Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of the publication date. However, because EAU updates their guidelines frequently, users may wish to consult the EAU Web site for the most current version available.
Levels of evidence (1a-4) are defined at the end of the "Major Recommendations" field.
Diagnosis: Initial Emergency Assessment
The initial management of urethral injury is resuscitation of the patient. In the absence of blood at the meatus or genital haematoma, a urological injury is very unlikely and is excluded by catheterisation. Maintain airway and respiratory function, secure the cervical spine if necessary, and address blood loss if present. This is particularly important in posterior urethral injuries because of their close association with pelvic fractures.
The next step includes taking a complete history and carrying out physical, laboratory and radiographic evaluations in order to identify all injuries accurately. A diagnosis of acute urethral trauma should be suspected from the history. A pelvic fracture, or any external penile or perineal trauma, can be suggestive of urethral trauma.
For penetrating injuries, the type of weapon used, including the calibre of the bullet, is helpful in assessing potential tissue damage. In a conscious patient, a thorough voiding history should be obtained to establish the time of last urination, the force of the urinary stream, whether urination is painful and whether haematuria is present.
The following clinical indicators of acute urethral trauma warrant a complete urethral evaluation:
- Blood at the meatus
- Blood at the vaginal introitus
- Pain on urination or inability to void
- Haematoma or swelling
- High-riding prostate
Retrograde urethrography is the gold standard for evaluating urethral injury. A scout film should be performed first to assess the radiographic technique, and to detect pelvic fractures and foreign bodies, such as bullets. This is performed using a Foley catheter in the fossa navicularis, with the balloon inflated using 1-2 mL of saline to occlude the urethra. Then, 20-30 mL of contrast material is injected while films are taken in a 30° oblique position. When severe pelvic fractures and associated patient discomfort are present, the oblique position may not always be possible. The radiographic appearance of the urethra permits classification of the injury and facilitates the subsequent management.
If posterior urethral injury is suspected, a suprapubic catheter is inserted. Later on, a simultaneous cystogram and ascending urethrogram can be carried out to assess the site, severity and length of the urethral injury. This is usually done after 3 months if a delayed repair is considered.
When the proximal urethra is not visualised in a simultaneous cystogram and urethrogram, either magnetic resonance imaging (MRI) of the posterior urethra or endoscopy through the suprapubic tract is used to define the anatomy of the posterior urethra. Since manipulation in the bladder can cause the bladder neck to open and give the false impression of incompetence, the endoscopic appearance of the bladder neck should be noted immediately on placing the scope into the bladder.
After assessing the endoscopic appearance of the bladder neck, the flexible endoscope can be advanced through the bladder neck into the posterior urethra to the level of obstruction. If there is a question about the length of the distraction, a simultaneous retrograde urethrogram can be performed while the endoscope is in the posterior urethra. The radiographic appearance of the bladder neck is important, but is not as reliable an indicator of continence as the endoscopic appearance is. Furthermore, there are patients who, despite evidence of an open or scarred bladder neck, will have acceptable continence after reconstruction. For this reason, the need for concomitant bladder neck surgery at the time of urethral reconstruction is debatable.
Ultrasonography is not a routine investigation in the initial assessment of urethral injuries but can be very useful in determining the position of pelvic haematomas, or the exact location of the bladder when a suprapubic catheter is indicated.
Computed tomography (CT) and MRI have no place in the initial assessment of urethral injuries. However, they are useful in defining distorted pelvic anatomy after severe injury and assessing associated injuries of penile crura, bladder, kidneys and intra-abdominal organs.
Urethroscopy does not have any role in the initial diagnosis of urethral trauma in males. In females, however, where the short urethra precludes adequate retrograde urethrography, urethroscopy is an important adjunct to the physical examination for the identification and staging of urethral injuries.
Anterior Urethral Injuries
Partial tears can be managed with a suprapubic catheter or with urethral catheterisation. Suprapubic cystostomy has the advantage that it not only diverts the urine away from the site of injury, but also avoids urethral manipulation, as well as allowing for a simultaneous study to be carried out at a later date.
