Any type of trauma may affect any part of the urethra but much the comm

Non-iatrogenic trauma to the urinary tract accounts for 1.5% of

all traumas and affects 1 : 45 000 population per year. Urethral
trauma accounts for 4% of this or 1 : 1 125 000 population [2].
Although it is very much less common, non-iatrogenic urethral
trauma is potentially much more serious than iatrogenic trauma
because the force required to injure the urethra in this way is very
much greater. Associated injuries are therefore not only to be
expected (in 86% of patients [2]) but usually dominate the
patients assessment and management, and may significantly
affect how the urologist is able to manage the patients urological
problem as a consequence. This particularly applies to pelvic
fracture-related urethral injuries (PFUIs) of the posterior urethra.
These are the commonest non-iatrogenic injuries in industrialised
societies and are usually due to motor vehicle accidents. Less
common are fall-astride or straddle injuries of the bulbar
urethra.

Penetrating injuries and particularly military injuries can

affect any part of the urethra although with blast injuries
from improvised explosive devices almost the entire
anterior urethra, together with the genitalia, may be
literally blown away.
Overall non-iatrogenic trauma in the developed world
affects the urethra with a rough incidence of 20 PFUI or
other injuries to the posterior urethra to five straddle or
other injuries to the bulbar urethra to one PFUI or other
injury of the penile urethra [3]. In less industrialised
societies penile urethral injuries remain uncommon but
the frequency of straddle trauma approaches that of
PFUIs [47].
HISTORICAL

THE ANATOMY AND PATHOLOGY OF URETHRAL INJURY

The anatomy of the urethra is described differently by
anatomists and by urologists. The Terminologia Anatomica[36]
does not recognise the existence of the anterior and posterior
urethra or of the bulbar and penile (pendulous) subdivisions of
the anterior urethra, which it calls the spongiose urethra, and it
regards the term membranous urethra as a misnomer as the
existence of the urogenital diaphragm (UGD) has been refuted.
For present purposes we will adopt the urological approach
[37] and consider the urethra to be divided into the posterior
urethra proximal to the perineal membrane and the anterior
urethra distal to the perineal membrane which is, in turn,
subdivided into a bulbar part and a penile part, accepting that
the distinction between the two is rather imprecise

Osteology

ring structure made up of the sacrum and two innominate bones

stability dependent on strong surrounding ligamentous structures
displacement can only occur with disruption of the ring in two places
neurovascular structures intimately associated with posterior pelvic ligaments
high index of suspicion for injury of internal iliac vessels or lumbosacral plexus

Ligaments
anterior
symphyseal ligaments
resist external rotation

pelvic floor
sacrospinous ligaments
resist external rotation

sacrotuberous ligaments
resist shear and flexion

posterior sacroiliac complex (posterior tension band)

strongest ligaments in the body
more important than anterior structures for pelvic ring stability
anterior sacroiliac ligaments
resist external rotation after failure of pelvic floor and anterior structures

interosseous sacroiliac
resist anterior-posterior translation of pelvis

posterior sacroiliac
resist cephalad-caudad displacement of pelvis

iliolumbar
resist rotation and augment posterior SI ligaments

Tile classification
A: stable
A1: fracture not involving the ring (avulsion or iliac wing fracture)
A2: stable or minimally displaced fracture of the ring
A3: transverse sacral fracture (Denis zone III sacral fracture)

B - rotationally unstable, vertically stable

B1: open book injury (external rotation)
B2: lateral compression injury (internal rotation)
B2-1: with anterior ring rotation/displacement through ipsilateral rami
B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)

B3: bilateral

C - rotationally and vertically unstable

C1: unilateral
C1-1: iliac fracture
C1-2: sacroiliac fracture-dislocation
C1-3: sacral fracture

C2: bilateral with one side type B and one side type C
C3: bilateral with both sides type C

