URETHRAL TRAUMA

(Brown & Martindale, Jou of Trauma, 2008)

SUB BAGIAN UROLOGIBAGIAN / SMF BEDAHFK UNS/RSUD Dr. MOEWARDI

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

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, bleedingPrimary 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

Impotence2.6 to 75 % after pelvic fracture42 % with urethral injury, 5 % withouth urethral

injury22.5 % after suprapubic inwelling catheterization 42 % after railroading procedureCause damage the neurovascular bundle (80-85

% vascular)

IncontinenceMechanism : destroyed or non function of the

urethral sphincter

ANTERIOR URETHRAL INJURY

The incidence is relatively low compare to the posterior urethra

Mechanism of injury :Due to instrumentation iatrogenic, self-

inflected, contusionBlunt trauma : straddle- type injuryGunshout, stab wounds

Mechanism and Imaging

History presence urethral injuryPresent the blood at the meatus (OUE)Inability to voidDysuria HematuriaButterfly 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 Torsion

First describe by Tailor (1897) , can occur pre-postnatally 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 and fix the contralateral testes

Methode of on fixation of the contralateral testes debatable

The three – points fixation using monofilamentous non-absorbable has been recomended

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