If the bladder is not easily palpable suprapubically, transabdominal sonography should be used to guide the placement of the catheter. The cystostomy tube is maintained for approximately 4 weeks to allow urethral healing. Voiding cystourethrography is then performed. Remove the suprapubic tube if normal voiding can be re-established and neither contrast extravasation nor stricture is present.
The potential early complications of acute urethral injuries include strictures and infections.
Extravasated blood or urine from the urethral tear produces an inflammatory reaction that can progress to the formation of an abscess. The extent of the infection depends on the fascial planes violated. The potential sequelae of these infections include urethrocutaneous fistulae, peri-urethral diverticulae and, rarely, necrotising fasciitis. Prompt urinary diversion coupled with the appropriate administration of antibiotics decreases the incidence of these complications.
After the patient has adequately recovered from any associated injuries, and the urethral injury has stabilised, the urethra can be thoroughly re-evaluated radiographically. When necessary, the appropriate reconstructive procedure is planned.
Blunt anterior urethral injuries are associated with spongiosal contusion, which makes it more difficult to evaluate the limits of urethral debridement in the acute phase. Acute or early urethroplasty is therefore not indicated, and the best management is simply suprapubic diversion.
Satisfactory urethral luminal recanalisation occurs in approximately 50% of partial anterior urethral disruptions. Short and flimsy strictures are managed with optical urethrotomy or urethral dilatation. Denser strictures require formal urethral reconstruction. Anastomotic urethroplasty is indicated in strictures of less than 1 cm in length.
Longer strictures of the anterior urethra should not be repaired by an end-to-end anastomosis, in order to avoid chordee. In these cases, flap urethroplasty is indicated. Almost all complete ruptures of the anterior urethra require anastomotic or patch urethroplasty at 3-6 months. The only exception to this is urethral injury associated with penile fracture; this usually results in partial urethral disruption and can be repaired at the time of cavernosal closure.
Male Urethral Injuries
Stab wounds, gunshot wounds and dog bites to the urethra often involve the penis and testes and often require immediate exploration. During surgery, the urethral injury can be surgically evaluated and repaired as needed. Urethral strictures form in fewer than 15% of these patients.
Primary urethral suturing involves direct visualisation of the severed urethral ends and creation of a watertight, tension-free repair. The patient should be in a supine position. Use a circumferential subcoronal incision to deglove the penis.
In complete disruptions, the corpus spongiosum is mobilised at the level of the injury and the urethral ends dissected distally and proximally. Urethral ends are spatulated, and end-to-end anastomosis is fashioned over 14 French Foley catheter. Suture small lacerations with fine absorbable material. Careful overclosure of the corpus spongiosum and skin prevents the subsequent formation of fistulae. Keep urethral debridement to a minimum since the spongiosum is well vascularised and will usually heal well.
As with any surgery, give pre-operative antimicrobial prophylaxis. Some experts recommend the post-operative continuation of prophylactic antibiotics, but the guideline panel is not aware of any data that prove that they help. After 10-14 days, obtain a peri-catheter retrograde urethrogram with the urethral catheter in situ. Provided there is no leakage at the anastomotic site, remove the urethral catheter. If there is leakage, leave the catheter in and repeat the cystourethrogram 1 week later.
If the urethra is so extensively disrupted that primary anastomosis is not feasible, then primary repair should be aborted. This occurs with defects of more than 1-1.5 cm in length. One should marsupialise the urethra preparatory to a two-stage urethral repair, and consider a suprapubic urinary diversion. Perform a delayed elective procedure a minimum of 3 months after injury. There is no role for acute placement of a graft or flap in the initial management of any urethral injury, since contamination or decreased blood supply can compromise such a repair.
Female Urethral Injuries
Most female urethral disruptions can be sutured primarily. These injuries often occur together with bladder ruptures. Frequently, if the bladder injury is going to be repaired primarily, the urethral disruption can be repaired at the same time. For proximal urethral injuries, urethral exposure is best obtained transvesically. Distal urethral injuries can be approached vaginally. Early repair of post-traumatic urethral fistulae can also be accomplished transvaginally.
