Urethral Injury

What the urethra is and how it is injured

In men, the urethra is about 18 to 20 cm long and divided into:

• Posterior urethra: the prostatic and membranous segments, within and just below the prostate. Injured mainly by pelvic fractures.
• Anterior urethra: the bulbar and penile segments. Injured mainly by straddle falls, penile fracture, and instruments.

In women, the urethra is short (about 4 cm) and urethral injury is rare, usually linked to severe pelvic fractures, often with vaginal tears, or to childbirth and surgery.

Causes

Symptoms

• blood at the urethral opening (meatus): the most important sign
• inability to urinate or a weak, painful stream
• blood in the urine
• pain in the perineum, penis or lower abdomen
• bruising and swelling of the perineum, scrotum or penis, sometimes in a butterfly pattern
• a high-riding or unusually mobile prostate on rectal examination in posterior injuries
• bladder fullness from urinary retention

Diagnosis

• Retrograde urethrogram: contrast dye is gently injected into the urethral opening while X-rays are taken. It shows whether the urethra is intact, partly torn or completely disrupted. It should be done before any attempt at catheterization when injury is suspected.
• CT scan to assess pelvic fractures and bladder or other injuries.
• Cystoscopy in selected cases, sometimes to guide a catheter across a partial tear.
• In women, examination under anesthesia and cystoscopy.

Treatment

Initial management

• Do not force a urethral catheter when injury is suspected, as this can turn a partial tear into a complete one.
• Suprapubic catheter: a tube placed through the lower abdomen into the bladder to drain urine.
• Endoscopic realignment: in selected cases, a catheter is passed across the injury using cameras.
• Treat associated injuries, such as pelvic fractures, bladder rupture and bleeding.

Repair

• Partial anterior tears often heal with catheter drainage alone over 2 to 3 weeks.
• Complete posterior disruptions after pelvic fracture are usually repaired after about 3 months (delayed urethroplasty), once swelling and bleeding resolve, by joining the healthy ends of the urethra.
• Penetrating or penile fracture injuries are often repaired immediately.

Complications

• Urethral stricture: scar tissue narrowing the urethra, the most common long-term problem; causes a weak or spraying stream, straining and urinary infections. Urethroplasty has high success rates.
• Erectile dysfunction: common after pelvic fracture urethral injuries, from nerve and blood vessel damage.
• Urinary incontinence: uncommon; more likely with bladder neck injury.
• Infection and fistula.

Outlook

With appropriate early drainage and specialist repair, most people regain good urinary function. Long-term follow-up for strictures and sexual function is important, and treatments for erectile dysfunction are available.

Frequently asked questions

What are the signs of a urethral injury?

The main signs are blood at the tip of the penis or urethral opening, inability to urinate, blood in the urine, and bruising or swelling of the perineum, scrotum or penis, usually after a pelvic injury or straddle fall.

What causes urethral injury?

Common causes are pelvic fractures from car crashes and falls, straddle injuries such as falling onto a bike crossbar, penile fracture during sex, and damage during catheter insertion or urological procedures.

How is a urethral injury treated?

Urine is first drained, often with a suprapubic catheter through the lower abdomen. Partial tears may heal with drainage alone. Complete tears are usually repaired surgically, often about 3 months later for pelvic fracture injuries.

Can a urethral injury cause erectile dysfunction?

Yes. Injuries to the posterior urethra from pelvic fractures often also damage the nerves and blood vessels needed for erections. Many men recover partly over time, and medicines, injections or implants can help.