In the posterior urethra the prostatic segment is supported by the

prostate itself and is held in place by the bladder, the lateral ligaments,
the endopelvic fascia and Denonvilliers fascia, all of which fix it
posteriorly or postero-laterally, and by the pubo-prostatic ligaments that
fix it anteriorly. Apart from the recto-urethralis, which is also posterior,
the only point of fixation of the membranous urethra is as it passes
through the perineal membrane inferiorly. Thus, subject to sufficient
external force, the membranous urethra, although heavily protected by
the pelvic ring, is the most easily injured because it is the least
supported segment, both longitudinally and circumferentially. The bulbar
urethra is well supported in both planes but so fixed in position that it is
vulnerable to a crush injury from the perineum against the underside of
the inferior pubic arch (Fig. 1) [4]; and the penile/pendulous urethra is
constrained in position only by clothing so it is relatively immune to
trauma except during sexual activity and warfare, military or urban. In
endoluminal trauma, the most vulnerable point of the urethra, assuming
it was previously normal, is as it passes through the perineal membrane
and just proximally because this is the most fixed point and the point at
which it curves up from the perineum towards the pelvis.
Figure 1. One of the earliest illustrations in the urological literature other
than of a surgical instrument, an X-ray or a point of technique, from
1930. The typical cause of a straddle injury of the bulbar urethra [4].

Aside from iatrogenic injuries, most bulbar injuries are crush injuries
and most penile urethral injuries are either tears or intraluminal,
when due to sexual misadventure, or penetrating injuries otherwise.
In the anterior urethra, the epithelium lies directly on the spongy,
vascular erectile tissue of the corpus spongiosum (Fig. 2) which is
itself tightly constrained by Bucks fascia around it (Fig. 3) [38,39],
which fixes it to the underside of the corpora cavernosa and to the
perineal membrane. The absence of a muscularis mucosae or other
sub-epithelial layer in the urethra is unusual compared with other
epithelially lined tubular structures and means that the urethral
epithelium is unsupported in the way that the gastro-intestinal
epithelium is, for example [40]. Consequently, if the epithelium is
breached, the spongiosum is immediately exposed to the adverse
effects of extravasated urine. This is spread through the spongiosum
under pressure as a consequence of voiding (Fig. 4), unless or until
Bucks fascia also ruptures. If that happens, extravasated blood and
urine are then constrained by Colles fascia (Figs 5,6) [39,41]. This is
more superficial and is fixed on either side to the ischio-pubic rami
and posteriorly to the perineal membrane. In this way the continuing
extravasation is directed, under increasing pressure, anteriorly to
the scrotum and the penis, deep to the dartos layer of each with
which Colles fascia is in continuity, and upwards alongside the
spermatic cord on either side to the abdominal wall

POSTERIOR URETHRAL INJURY

Although it is cof the pelvis but a disruption of the
pelvic ring [5458].
Pelvic-ring disruptions may be classified in various
ways [55,56] but they are most commonly classified
according to the nature of the instability that results.
Thus the pelvic ring may be stable, or rotationally
unstable but vertically stable, or both rotationally and
vertically unstable. Urethral injury as a result of pelvic
ring disruption typically occurs with rotationally
unstable injuries, particularly lateral compression
injuries. It does not occur with stable pelvic injuries, the
pelvic ring must be disrupted [54,57,58]. So in addition
to the radiologically obvious fractures of the anterior
part of the pelvic ring on a plain X-ray there will be at
least some ligamentous disruption affecting the sacroiliac joints posteriorly, although this may only be
assessable by CT

In our experience, partial injuries of the urethra are more common than complete injuries
(although this is contentious, see below) and complete injuries are related to the most
unstable type of fractures that are both or both rotationally and vertically unstable [57].
These injuries require a very severe force to produce them. Most, these days, are due to
motor vehicle incidents (6884%) when the victim may be a passenger or driver or, more
commonly, a pedestrian; or as a result of a fall from a great height (625%) or a direct
crushing injury; and occur predominantly in younger men (and women) with a mean age of
33 years [54]. Interestingly, only 510% are complicated by PFUI [54]. It has always proved
difficult to explain why this is so. It was recognised well over 100 years ago that the typical
injury was a lateral compression injury to the pelvic ring [11,12]. In those days, it was
commonly due to a side-on crush injury at work or a fall from a horse when the horse then
fell on the victim. It was originally thought that the injury was due to either a switchblade
injury by a bone fragment or a scissor injury by the inferior pubic rami cutting across the
urethra as they passed one over the other in a lateral compression injury [12]. It was
subsequently noted that the bladder and prostate were typically dislocated backwards
causing an S-bend deformity at the site of injury if the lumen of the urethra was
maintained, either because it was an incomplete injury or because of subsequent
catheterisation (Fig. 7) [11,12,25,59,60]. These authors concluded that the occurrence and
nature of the urethral injury were related to the effect of the causative trauma on the
ligamentous attachments of the urethra and that direct injury by bone fragments, the socalled switchblade injuries (Fig. 8) or scissor injuries (Fig. 9), were rare

