Urethral injuries is a partial or complete violation of the integrity of the urethra under the influence of destructive mechanical factors. It manifests itself with urethrorragia, dysuria, urinary retention, pain, hematoma, swelling in the area of damage. It is diagnosed using an urine analysis, urethral ultrasound, retrograde urethrography. In case of bruises, conservative anti-inflammatory, analgesic, hemostatic therapy is possible. To eliminate ruptures, catheterization of the bladder, epicystostomy, primary, delayed, late urethral plastic surgery are performed.
ICD 10
S37.3 Urethral injuries
Meaning
Urethral injuries are a common type of injury, which in peacetime is detected in 15% of men with injuries of the genitourinary organs, during the war — in 30% of affected patients. In women, this pathology is rare due to the small size of the urethral canal and its location in the pelvis. Up to 96% of urethral injuries in peacetime are closed, during military operations the number of open gunshot wounds of the urethra increases sharply. The urgency of timely diagnosis and proper treatment of such injuries is due to the rapid development of severe disabling complications and an increase in mortality with a delay in the provision of specialized care.
Causes
The significance of individual etiological factors causing traumatic damage to the urethra depends on the sex of the victim, the time and circumstances of injury (peace period, hostilities), the presence of prerequisites (state of alcoholic intoxication, victimogenic behavior, urological, gynecological diseases). Specialists in the field of urology and traumatology distinguish the following groups of causes of urethral injuries:
- Industrial and household injuries. In peaceful conditions, men’s urethra is most often injured due to an accident, falling from a height with a perineum hitting a hard object, in accidents at home, at work, while playing sports. The posterior part of the male and female urethra is damaged by combined injuries with a fracture of the pelvic ring.
- Violent actions. Closed injuries of the anterior urethral canal are the result of fights or attacks by intruders with blows to the perineum. The most common causes of open injuries in men during the war are gunshot wounds, during the peace period — stab wounds, bites of domestic and stray animals.
- Sexual experiments. Both men and women may have their urethral wall damaged by the introduction of hard or sharp foreign objects into the lumen during masturbation. In some cases, such actions are caused by mental disorders (mental retardation, delirium and imperative auditory hallucinations in schizophrenia, psychoses of various genesis).
- Obstetric injuries. Pathological childbirth is leading in the occurrence of urethral injuries in women. The urethra is destroyed during ischemia and necrosis due to compression by the head of a large fetus, with vaginal ruptures, rough obstetric operations (forceps, vacuum extractor, fetal extraction by the pelvic end).
- Iatrogenic effects. In case of violation of the technique of procedures, part of diagnostic and therapeutic medical manipulations is complicated by urethral injuries. The integrity of the mucous membrane, and sometimes the deeper layers of the urethral wall, may be disrupted during catheterization of the bladder, cystoscopy, and urethra augmentation due to the presence of constrictions.
Pathogenesis
The mechanism of damage to the urethra is determined by the characteristics of the factor that caused the injury. In 40-60% of cases, the urethral canal is damaged in fractures with displacement of the pelvic ring due to stretching between the attachment points of the ligamentous apparatus to the bones. In some patients with polytrauma, the destruction of the organ by acute bone fragments is possible. The leading link in the pathogenesis of most blunt closed injuries of the urethra is a violation of blood circulation and trophic walls due to the formation of a hematoma, less often with sharp strong blows there is a partial rupture of the membranes of the organ.
Ischemia and tissue crushing, leading to necrosis, are also noted with prolonged compression of the urethra in childbirth. Most open injuries are provoked by incision or rupture of tissues by foreign objects. With careless insertion of medical instruments into the urethra, the epithelial layer is usually injured, less often other membranes. Regardless of the type of exposure, traumatic inflammation occurs in the destruction zone with a violation of hemodynamics, swelling of tissues, irritation of pain receptors, violation of the natural passage of urine, bleeding of varying intensity is observed with the destruction of blood vessels.