Posterior Urethral Injuries
It is important to distinguish between inflammatory or iatrogenic posterior urethral strictures and true pelvic fracture urethral distraction defects as the principles of their surgical management are entirely different. Urethral stricture indicates a narrowing of the urethral lumen. In urethral distraction defects, there is a gap between the two otherwise normal ends of the urethra. The dismembered ends of the urethra retract, and the space between them fills with fibrous tissue. There is no urethral wall in the scarred space, and any lumen represents merely a fistulous tract between the urethral stumps. A further difference between inflammatory strictures and distraction defects is that the urethral stumps are usually not fibrotic and can be re-anastomosed without tension after distraction injury. Once anastomosed, they usually heal without stricture.
Partial Urethral Rupture
Manage partial tears of the posterior urethra with a suprapubic or urethral catheter. Perform urethrography at 2-weekly intervals until healing has occurred. They may heal without significant scarring or obstruction if managed by diversion alone. Manage residual or subsequent stricture with urethral dilatation or optical urethrotomy if short and flimsy, and with anastomotic urethroplasty if dense or long.
Complete Urethral Rupture
Acute treatment options include:
- Primary endoscopic realignment
- Immediate open urethroplasty (which should be considered experimental and rarely or never used in patients without associated rectal or bladder neck injury)
Delayed treatment options include:
- 'Delayed primary urethroplasty' (which implies primary repair 2 weeks after injury and for which there is a lack of supporting evidence in male patients)
- Delayed formal urethroplasty at 3 months after injury (the most standard approach)
- Delayed endoscopic incision of the scar tissue between the urethral ends (so-called 'cut-to-the-light' or similar procedures)
The management of complete posterior rupture of the urethra has changed in recent years. There is now more active orthopaedic management of pelvic fractures with immediate external and internal fixation. This has led to the option of early repair of urethral injuries.
In the absence of indications for immediate exploration, posterior urethral disruption can be managed in a delayed primary fashion. Primary realignment requires placement of a suprapubic tube at the time of initial injury, with repair undertaken when the patient is stable, usually within 7 days. At this time, patients are stable, and most pelvic bleeding has resolved. The aim of internal realignment is to correct severe distraction injuries rather than to prevent a stricture occurring, although it will also ensure that it is easily treated if it does occur.
Open realignment has been described, but it should be performed only in patients who undergo open abdominal or pelvic surgery for associated injuries or internal bone fixation. Haematomas that prevent adequate pelvic descent can be evacuated at this point in these cases.
Concomitant bladder neck or rectal injuries should usually be repaired immediately, and open or endoscopic urethral realignment over a catheter at the same time might be advisable. The reasons for immediate repair of bladder neck and rectal injury are:
- Unrepaired bladder neck injury risks incontinence and infection of the pelvic fractures.
- Unrepaired rectal injury carries the obvious risk of sepsis and fistula, and early exploration is indicated to evacuate contaminated haematomas and perform colostomy.
- Urethral realignment over a stenting catheter is appropriate in such cases.
The overall condition of the patient and the extent of the associated injuries greatly affect the decision to proceed with primary realignment. Most patients with pelvic crush injuries have multiple organ injuries. Associated lower extremity fractures can prevent placement in the lithotomy position, which may be required for primary realignment (although bedside flexible cystoscopy can be used). Head injuries increase the adverse risks of anaesthesia. If these conditions are controlled, such that a haemodynamically stable patient can safely undergo a lengthier anaesthesia and can be placed in the lithotomy position, endoscopic urethral realignment could be considered during the first 2 weeks after trauma.
Immediate Open Urethroplasty
Immediate open urethroplasty of posterior injuries is not indicated because of poor visualisation and the inability to assess accurately the degree of urethral disruption during the acute phase, characterised by extensive swelling and ecchymosis. The difficulty in identifying structures and planes hampers adequate mobilisation and subsequent surgical apposition. Incontinence and impotence rates are higher than with the other techniques described in these guidelines (impotence 56%, incontinence 21%, restricture 49%).
However, in posterior urethral injuries associated with concomitant bladder neck or rectal injuries, immediate open exploration, repair and urethral realignment over a catheter is advisable. In children, similar results have been reported with delayed repair and immediate open urethroplasty.
Delayed Primary Urethroplasty
Delayed primary urethroplasty is mainly indicated in female urethral disruption, although no large series exists. It requires placement of a suprapubic tube at the time of initial injury, with repair undertaken when the patient is stable, usually within 7 days.
