Pelvic Fracture Urethral Injuries
A pelvic fracture is a serious injury that can tear the urethra beneath the prostate, ranging from a partial to complete rupture. It is most often caused by motor vehicle accidents but can also result from crush injuries, such as work-related falls or other trauma. This type of injury may also be referred to as a prostatomembranous urethral injury or a pelvic fracture urethral distraction defect. Regardless of the name, patients typically think of it as a torn urethra that needs repair.
Initial Evaluation and Management of Pelvic Fracture Urethral Injury
Patients with pelvic bone fractures are typically taken to the Emergency Room, where blood at the tip of the urethra often indicates a pelvic fracture urethral injury. If this occurs, a urethral imaging X-ray study is performed to confirm the diagnosis.
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Men with a complete urethral tear are unable to urinate and require an emergency suprapubic tube. This catheter is inserted into the bladder through the lower abdomen, allowing urine to drain into a collection bag while the urethra heals. Proper size and placement of the tube are essential for effective bladder drainage during recovery.
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If the urethra is completely torn, a urologist may attempt a procedure called primary realignment, where a catheter is inserted through the penis to help the severed ends of the urethra come together as healing occurs. However, its effectiveness is debated. This technique is not considered effective for urethral tears caused by pelvic fractures. Importantly, if the catheter is removed and the urethra does not stay open, repeated catheterization should not be used in place of surgical repair, as it only delays proper treatment.
Delayed Repair of Pelvic Fracture Urethral Injury
Most men with urethral tears and suprapubic tubes must wait for surgery, typically around three months, to allow healing before undergoing posterior urethroplasty. If other injuries, like bone fractures, are present, the wait may be longer. During this time, the suprapubic tube allows the bladder to empty while the torn urethra seals and surrounding swelling reduces. After three months, scarring remains, and the ends of the urethra cannot be naturally reconnected. Delaying surgery allows for precise evaluation of the defect’s length and location, ensuring optimal surgical planning.
Evaluation of a Torn Urethra Prior to Surgery
The evaluation of patients with posterior urethral disruptions involves both a retrograde urethrogram, where contrast is injected through the urethra to capture images, and a cystourethrogram, which uses a scope through the suprapubic tube tract. These tests are usually performed in the operating room.