Classification
When systematizing injuries of the urethra, their localization, the degree of violation of the integrity of the membranes, the presence of other injuries are taken into account. In men, there are injuries to the anterior (spongy) and posterior (membranous, prostate) parts of the urethra. In the first case, the part of the organ passing through the penis is injured, in the second — the perineal and pelvic areas of the urethra. If the lumen of the organ does not communicate with the surrounding tissues, the wound is considered non—penetrating (bruise, stretching, tearing of the mucous membrane, tangential injuries), with the destruction of all layers of the urethral wall – penetrating (partial, complete rupture). Closed injuries have no communication with the environment, when open, the integrity of the skin is violated. In the absence of damage to adjacent organs, the injury is called isolated, in the presence of other injuries and fractures — combined. The degree of traumatic injuries plays a great role in choosing the tactics of patient management:
- Urethral injury. The most common variant of non-penetrating closed injuries, in which swelling occurs due to a blow, hemodynamics is disrupted in the wall of the organ or surrounding tissues, and a hematoma is often formed. A wait-and-see conservative tactic with condition monitoring is allowed.
- Stretching of the urethra. The integrity of the walls is preserved, but the urethra is lengthened by tensile mechanical loads. The main danger is possible circulatory disorders in the urethral tissues. Patients are provided with dynamic monitoring.
- Partial rupture of the urethra. The injury may be limited in depth (non-penetrating tears) or in extent (non-circular penetrating injuries). To restore integrity, catheterization is usually used, less often reconstructive plastic surgery is required.
- Complete rupture of the urethra along the circumference. Taking into account the severity of the injuries received , injuries with a distance between the parted ends of up to 2 cm and more than 2 cm are distinguished . Restoration of the urethra is impossible without performing reconstructive plastic surgery.
Urethral fractures are considered as a separate category of injuries. Their main features are considered to be the massive destruction of both the walls of the organ and the surrounding tissues. The crushed damages are usually open. For victims with similar injuries, the final reconstruction of the urethral canal is often performed in the long term.
Symptoms
A closed traumatic injury without a complete rupture of the organ is manifested by soreness, pain, difficulties during urination, bloody staining of the first portion of urine, blood secretions from the urethra between urination. Usually, a hematoma is determined in the perineum, scrotum, swelling in the area of damage to the anterior part of the urethra. The complete rupture of the urethral canal is indicated by the cessation of urination, heaviness, pain in the lower abdomen, imperative inconclusive urge to urinate caused by overflow of the bladder. In women, with a combined rupture of the anterior vaginal wall, urine may flow through the vagina. With open injuries, a puncture or a gaping wound in the area of the penis, perineum is revealed.
Complications
Severe and combined urethral injuries in 45-98% of victims are complicated by traumatic shock, which in 7-10% of cases causes death. Massive damage to the posterior parts is often accompanied by significant hemorrhages in the pelvic cavity and secondary acute anemia. With penetrating wounds, urinary infiltration of tissues occurs, urogematomas are formed, which can fester when an infection is attached. Postrenal stagnation of urine promotes ascending infection with the development of cystitis, pyelonephritis, in severe cases — renal failure, urosepsis. Long-term consequences of urethral injuries are frequent urethritis, urethral strictures, erectile dysfunction, urinary incontinence, external (cutaneous), urethro-rectal, urethro-vaginal fistulas, urolithiasis.
Diagnostics
Sufficient grounds for suspicion of injury to the urethra are the characteristic clinical picture and the presence of anamnestic information about mechanical effects on the perineum, genitals. To confirm the traumatic injury, to determine its degree and nature, such instrumental methods of examination are usually prescribed as:
- Ultrasound. It is used for rapid diagnosis of urethral injuries. The advantage of ultrasound examination of the urethra is its non-invasiveness. Echographic visualization of the urethra allows you to assess its shape, lumen, and condition of the walls. The technique is applicable only in men. In combination with ultrasound of the kidneys, ureters, and bladder, it provides rapid detection of combined traumatic damage to the pelvic organs.