Delayed primary repair tries to preserve as much urethral length as possible, and to avoid the urethra becoming embedded in dense scar tissue with consequent incontinence. Surgical exploration should be attempted via the retropubic route for proximal injuries, and the vaginal route for distal injuries.
Delayed urethroplasty is the procedure of choice and the gold standard for the treatment of posterior urethral distraction defects. Most posterior urethral distraction defects are short, and these can generally be resolved by a perineal approach anastomotic repair, provided that they are not associated with extensive haematoma-fibrosis and the bladder neck mechanism is occlusive and competent. After division of the bulbar urethra at the distal point of obliteration, mobilisation of a normal bulbar urethra to the base of the penis generally achieves 4-5 cm of elastic lengthening. This is usually sufficient to achieve a tension-free 2 cm spatulated overlap anastomosis, after bridging a gap of 2.0 to 2.5 cm without rerouting.
This technique has the advantage that associated injuries, damaged skin and tissues, and pelvic haematoma have resolved by the time it is performed. The only problem with this approach would be the length of time that the patient must have a suprapubic catheter in place before definitive treatment.
When the prostatobulbar gap is longer than 2 to 3 cm as a result of a high dislocation of the prostate, or when the available elongation of the mobilised urethra has been foreshortened by damage caused by a previous surgical procedure, additional procedures may be required. The following manoeuvres are carried out sequentially to gain sufficient anterior urethral mobility to bridge up to 8 cm of separation, and are referred to as the 'progressive perineal approach':
- Midline separation of the proximal corporal bodies
- Inferior pubectomy
- Supracorporal urethral rerouting
In addition to its use as an initial therapy for posterior urethral distraction injuries, the progressive perineal approach can also be applied successfully to salvage procedures following failed repair.
Reconstruction of Failed Repair of Posterior Urethral Rupture
Restenosis after delayed urethral repair mostly occurs within 6 months. If the anastomosis has a normal caliber at 6 months, then it is extremely unlikely that the patient will develop further stricturing.
Delayed Endoscopic Optical Incision
The procedure is only indicated if the urethral defect is short, the bladder neck is competent and there is minimal displacement of the prostate and proximal bulbous urethra. Although immediate restoration of urethral continuity is commonly possible, failure is common. Urethral dilatation, optical urethrotomy and transurethral resection of stricture will be needed in about 80% of patients. Most repeat urethrotomies are performed in the first year of follow-up.
Recommendations for Treatment: Algorithms
The optimal management of patients with prostatomembranous disruptions should not be thought of as delayed repair versus other types of treatment modalities. Each patient should be assessed and managed according to the initial clinical circumstances. It is impractical to suggest that all patients be managed by one single method because of the variability of each case and the severity of associated injuries. The intervention should be guided by the clinical circumstances. The following algorithms are suggested for the treatment of urethral injuries in males and females (see the original guidelines document for these algorithms):
- Management of Posterior Urethral Injuries in Men
- Management of Anterior Urethral Injuries in Men
- Management of Urethral Injuries in Women
Iatrogenic Urethral Trauma
The diagnostic investigation of iatrogenic urethral trauma does not differ from that of other urethral injuries.
Temporary urethral stenting with an indwelling catheter is a good conventional therapeutic option for treating acute false passage. The placement of a urethral catheter may be impossible, and endoscopic assistance or even placement of a suprapubic tube might be necessary (Level of evidence: 3).
Iatrogenic prostatic urethral strictures after radical prostatectomy can be successfully treated by endoscopic management, either by incision or resection. Failure rates can be high, and repeat therapy might be necessary. The alternative is an indwelling catheter, urethral dilatation or open procedures. Open procedures might be required to salvage recurrent cases, but have increased morbidity (Level of evidence: 2b).
Conservative treatment in patients with urethral lesions caused by radiotherapy is often ineffective. Major surgery or lifelong suprapubic diversion might ultimately be necessary (Level of evidence: 3).
- Avoid traumatic catheterisation.
- Keep the length of time an indwelling catheter is present to a minimum.
- Major abdominal and pelvic surgery should be undertaken with a catheter inserted.
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities