is a common lesion and generally regarded casually by the medical profession, but urologists are aware of its potential serious complications: (a) difficulty in voiding, requiring dilatation several times a year for an indefinite period; (b) painful, difficult dilatations causing further scarring, false passages, bleeding, bacteremia or septicemia; (c) episodes of acute reten-
792 CMA JOURNAL/OCTOBER 8, 1977/VOL. 117
Complications specific to posterior urethral rupture Impotence: The incidence of sexual impotence is high (approximately 40%) in patients with rupture of the posterior urethra.2 The patients are unable to obtain a functional erection, presumably owing to injury of the parasympathetic nervi erigentes as they traverse the prostate and urogenital diaphragm. Incontinence of urine: Rupture of the membranous urethra invariably damages the intrinsic urethral sphincter (Fig. 1). However, passive urinary continence will be preserved unless the internal sphincter (bladder neck) is also damaged by the accident or by subsequent surgical interference. Conclusion The diagnosis of urethral injury requires knowledge of urethral anatomy, modes of injury, clinical signs and urethrographic appearance of the lesions. Management is founded on diverting the urinary stream from the site of injury with a urethral catheter or cystostomy tube or exteriorization by urethroplasty. Awareness of the possible complications is essential to intelligent management. References 1. MccALLUM RW, COLAPINTO V: Urological Radiology of the Adult Male Lower Urinary Tract, Springfield, IL, CC Thomas, 1976 2. GIBsoN GR: Impotence following fractured pelvis and ruptured urethra. Br .! Urol 42: 86, 1970
Correction In the r6sum6 of "Coronary artery surgery. 2. Results, indications and recommendations" (Can Med A ssoc 1 117: 455, 1977) a line was omitted inadvertently by the printer in the last stage of production. The sentence (with the missing portion in italics) should read: "La grande majorit. des etudes rapport.es portant sur le traitement de malades par pontage aortocoronarien n'ont pas 6t6 des 6preuves cliniques avec partitions al6atoires des sujets entre le traitement medical et le traitement chirurgical ."
