URETHRAL INJURIES

Causes

  • Urethral trauma (for example a fall astride a projecting object, cycling accident)
  • Fracture of pelvis in road traffic accident, penetrating wounds (bullet wounds, etc.)
  • Iatrogenic injuries.

Clinical Features

  • Patient presents with difficulty or inability in passing urine.
  • There may be blood at the external meatus.

Management Where There Is No Urologist

  • Admit for
    • Resuscitation and suprapubic catheterization.
    • Complications of ruptured urethra
    • Subcutaneous extravasation of urine and urethra stricture. This is made worse by infection or iatrogenically by inadvertent attempts to catheterize or do urethrography or urethroscopy, early.
  • Start on appropriate antibiotic cover.

The following should be noted:

  • Do not catheterize the patient per urethra.
  • Give analgesia: Morphine or pethidine.
  • If bladder is full, empty through a suprapubic cystostotomy, but if the patient has passed urine “leave alone”.
  • Start antibiotics, first line nitrofurantoin 100mg 6 hourly for 7 days. For injuries at risk of infection with skin pathogens, use amoxicillin + clavulanic acid 625mg orally 8. Group and cross-match blood.
  • Order a plain pelvic radiograph. An ascending and descending urethrogram should be ordered thereafter.
  • Carry out the following procedure for suprapubic cystostomy under strict aseptic preconditions:
    • Clean the abdomen and hypogastrium well with an antiseptic and drape with sterile towels.
    • Feel for the distended bladder and 2–3cm above the upper pubic margin.
    • Infiltrate local anaesthetic.
    • Make a 2cm transverse incision and dissect the tissues with a haemostat.
    • Open the bladder under direct vision and introduce a 16F Foley’s catheter.
    • Close the layers around the catheter with stitches.
    • Balloon the catheter and leave it to drain for 14 days (in the meantime refer the patient).
  • Refer to urologist where indicated.

Management at Hospital

Definitive treatment will depend on which part of the urethra is ruptured, anterior (bulbous) or posterior (membranous). This is specialized treatment for which the patient should be referred to a urologist.