- Retrograde urethrography. It is considered the most accurate method of diagnosis. In the presence of penetrating injuries, the contrast agent injected into the external urethra spreads into the surrounding tissues. Urethrography is necessarily performed before catheterization of the urethra to assess the extent of ruptures. For more informative, the method is supplemented by intravenous urography in two projections.
Auxiliary diagnostic methods are urine analysis, in which unchanged erythrocytes are determined, and a rectal examination that reveals a high prostate standing with complete circular urethra ruptures. To determine the condition of adjacent organs, a pelvic overview radiography is recommended. Endoscopic methods are usually not used in order not to aggravate tissue damage. In the general blood test, the level of erythrocytes and hemoglobin may decrease, the content of leukocytes moderately increases, and ESR may accelerate. Differential diagnosis is carried out between different types of injuries of the urethral canal, with traumatic injuries of the bladder, bruise, fracture of the penis without violating the integrity of the urethra. According to the decision of the urologist, the victims are advised by a traumatologist, surgeon, therapist, anesthesiologist-resuscitator, andrologist examines men, obstetrician-gynecologist examines women.
Treatment
Conservative management is allowed in the presence of non-penetrating bruises, sprains and the provision of specialized care no later than 6-12 hours after receiving a traumatic injury. The optimal solution in such cases is to provide rest, applying cold, prescribing NSAIDs that have an anti-inflammatory and analgesic effect, hemostatic drugs, sedatives and tranquilizing agents. Preventive antibiotic therapy is carried out to prevent possible infectious complications of the injury. In case of violation of urinary excretion, a rubber catheter is installed for up to 7 days. In other cases, surgical treatment is recommended.
When choosing an operation, the severity of the patient’s condition and the features of the traumatic injury (localization, severity, type, combination with other injuries) are taken into account. The main tasks of surgical intervention are considered to be ensuring unhindered outflow of urine, creating conditions for the healing of damaged tissues or reconstructive restoration of the urethra. The main types of operations for traumatic destruction of the urethra are:
- Suprapubic epicystostomy. With partial ruptures, the removal of urine through the cystostomy reduces the load on the walls of the urethra, with complete ruptures, it eliminates acute urinary retention. Depending on the degree of damage, epicystostomy is supplemented with catheterization of the bladder or reconstructive plastic surgery of the urethra, corresponding to the type of damage.
- Primary urethrourethroanastomosis. Comparison of the gap is possible with a slight divergence of its ends, the absence of massive urohematomas, and a satisfactory condition of the victim. The advantage of the primary suture of the urethra is the low probability of erectile dysfunction. Intervention is more often carried out with injuries to the spongy part of the organ.
- Delayed urethral plastic surgery on a catheter. The urethra is catheterized for 2-3 weeks with a tube made of biologically inert material, which is installed through a high section of the bladder. The wall defect is sutured after the condition of the victim is stabilized. Delayed interventions are recommended for posterior injuries.
Patients with open injuries undergo primary surgical treatment of the wound. In the presence of urinary congestion, urogemat provides their opening and drainage. The complicated course of the traumatic process often requires late reconstructive plastic surgery to eliminate strictures, fistulas and other long-term consequences.
Prognosis and prevention
The outcome of urethral injuries depends on the severity of the injury and the extent of the anatomical defect. The prognosis is most favorable for isolated non-penetrating wounds. More than half of patients with small partial ruptures have independent recanalization of the urethra. With a complete circular break of an organ with significant diastasis of the ends, long-term treatment and reconstructive operations are usually required. Prevention of urethral injuries involves compliance with safety standards at work, at home, increased caution during sports training, engaging in traumatic hobbies, limiting the consumption of alcoholic beverages. An important role in the prevention of iatrogenic injuries is played by timely detection and adequate treatment of prostate diseases, the choice of optimal obstetric tactics at the risk of complications in childbirth.