URETHRAL TRAUMA

SUB BAGIAN UROLOGI

BAGIAN / SMF BEDAH
FK UNS/RSUD Dr. MOEWARDI

(Brown & Martindale, Jou of Trauma, 2008)

POSTERIOR URETHRAL INJURY

Is not common associated with pelvic fracture

Most patients best treated by SPC for 3 month, then end to
end anastomotic urethroplasty

Mechanism of injury :
Fracture pelvic 90 %, 5 10 % associated urethral injury
60 % posterior urethral injury are complete rupture, 40 %
incomplete
Impotence occurs 10 20 % of pelvic fracture injury, and
about half with urethral rupture
Diagnosis and imaging :
Blood at the external urethral meatus
Imaging : urethrography

MANAGEMENT
MANAGEMENT

Immediate

management in pelvic
fracture and injuries to the posterior
urethra is controversy

Primary realignment, primary repair

Delayed primary repair a few days later
Delayed primary realignment a few days later
Suprapubic catheterization, repair 3 month or so
later

Early surgery for ruptured posterior urethra :

Traditional

treatment railroading (open

surgical procedure, endoscopically)
Stricture rate 70 %
Open railroading complication :
Impotence, incontinence, infection, bleeding
Primary repair by end to end anastomosis
Delayed primary repair and realignment for
rupture posterior :
Indication

for the distracted pie-in-the-sky

bladder
Evacuation of the haematoma
Open or endoscopic realignment

Delayed surgery for rupture posterior

urethra :
Suprapubic catheterization for 3 month
is the GOLD STANDARD of treatment
follow by end to end anastomosis
Suprapubic catheterization and delayed
uretheoplasty cause the least harm
10 - year stricture-free survival 90 %

Complication
Impotence
2.6 to 75 % after pelvic fracture
42 % with urethral injury, 5 % withouth urethral
injury
22.5 % after suprapubic inwelling catheterization
42 % after railroading procedure
Cause damage the neurovascular bundle (80-85
% vascular)
Incontinence
Mechanism : destroyed or non function of the
urethral sphincter

ANTERIOR
ANTERIOR URETHRAL
URETHRAL INJURY
INJURY

The

incidence is relatively low compare to

the posterior urethra

Mechanism of injury :
Due to instrumentation iatrogenic, selfinflected, contusion
Blunt trauma : straddle- type injury
Gunshout, stab wounds

Mechanism and Imaging

History

presence urethral injury

Present the blood at the meatus (OUE)
Inability to void
Dysuria
Hematuria
Butterfly hematoma

Butterfly
hematoma

(Sullivan & Morgan, 2004)

Retrograde Urethrography :
Normal

urethrography diagnosis
contusion

Contrast

extravasation and some contrast

reaching the bladder partial disruption

Contrast

extravasation without contrast

reaching the bladder complete
disruption

Management
Catheterization

the protocol in severely injury

patient by the trauma team during primary resuscitation

Not

catheterization partial tear covert to complete

Initial

management :
1. Adequate drainage of urin
2. Minimize potential complication (stricture, fistula,
infection)

Stable

patient retrograde urethrogram

Unstable

patient pass catheter can be made,

suprapubic catheterization stable retrograde study

Partial

tear suprapubic or urethral

catheterization, 2 weekly interval
urethrogram

Stricture

manage direct visual

uretrotomy

Blunt

trauma complete disruption

suprapubic catheterization urethroplasty
3-6 months

SCROTAL EMERGENCY

(Zomorrodi et al, Int. Med J Vol. 6, 2007)

Etiology Acute
Scrotal

(Sullivan & Morgan, 2004)

Torsion

of the testicle is a urological

emergency the risk testiculer loss

Can

occur at any age, most common

during adolescent (12 18; peak 14 16
years old)

In

adult the torsion is intravaginal, in

neonates is extravaginal

Left

testes more frequently than the right

( 6 : 4 ), bilateral < 1 %

Common

in cold weather due to

cremasteric contraction

When

torsion occurs venous blood

supply obstruction secondary edema
and hemorrhage subsequent arterial
obstruction testicular necrosis

Degree

and duration of torsion affect the

severity ischemic damage

Extravaginal
Extravaginal Torsion
Torsion

First

describe by Tailor (1897) , can occur prepostnatally

75 % prenatally and 25 % postnatally within 30
days of birth

Present

hard scrotal mass at time delivery

Some

infants have oedematous, erythematous

scrotum, inflammatory reaction surrounding area

The

diagnosis depend on physical examination

Rarely

neonates with normal postnatal examination

then found swollen tender testes in 1 month of life

Management
The

management is controversial

Some

surgeons no exploration

Exploration

testes

and fix the contralateral

Methode

of on fixation of the
contralateral testes debatable

The

three points fixation using

monofilamentous non-absorbable has
been recomended

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