In our experience, partial injuries of the urethra are more common than complete injuries
(although this is contentious, see below) and complete injuries are related to the most
unstable type of fractures that are both or both rotationally and vertically unstable [57].
These injuries require a very severe force to produce them. Most, these days, are due to
motor vehicle incidents (6884%) when the victim may be a passenger or driver or, more
commonly, a pedestrian; or as a result of a fall from a great height (625%) or a direct
crushing injury; and occur predominantly in younger men (and women) with a mean age of
33 years [54]. Interestingly, only 510% are complicated by PFUI [54]. It has always proved
difficult to explain why this is so. It was recognised well over 100 years ago that the typical
injury was a lateral compression injury to the pelvic ring [11,12]. In those days, it was
commonly due to a side-on crush injury at work or a fall from a horse when the horse then
fell on the victim. It was originally thought that the injury was due to either a switchblade
injury by a bone fragment or a scissor injury by the inferior pubic rami cutting across the
urethra as they passed one over the other in a lateral compression injury [12]. It was
subsequently noted that the bladder and prostate were typically dislocated backwards
causing an S-bend deformity at the site of injury if the lumen of the urethra was
maintained, either because it was an incomplete injury or because of subsequent
catheterisation (Fig. 7) [11,12,25,59,60]. These authors concluded that the occurrence and
nature of the urethral injury were related to the effect of the causative trauma on the
ligamentous attachments of the urethra and that direct injury by bone fragments, the socalled switchblade injuries (Fig. 8) or scissor injuries (Fig. 9), were rare

Figure 7. The S-bend deformity. (a) The mechanism,

reproduced from Deanesly, 1907 [12]; (b) The
mechanism, reproduced from Bailey, 1927 [25]; (c) RUG
to show the characteristic appearance.
Download figure to PowerPoint
Figure 8. The consequences of a switchblade injury
caused by a bone fragment. Note that the injury is lower
than usual compared with figures 13, 14 and 15. It also
tends to be longer.
Download figure to PowerPoin t
Figure 9. A scissors injury due to overlapping of the
two pubic bones caused by a lateral compression injury
of the pelvic ring. This has caused a urethral contusion.

More recent reports have concluded that the injury was due to a
transversely orientated force vector that sheared the prostate off the
membranous urethra at the level of the superior fascia of the UGD [59,61]. It
was later thought to be due to a cranially orientated force vector due to
compression of the pelvic viscera during the disruption of the pelvic ring.
This caused the bladder and prostate as a unit to be squeezed upwards out
of the pelvis and so be avulsed from the membranous urethra at the level of
the UGD [54,62]. This concept of the bladder/prostate being squeezed so
forcefully that they were plucked from the urethra at the level of the UGD
suffered somewhat when it was shown that the UGD does not actually exist
[63].
More recent investigations have shown that the site of injury is usually at
the junction of the membranous urethra and the bulbar urethra. The most
significant evidence for this is that the verumontanum is always a distance
above the site of rupture, even after trimming and spatulation of the
proximal urethra at subsequent surgery, and that the urethral sphincter
mechanism is usually preserved, at least in part, even after this surgery [50
53].

Still more recent evidence reaffirms the hypothesis that the

consequences of a rupture of the pelvic ring are mediated
through the attachments of the perineal membrane and the
pubo-prostatic ligaments to the urethra and the way these
ligamentous structures respond to pelvic-ring disruption [57].
Similar to other ligamentous structures subject to trauma, they
may be ruptured in mid-substance or from their attachments at
either end. If they are ruptured mid-substance or are avulsed
from their bony/periosteal attachments the urethra will be left
intact. If, on the other hand, they rupture at the site of their
attachment to the urethra, a urethral rupture (partial or
complete) may occur. Hence the reason why the urethra is not
usually ruptured during pelvic-ring disruptions as well as the
explanation for how it sometimes is (Fig. 10) [57].
Figure 10. The mechanism of urethral injury [57].

Sometimes trauma produces a vertical tear of the prostatic urethra and

bladder neck, possibly mediated by the pubo-prostatic ligaments, rather
than a horizontal rupture at the bulbo-membranous junction mediated by
the perineal membrane, although both can occur (Fig. 11) [64]. It should
be noted that although these injuries are commonly called bladder neck
injuries, it seems that it is the prostatic urethra that is primarily damaged
and that the bladder neck and the membranous urethra are affected
secondarily [64]. These vertical tears are proportionately more common
in women [6567]. In the most severe injuries in men, the front of the
prostate may be torn off or there may a transverse rupture both above
and below the prostate leaving a sequestered prostate between (Fig. 12)
[64]. The end result is that in a typical injury at the level of the perineal
membrane there is bleeding but no urinary extravasation until,
ultimately, the bladder gets so full that it has to empty or rupture
whereas in the atypical variants, prostatic and bladder neck disruption
leads automatically to extravasation as well as bleeding, which makes
the patient more sick more quickly, for all the reasons discussed above.

