Rosen & Barkin's 5-Minute Emergency Medicine Consult (740 page)

• 368.13 Visual discomfort
  
• 370.24 Photokeratitis
  

BASICS

• Blood at the urethral meatus, a palpable full bladder, inability to void, and/or gross hematuria are common findings with urethral trauma.
  
• Found in 14% of pelvic fractures
  
• High association with bilateral pubic rami fractures (aka, straddle fractures)
  
• Females: Urethral injuries are rare likely due to short, unexposed, and mobile urethras.
  
• Girls <17 yr old: Higher injury rate likely from a more flexible pelvic ring
  
• Bladder neck most commonly injured location.
  
• Males: The urethra is divided into 2 sections.
  
• Posterior urethra:
  
  • More commonly injured (∼90%)
    
  • Prostatic portion
    
  • Membranous
    
• Anterior urethra:
  
  • Injuries are rare
    
  • Bulbar
    
  • Penile
    
• Posterior urethra injuries comprise up to 90% of trauma:
  
  • Type 1: Urethra stretched but not ruptured
    
  • Type 2: Prostatic/membranous portions disrupted (either partially or completely); urogenital diaphragm intact
    
  • Type 3: Urethral disruption both proximal and distal to the genitourinary diaphragm
    

• Females:
  
  • Rare with pelvic fractures
    
  • Straddle injuries
    
  • Childbirth or vaginal surgery
    
  • Sexual trauma/abuse
    
• Males:
  
  • More common with pelvic fractures
    
  • More common with straddle injuries
    
  • Penetrating trauma, mutilation
    
  • Sexual activity/instrumentation
    

DIAGNOSIS

• Males:
  
  • Blood at the urethral meatus
    
  • Gross hematuria
    
• Females:
  
  • Blood in the vaginal vault
    
  • Gross hematuria
    

Trauma to pelvic area

• Exam of the torso and pelvis during the secondary survey may elicit pelvic pain.
  
• Triad of blood at the urethral meatus, inability to urinate, and a palpably full bladder
  
• Blood at the meatus found in 50% of cases.
  
• Urologic injury can be indicated by gross hematuria (any color to the urine other than clear or yellow)
  
• Digital rectal exam: “High-riding prostate” has a sensitivity of <50%. Do not rely on this finding to rule out urethral trauma if suspected.
  
• Bedside US: FAST exam, suprapubic views may reveal blood surrounding the bladder.
  

• Females:
  
  • Perform a detailed vaginal exam to exclude vaginal laceration or other etiologies of bleeding.
    
  • If injury is suspected, radiologic evaluation of urethra should be performed.
    
  • If not possible, suprapubic aspiration or cystostomy should be done.
    
• Male:
  
  • If injury is suspected, radiographic evaluation of urethral integrity should be performed before urinary catheter placement to prevent turning a partial urethral tear into a complete tear.
    
  • If not possible, suprapubic aspiration or cystostomy should be performed.
    

• If an exam of the male or female genitalia cannot easily be performed, exam under anesthesia should occur.
  
• An exam with procedural sedation or in the OR, in addition to being better tolerated by the patient, allows the physician to rule out sexual abuse and to confirm that the injury is consistent with the history.
  

Urinalysis, hematocrit, BUN, creatinine

• Retrograde urethrography (RUG):
  
  • Water-soluble contrast is injected via a catheter-tipped syringe at the urethral meatus.
    
  • Extravasation of contrast and its relation to the prevesical space and urogenital diaphragm should be noted.
    
  • Proximity of the extravasation to the meatus and the bladder should be appreciated.
    
  • If the urethral tear is complete, there will be no contrast within the bladder and marked extravasation will occur.
    
  • A partial tear will demonstrate contrast material within the bladder with varying amounts of extravasation.
    
• Excretory urethrography should be performed to define proximal urethral tears.
  
• Cystography
  
• 40% of urethral injuries have concomitant bladder injuries.
  

Urethral trauma warrants urgent urologic consultation.

• Perineal and vaginal trauma
  
• Bladder injury
  
• Ureter or kidney trauma
  

TREATMENT

Pre-hospital trauma protocols

Stabilization of multiple traumas takes precedence.

• Urethral contusions, lacerations, and avulsions are best managed by an experienced urologist.
  
• Bladder decompression is an important initial intervention. If urethral Foley catheter placement is not possible, suprapubic aspiration/cystostomy may need to be performed.
  

Appropriate analgesia

Opioids:

• Morphine, dilaudid, or fentanyl, as needed per trauma protocols for pain
  

FOLLOW-UP

• Concurrent traumatic injuries
  
• Need for emergent operative management of urethral, penile, or bladder injuries
  
• Partial lacerations:
  
  • Managed with urethral or suprapubic drainage
    
• Complete lacerations:
  
  • Managed surgically or with suprapubic drainage alone:
    
    • Some are repaired with end-to-end anastomosis.
      

Isolated urethral injuries frequently may be managed in the outpatient setting after appropriate urinary catheterization or suprapubic cystostomy with next-day urologic follow-up.

Urologic follow-up is necessary if patient is discharged from ED.

Urologic follow-up is necessary for all patients with urethral injuries.

• Consult urology before attempting to insert a Foley in a trauma patient in whom urethral injury is highly suspected.
  
• Passing a Foley catheter against resistance could convert a partial tear to a complete tear.
  
• Failure to recognize a urethral injury can result in urinary incontinence and sexual dysfunction.
  

• Goldman SM, Sandler CM, Corriere JN Jr., et al. Blunt urethral trauma: A unified, anatomical mechanical classification.
  J Urology
  . 1997;157:85–89.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  7th ed. Philadelphia, PA: Mosby Elsevier; 2010.
  
• Rosenstein D, McAninch J. Urological emergencies.
  Med Clinics of North Am
  . 2004;88(2):495–518.
  
• Walsh P, et al.
  Campbell’s Urology.
  9thed. New York, NY: Saunders;2007.
  

See Also (Topic, Algorithm, Electronic Media Element)

Pelvic Trauma

CODES