1. Management of Urethral &
Bladder Injuries
Dr. Amar Ul Ala Butt
Consultant Urologist
06 R M 12967
MOH 88/458 BCH 7/1

2. URETHRAL INJURIES
& MANAGEMENT

3. Anatomy
1. Posterior urethra.
• Prostatic
• Membranous
2. Anterior urethra.
• Bulbous
• Pendolous

4. prostatic
membranous
pendulous
bulbar

5. Posterior urethral injuries.
• Posterior urethra injured in 1.6-9.9% of
pelvic fracture.
• Complete: 73%
• Partial: 27%

6. Causes.
• Shearing force.
• Direct laceration by pelvic bone fragment.
• Distraction,caused by pelvic fracture b/w
pubic symphysis & pubic rami.

7. Symptoms and Signs
• Blood at the urethral meatus. Do not, do
not, do not try to pass the catheter if it’s
present!!!
• Inability to urinate
• Palpapable bladder
• Pelvic hematoma
• Superiorly dispalced prostate

9. Diagnosis
•Immediate retrograde
urethrogam.

10. Posterior urethra laceration

11. Posterior urethra –complete
tear

12. Treatment
• Suprapubic cystostomy (Initial treatment)
• If incomplete laceration – spontaneous healing
in 2-3 weeks
• Complete laceration – reconstruction after 3
months
• Primary repair – not recommended. Surgery is
difficult because of hematomas.

13. Complications.
1. Stricture:
• Primary repair →50%
• Delayed repair→ 5%
2. Impotence:
• Primary repair →30-80%
• Delayed repair →30-35%
3. Incontinence:
• <2% pts
• Typically ass:with sacral fracture & S2-S4 nerve injury.

14. Anterior Urethral Injuries
• Causes.
• Stradle injuries→Laceration or Contusion
• Self instrumentation or iatrogenic may
cause partial disruption.

15. Symptoms & Signs
• Histry of fall
• Local pain in perineum
• History of instrumentation
• Massive prineal hematom
• Butterfly sign(hematoma)

17. Treatment
• Contusion:.if no extravasion urethra intact,after
urethrography pt:allowed to void if ok no addional
treatment.
• If bleeding present urethral cathetar can be done.
• Laceration:.S/P cystostomy→14-21 days
• Urethral cathhetar avoided bcz it converts incomplete
tear to complete one.
• Pts: who develops complete oclusion of urethra should
have S/P for 3-6 months before definite repairs.

18. Bladder Trauma
• Adult: Extraperitoneal organ
• Bladder dome = weakest point
• Blunt: 60-85%
• MVA: #1 cause
• Important to recognize
– Pelvic/abdominal wall abscess/necrosis
– Peritonitis
– Intra-abdominal abscess
– Sepsis / Death

20. Types of rupture
• Extraperitoneal
– Most common
– Pelvic # in 89-100%
– Bladder rupture in 5-10% of all pelvic #
• Intraperitoneal
– Extravasation of urine in abdomen
– Sudden force to full bladder
– Associated injuries +++ Mortality
(20%)

21. Clinical Presentation
• 98% : Gross hematuria
• 2%: Microscopic hematuria + Pelvic #
• 100%: Gross hematuria
• 85% Pelvic #
•McConnel et al. Rupture of the bladder. Urol Clin North Am. 1982.
•Carroll et al. Major bladder trauma: Mechanisms of injury and a
unified method of diagnosis and repair. Journal of Urology. 1984.
•Morey AF et al. Bladder rupture after blunt trauma :
guidelines for diagnostic imaging. Journal of Trauma-Injury
Infections & Critical Care. 51(4): 683-6, 2001 Oct.

22. Investigation
• Cystography: Gold standard
• CT Cystography : New trend
• Peng et al. AJR 1999.
– Prospective study
– 55 patients. 5 bladder rupture
– Cystography VS. CT cystography
– Ruptures confirmed by Surgery
– 100% sensitive and specific
Peng et al. CT cystography versus conventional cystography
in evaluation of bladder injury. AJR 1999; 173:1269-1272.

23. Investigation…
Deck et al. Journal of Urology, 2000.
– Retrospective study
– 316 patients with CT Cystography
– Sensitivity/Specificity = 95% and
100%
– But 78% and 99% for intraperitoneal
rupture
– Comparable to Cystography alone
– Identifies other injuries
Deck AJ et al. CT Cystography for the diagnosis of
traumatic bladder rupture. J Urol, Jul. 2000; 164(1); 43-6.

24. Standard Helical CT
• Pao et al. Acad Radiol 2000.
– With IV contrast
– Misses bladder rupture
– 100% sensitive if “free fluid” criteria
used.
– Can R/O bladder injury if NO free fluid.
– Not specific.
– Not accepted as diagnostic tool.
Pao et al. Utility of routine trauma CT in the detection of
bladder rupture. Acad Radiol 2000; 7:317-324.

25. Treatment
• Penetrating injuries: OR
• Blunt
– Intraperitoneal: Almost all OR
– Extraperitoneal: Urethral cath. drainage x 7-
10 days.

31. Conclusion
• No Foley if you suspect urethral trauma
• Pelvic # + Microhematuria GU
investigation
• Don’t remove Foley if you suspect a partial
tear of urethra afterwards.

32. THANKS