EXPERIMENTAL STUDIES OF URETHRAL INJURY

There have been a small number of experimental studies of urethral transection
with or without additional crush injury [6871]. There are four main findings:
1If the urethra is only partially injured (as defined below) then there is the
possibility of complete healing of all layers without stricture formation, whereas
with a complete injury this does not happen.
2The reason why a complete injury does not heal is because the epithelium of the
two ends retracts and the space in between fills with fibrosis (Fig. 13).
3For this reason, apposition of the two ends alone is not sufficient to allow
epithelial healing after a complete rupture, the two ends must be sutured together.
If not, the presence of a stenting catheter may preserve luminal continuity through
the segment of fibrosis but the lining epithelium is not normal urethral epithelium
and so this section is a false passage and behaves as such.
4The presence of a stenting catheter across a ruptured urethra makes no difference
to the outcome, whether partial or complete and whether sutured or not, as long as
the urine is diverted by a SPC.
Figure 13. Urethral disruption, in this diagram after a PFUI. Note the initial
retraction of the tissues then the filling of the dead space with fibrosis.
Download figure to PowerPoint

TYPES OF URETHRAL INJURY

It is usual to consider urethral trauma to be of three types:
1contusions
2partial ruptures
3complete ruptures
It is often unclear in the older (or even the more recent) publications what an
author means by partial or complete, particularly before the introduction and
widespread adoption of urethrography, when the diagnosis was made by
catheterisability (as described above), or otherwise when urethrography is not
performed. This can cause considerable confusion in the interpretation of
publications about the relative merits about different approaches to treatment
(see Part 2 of this review). The terms should refer to the circumferential
integrity of the urethra (Fig. 14). An injury that has incompletely ruptured part
of the circumference of the urethra is a contusion. An injury that has completely
ruptured part of the circumference of the urethra is a partial injury. An injury
that has completely ruptured the entire circumference of the urethra is a
complete rupture. This distinction is not always made clear but it is important
because, as stated above, if even part of the circumference of the urethra is left
intact after an injury then healing is possible without stricture formation [68]. If
the entire circumference is ruptured then healing does not occur and a stricture
is inevitable [70,71]. Most ruptures of the anterior urethra are reported to be
partial [25,72,73] and most in the posterior urethra, complete [54,74,75]; but
given that urethrography is not universally used, that urethrographic diagnoses
are presumptive, that most patients do not have endoscopy and that the
appearance at delayed urethroplasty does not allow a distinction between the
two in most cases, it is difficult to know how reliable this information is. Our
experience is that partial injuries predominate in all locations [57]. Others are
of the same opinion [59,76], including the author of the only study we are

IMPLICATIONS FOR TREATMENT

There are therefore three main considerations in the
management of urethral injuries:
1To provide urinary drainage in the most expedient way to
relieve symptomatic retention (and, at the same time, to
allow monitoring of urinary output).
2To provide urinary drainage so that urinary extravasation
and its secondary effects, and specifically infection and
fibrosis, do not occur (both 1 and 2 are achieved by SPC but
it is worth emphasising that there are two separate reasons
why this is important).
3To create the best possible circumstances for healing and
complete recovery, thereby reducing the risk of a
subsequent stricture

By consensus the term stricture is applied to constrictions of the lumen of the

anterior urethra in which the epithelium and the corpus spongiosum are both
involved in the fibrotic process (and in which their overall continuity is
maintained) [37]. In the membranous urethra there is no corpus spongiosum
and so, by the same consensus, the terms contracture or stenosis are
preferred to the term stricture.
There is no consensus about the terminology after trauma. Uncontroversially,
a post-traumatic fibrotic constriction of the anterior urethra is still called a
stricture even when, as after a severe straddle injury, there has been
ischaemic necrosis and loss of a segment of the urethra and therefore loss of
continuity of both the lumen and the wall of the bulbar urethra. However,
there is a great deal of controversy about the terminology of posterior
urethral injuries and their outcome. This was instigated by Turner Warwick
[77], who sought to distinguish constrictions of the membranous urethra (due
for example to instrumentation) in which the integrity of the urethra was
otherwise preserved, which he called continuity strictures, and constrictions
after rupture of this part of the urethra which he called distraction defects. As
he believed that most, if not all, PFUIs that caused contractures (or
stenoses) were complete injuries, then, by extension, all of these injuries
came to be called pelvic fracture-urethral distraction defects (PFUDDs). (The
term continuity strictures never caught on, although the term sphincter
stricture is commonly used, at least by us).

