9. How would you manage an injury to the urethra?
Correct answer:
Satisfactory management depends on a high index of suspicion leading to early diagnosis, as extravasation of urine is liable to lead to secondary infection, which will greatly complicate the condition. The presence of bleeding from the meatus, or a fracture of the pelvis, combined with urinary retention, should alert to the possibility.
Initial management. (1) A rectal examination is performed to determine whether the prostate is palpable and in the normal position. An absent or high prostate implies a complete rupture of the membranous urethra, and urgent exploration is indicated. (2) A urethrogram is performed using water-soluble contrast medium to identify any extravasation or loss of continuity, and localize the site of injury. (3) Contrast-enhanced computed tomography is usually required to evaluate the pelvic injuries fully. (4) The ABC of resuscitation should not be forgotten, since many of these injuries occur in conjunction with a pelvic fracture.
Membranous urethral injuries. (1) Complete rupture, in which rectal examination confirms that the prostate (and therefore bladder) is floating out of the pelvis. Initial management is the passage of a suprapubic catheter. Subsequent management depends on the associated injuries, for example whether the pelvis is to be fixed by internal fixation. Surgery is performed either early, around the time of the pelvic fixation, or after an interval of around 6 weeks. Primary anastomosis is rarely possible. Instead, the base of the bladder and the urethra are approximated. The retropubic space is explored and haematoma evacuated. A urethral catheter is passed and railroaded into the bladder. The bladder is approximated to the ruptured urethra by means of sutures in the anterior prostatic capsule. The urethral catheter will remain in situ for 2 weeks. (2) Incomplete rupture. If there is little extravasation, and continuity is preserved, a well-lubricated urethral catheter should be passed carefully, and left in place for 10 days.
Bulbous urethral injuries. (1) Complete rupture. A complete laceration is an indication for urgent open repair, with suture of the tear and diversion of the urinary stream by suprapubic drainage. (2) Incomplete rupture. If there is little extravasation, and continuity is preserved, a well-lubricated urethral catheter may be passed carefully, and left in place for 10 days. Alternatively a suprapubic catheter can be inserted.