And so there are two terminological issues: is it appropriate

to call a complete (or incomplete) loss of continuity of the
anterior urethra after a crushing straddle injury a stricture?
And is it appropriate to call an incomplete, or even a
complete, loss of continuity of the posterior urethra a PFUDD,
when the two ends are not distracted and when distraction
was probably not the cause? We prefer to distinguish injuries
from strictures at all sites because the pathology and surgery
are completely different; hence our preference for the term
PFUI. However, we recognise that there needs to be a term
to describe the fibrotic consequence of injury in which there
is still a urethral lumen, as distinct from a complete
obliteration with no preservation of the lumen. For this
reason we will use the term stenosis.

CLINICAL FEATURES AND INVESTIGATION

The cardinal features of urethral injury are voiding

Urethral bleeding..
Voiding difficulty due to reflex retention leading to palpable bladder.
In patients with a PFUI, a displaced or impalpable prostate on rectal
examination was a third feature
Nowadays, when many patients are seen within an hour of their injury,
these clinical features need to be interpreted in the light of the clinical
situation. The same is also true of the overt classical clinical signs of
perineo-pelvic trauma after external violence; these too take time to
develop. So if a patient appears in the emergency room within an
hour of injury there may be little to show for it, however severe the
injury. The typical butterfly haematoma after a straddle injury of the
bulbar urethra takes a day or two to develop ; the physical signs of
PFUI even longer. Even urethral bleeding may take >1 h to become
apparent. Indeed, it has been shown that even in a specialist trauma
centre, 2025% of patients with pelvic-ring disruption and a PFUI have
their urological injury overlooked initially because of absent physical
signs or misleading imaging.

In ideal circumstances, in a conscious, orientated patient who is not severely

injured, it is possible to make a clinical assessment and arrange further
investigation relatively leisurely. But in a severely traumatised patient the
emergency team will want to know the urinary output to be able to monitor
resuscitation and an inability to pass a catheter for this purpose may be the first
sign of urethral trauma. Might catheterisation make matters worse? In the era
before modern catheters and antibiotics this was certainly possible, by causing
further trauma and increasing the risk of infection. Nowadays, with modern
catheters and antibiotics, this is probably not so , as long as it is not assumed
that a small amount of blood-stained fluid means that the catheter is in the
bladder because it almost certainly is not ; and as long as it is not assumed that
if the catheter goes into the bladder that there is no urethral injury, because
there sometimes is . In practice many, if not most patients in an emergency
setting are catheterised routinely, before they are seen by a urologist, and only
have urethrography if catheterisation fails. In other words the initial diagnosis of
urethral injury is usually made by catheterisability, just as it always used to be.
This preselects the group of uncatheterisable patients in whom urethrography is
more likely to show more severe injuries than in an unselected group of patients

Retrograde urethrography (RUG) was first described

by Cunningham [84] but it was Flocks [85] who
refined and detailed the technique, and McCrea [86]
who first suggested its use in trauma. Thereafter it
was used increasingly frequently, but even those who
advocated it found it unreliable and potentially
capable of causing further damage [59,87]. More
recently the technique has been further refined and
the usual types of injury have been classified. Only in
the last 10 years has urethrography become a routine
(but by no means universal) investigation of patients
with suspected urethral injury, outside of specialist
centres.

The Goldman classification of urethral injury based on

RUG ClassificationDescription*For current anatomical
thinking, this should be read as the perineal membrane
as discussed in the text.
Type 1Posterior urethra stretched but intact.
Type 2Tear of the prostato-membranous urethra above
the UGD*
Type 3Partial or complete tear of both the anterior and
posterior urethra, with disruption of the UGD*
Type 4Bladder injury extending into the urethra
Type 4aInjury of the bladder base with peri-urethral
extravasation simulating posterior urethral injury.
Type 5Partial or complete pure anterior urethral injury

he most common type of injury, not surprisingly, given the nature of the injury as
described above, is type 3 with extravasation both above and below the perineal
membrane (Fig. 16). RUG is accurate in locating the site of the injury; it is less
accurate in defining the type of injury and particularly in distinguishing between
partial and complete injuries. A partial injury can be assumed if radiological contrast
material enters the bladder (Fig. 17) but a complete injury cannot be assumed if it
does not (Fig. 18) because it may simply be following the path of least resistance if it
fails to cross the urethral sphincter. Furthermore, repeat urethrography a day or two
after a urethrogram has shown an apparently complete injury may show that this is
in fact incomplete. Thus both catheterisability and RUG are likely to over-diagnose
complete injuries. This classification system, the Goldman [89] modification of the
Colapinto and McCallum system [88], is therefore flawed as are the other systems
that have been suggested [9193] because they all flounder around the problem of
accurate radiological distinction between partial and complete injuries and of the
relevance to clinical management, if management is simply a question of urethral
catheterisation or SPC if that fails. The system proposed by the authors of the
European Association of Urology guidelines on urethral trauma attempts to combine
radiological classification with clinical relevance and although, in our opinion, it is the
best available, the same problems still apply and their proposed clinical
management is vague (Table 2) [93].

Table 2. The European Association of Urology classification of urethral

injury [93]] ClassificationDescriptionAdvised clinical managementType
1Stretch injury. Elongation of the urethra without extravasation on
urethrographyNo treatment requiredType 2Contusion. Blood at the urethral
meatus; no extravasation on urethrographyCan be managed
conservatively with suprapubic cystostomy or urethral catheterisationType
3Partial disruption of anterior or posterior urethra. Extravasation of
contrast at injury site with contrast visualized in the proximal urethra or
bladderCan be managed conservatively with suprapubic cystostomy or
urethral catheterisationType 4Complete disruption of anterior urethra.
Extravasation of contrast at injury site without visualization of proximal
urethra or bladderWill require open or endoscopic treatment, primary or
delayedType 5Complete disruption of posterior urethra. Extravasation of
contrast at injury site without visualization of bladderWill require open or
endoscopic treatment, primary or delayedType 6Complete or partial
disruption of posterior urethra with associated tear of the bladder neck or
vaginaRequires primary open repair

Most patients with PFUI will have CT of the pelvis as part of

their initial assessment. This is helpful in the orthopaedic
assessment of pelvic-ring disruption, to exclude other
abdominal and pelvic injuries and for the assessment of the
bladder, but not much help in the diagnosis and
management of urethral trauma except in the diagnosis of
ruptures of the prostatic urethra and bladder neck .
Obviously there several investigations, particularly
endoscopy (retrograde or antegrade through the suprapubic
track, if there is one) and MRI that may be important for the
further evaluation of any residual urological disability, but
they are not generally helpful in the acute management of
the injury.

EMERGENCY MANAGEMENT
If the injury is iatrogenic and the patient is still anaesthetised then
urethral catheterisation over a guidewire may be possible otherwise a
SPC should be placed. In other circumstances, in a patient with an empty
(intact) bladder there is no urgency to deal with the urethra. If the patient
has a urethral injury in relation to a penile fracture it may be possible to
pass a urethral catheter (if necessary) until the patient is ready for
surgery. If a patient with a PFUI is going to have immediate surgery for
other injuries then an open SPC placement can be performed in the
operating theatre. Otherwise, in all other circumstances, a percutaneous
SPC should be placed under ultrasonographic guidance [93], at least in
the first instance. It may be appropriate to replace a percutaneous
catheter with a more substantial catheter for longer term urinary
drainage at a convenient time later. This might be after the patients
other injuries have been attended to or as a preliminary to internal
fixation of the pelvic ring, in which case the catheter can be placed out of
the orthopaedic surgeons way.

The management of the patient who has been catheterised is

important but rarely described. Our practice is as follows. If a urethral
catheter was passed with ease and there has been no urethral bleeding
before or since then it is safe to assume that there has been no urethral
injury and to remove the catheter as the patient begins to mobilise, but
the patient must be observed to check that voiding is resumed without
difficulty. If there has been urethral bleeding at any stage in a
catheterised patient then a urethral contusion or a partial rupture are
possible and so a peri-catheter urethrogram should be ordered to look
for extravasation and to make sure that it has cleared before the
catheter is removed. If a SPC was placed after a urethrogram had
shown a urethral injury it should be left for 23 weeks to allow time for
healing before a urethrogram to see if this is so, in which case the
catheter can clamped for a trial of voiding. If there was no urethrogram
and the SPC was placed empirically then a urethrogram should be
arranged when the patient is fit enough and then managed as above

Iatrogenic trauma is the commonest type of trauma and most

iatrogenic trauma is due to catheterisation . Other causes include other
forms of diagnostic or therapeutic instrumentation, particularly in the
presence of a previously unsuspected stricture or otherwise attempting
an optical urethrotomy of a known stricture without passing a guidewire
first, leading to loss of orientation. It is insufficiently appreciated how
traumatic instrumentation can be but even a condom drainage device
can cause problems .
Complication of catheterisation: a kippered urethra.
If it is possible to pass a small calibre urethral catheter over a guidewire
through the site of injury then that should suffice to allow the trauma to
settle, otherwise a SPCshould be placed with a trial of voiding a few
days later or longer according to circumstances.
The distal penile urethra is sometimes damaged during ritual
circumcision leading to urethrocutaneous fistulation and the more
primitive the technique the higher the risk and the worse the fistula.
Unless the opportunity exists to treat the damage primarily, it is best to
leave it for 3 months at least to allow the local response to the injury to
settle before repairing it as one would any other penile
urethrocutaneous fistula.
Figure 4. Urethrocutaneous fistula as a result of attempted
circumcision. The procedure was abandoned because of bleeding

OPEN (OR PENETRATING) INJURIES

All penetrating injuries of the urethra, at any point along its
length should be explored, debrided if necessary, repaired if
possible and the patient left with a SPC or urethral catheter or
both and a wound drain if there has been significant
contamination or extravasation [35]. Whereas exploration
should always be undertaken, debridement may not be
necessary because the genital skin and the corpora cavernosa
and spongiosum are well vascularised [311], as is the
posterior urethra on the rare occasions it is injured by gunshot
wounds [4]. The only repair appropriate is suture closure or
end-to-end anastomosis if these can be achieved without
tension and this may not be possible [4]. This is not the time
for a graft or flap repair. A pair of catheters and a wound drain
is always safe.
War wounds throughout the ages [511] are interesting but
very uncommon. The more recent the conflict the worse the
injuries (sometimes with appalling injuries, particularly since
the introduction of land mines) but the better the medical care
so the more likely the injured are to survive

CLOSED (OR NON-PENETRATING) INJURIES

PENILE URETHRAL INJURIES
The commonest type of non-iatrogenic penile urethral injury
is that associated with penile fracture (Fig. 5). It is also the
one circumstance in which cystoscopy is more reliable than
urethrography in identifying or excluding urethral injury.
Repair of the penile fracture itself usually takes precedence.
In theory, and in practice in patients who refuse surgery,
the urethra (and the penis) can be managed conservatively,
by catheterisation, if there is no extravasation and not
much bleeding [12]. However, immediate repair is the rule
these days, if only because it is the more cost-effective
approach, in which case the corpus spongiosum is repaired
over a urethral catheter at the same time as the corpus
cavernosal tear .

BULBAR URETHRAL INJURIES

Blunt injuries occur in the bulbar segment of the urethra because it is fixed beneath the inferior pubic
arch. As a result straddle injuries or kicks to the perineum crush the bulbar urethra against the
inferior pubic arch leading to contusion or rupture ..

Because these are crush injuries they are best managed by SPC to prevent
extravasation . The urge to explore the perineum should be resisted unless there is a
more than usually large haematoma, or a penetrating wound, or if urinary extravasation
has occurred in which case the wound needs to be drained. About 60% of injuries are
incomplete and most of these (90%) will heal without stenosis with SPC alone [15,16].
With attempted urethral realignment over a urethral catheter, the rate of stenosis jumps
from 10% to 65%[15,16]. About 40% are complete urethral ruptures and although
75% will develop stenoses when managed by a SPC alone that figure reaches almost
100% with attempted realignment in addition [15,16].

Thus, it is best to put in a SPC, leave it for 3 weeks to allow

time for healing, and then clamp the catheter for a trial of
voiding. If voiding is difficult, urethrography is the next step
with a view to urethroplasty in due course. If a stenosis is
going to develop it usually does so almost immediately but it
sometimes takes 6 months to manifest itself [15].
Generally these stenoses are dealt with by an overlapping
spatulated bulbo-bulbar anastomotic urethroplasty, with or
without opening of the intercrural space to relieve tension at
the anastomosis (Fig. 7) [17]. The procedure is best left 3
months from the time of injury. If performed earlier the tissues
are often still insufficiently recovered to be able to hold
sutures. Occasionally, with more severe stenoses or
obliterations, an augmented anastomotic repair is necessary.
In these circumstances the two ends of the urethra can be
brought together end-to-end but cannot be overlapped without
tension, even after opening the intercrural space. So the two
ends are spatulated dorsally, sutured to each other over their
ventral hemi-circumference and then the dorsal hemicircumference is reconstituted with a graft, generally of buccal
mucosa

The more serious injuries of this type, with ischaemic necrosis and loss of a
segment of the bulbar urethra and corpus spongiosum and with similar
damage to the corpora cavernosa, can be difficult to repair, more difficult
than the average repair of a pelvic fracture-related urethral injury(PFUI),
which is generally regarded as the most surgically challenging form of
urethral injury to repair
After some less dramatic injuries, typically a bicycle accident or an injury to
the perineum during some sporting activity, the patient presents some
months or years later with voiding difficulty [15]. The diagnosis is made with
a RUG. The injury pattern is the same. Such patients are also best
managed by anastomotic or augmented anastomotic urethroplasty usually
with a very satisfactory outcome

POSTERIOR URETHRAL INJURIES

This is a far more controversial topic especially the immediate
management and the nature of the procedure in those patients who
undergo delayed urethroplasty (DU).
Immediate management [1]
There is no controversy that suprapubic cystostomy is critically
important to provide urinary drainage and that if extravasation has
occurred then it too should be drained. It is also uncontroversial that
many patients will go on to develop a stenosis or obliteration at the
site of injury and that (in theory if not in practice) this is best dealt
with by an anastomotic urethroplasty 3 months later, when the
patient has recovered from the pelvic fracture and any other
associated injuries. Indeed, in most circumstances, having
established SPC and wound drainage (if necessary), other injuries will
usually take priority in the immediate and early management of the
patient. The controversial area is whether anything else could be
done or should be done other than SPC drainage, at the time of injury
or shortly afterwards, to reduce the risk or severity of a subsequent
stenosis and therefore the scope and scale of the surgery to deal with
it. There are therefore two different approaches: firstly to simply
place a SPC and do nothing else until such time as a DU is clearly
necessary; or alternatively to do one of several interventions that
might possibly reduce the risk of stenosis or obliteration, or otherwise
make any subsequent surgery simpler

Most of these alternatives are a variation on the theme of retrograde catheterisation

devised by Verguin and described in Part I [1]. This was rediscovered and popularised in
the 1890s and became standard treatment during the 1920s and 1930s, particularly after
Banks [18] and subsequently Davis [19] described the technique of combined
antegrade/retrograde passage of specially modified urethral sounds (Fig. 10[19]), and thus
of a urethral catheter, without the need for perineal exploration. All the procedure was
originally intended to do was to restore luminal continuity if this was completely disrupted
so that when the urethral catheter was removed the patient could be maintained thereafter
by regular urethral dilatation to deal with the almost inevitable stenosis. Otherwise the
patient would be left with an impassable block of fibrosis between the two displaced ends of
the urethra, which was an almost insurmountable surgical problem in the era before
urethroplasty. The results were better than before but were nonetheless poor because
posterior dislocation of the prostate and the S-bend deformity that resulted left the patient
with a difficult stenosis to manage for the rest of his life, even if luminal continuity had been
initially maintained. Various techniques were therefore described to realign the prostate to
the bulbar urethra to correct the posterior displacement of the prostate and the S-bend
deformity. The first attempt used traction with a Pilcher bag and subsequently a Foley
catheter to pull the posterior urethra and the prostate back into position. Other surgeons
tried various types of suturing through the apex of the prostate.They were not very
successful but then, of course, they did not actually realign the urethra: they simply
maintained luminal continuity. Indeed, whether anything short of surgical mobilisation of the
two ends of the urethra and internal fixation of the pelvic-ring disruption could actually
restore normal alignment is debatable. Other than that, the main disadvantages of
realignment were that it was traumatic, at a time when the patient was least able to cope
with additional trauma, and that it was thought to lead to an excessive incidence of erectile
dysfunction (ED) and incontinence by dissecting around the apex of the prostate

to an already severely traumatised pati

e main indications for primary repair are penetrating injuries, injuries of the bladder neck an
1989, Gelbard et al. [32] proposed a new approach to PR: endoscopic PR (ePR). This was p
a more or less inevitable development: several authors in the early 1980s had already desc

PR should confer no advantage. Firstly it is not realignment, it is restoration or maintenance