Traumatic rupture of the female urethra

[Fractures of the pelvis causing vaginal wound]

Les fractures du bassin surviennent le plus souvent au décours d´un traumatisme violent. Malgré ce contexte de haute vélocité, ces lésions sont rarement associées à des plaies du vagin et les données sur l´évolution sont rares. L´objectif de notre étude était de décrire les lésions anatomocliniques, le traitement et l´évolution de ces lésions. Nous avons observé cinq cas de plaies du vagin au cours d´une fracture du bassin chez la femme au cours de ces dix dernières années. Les patientes avaient un âge moyen de 23,6 ans. Le motif principal était les accidents de la voie publique. Deux patientes présentaient des plaies linéaires et trois présentaient des plaies délabrantes. Des sutures vaginales ont été réalisées chez toutes les patientes. Au recul moyen de deux ans, l´évolution a été favorable avec cicatrisation de la plaie vaginale et de l´os. Les activités génitales et obstétricales n´ont pas été compromises. Ce sont des lésions qui passent le plus souvent inaperçues. Il faudra y penser devant tout traumatisme du bassin chez la femme.

Analysis of anastomotic urethroplasty for pelvic fracture urethral distraction defect: Decadal experience from a high-volume tertiary care center

Context:

Pelvic fracture urethral distraction defect (PFUDD) may be challenging for the treating urologist. Anastomotic urethroplasty is the established surgical procedure for the treatment of PFUDD. Few studies in literature focus purely on PFUDD, and majority of the studies include anterior urethral stricture as well. The period of these studies is relatively short. We conducted a retrospective analysis of patients who underwent primary or redo anastomotic urethroplasty for PFUDD over a period of 12 years at a tertiary care center in northern India.

Aims:

The aim is to study anastomotic urethroplasty for pelvic fracture urethral distraction defect with regard to long-term success rate and complications.

Settings and Design:

This was a retrospective study. Subjects and

Methods:

This retrospective study was conducted in the Department of Urology, King George's Medical University, Lucknow, India, from August 2004 to July 2016. All patients who underwent progressive perineal anastomotic repair of PFUDD were included in this study. Demographic findings, type of pelvic fracture, length of distraction defect as per retrograde urethrography (RUG) and micturating cystourethrography, any history of erectile dysfunction in the preoperative or postoperative phase, and urinary incontinence in postoperative phase were analyzed. Decision regarding catheter removal was taken after pericatheter RUG at 4 weeks. Follow-up was done at 3 and 6 months in postoperative period.

Results:

A total of 226 anastomotic repairs were done in 221 patients. Of the 221 patients, 51 (23%) were redo urethroplasty. The mean age of patients was 27.6 years. The mean length of distraction defect was 2.7 cm. The mean duration of hospital stay was 6 days. Primary urethroplasty was successful in 163 (93.14%) of 175 patients and redo urethroplasty in 44 (86.27%) of 51 patients. Out of 165 patients, 18 (10.9%) patients reported occasional incontinence while 6 (3.63%) patients reported mild incontinence.

Conclusions:

Anastomotic urethroplasty is the definitive procedure for PFUDD. Our success rate for primary deferred anastomotic urethroplasty is 93.14% and for redo anastomotic urethroplasty is 86.27%.

Female urethral injuries associated with pelvic fracture: a systematic review of the literature

To review systematically the literature on female urethral injuries associated with pelvic fracture and to determine the optimum management of this rare injury. Using Meta-analysis of Observational Studies in Epidemiology criteria, we searched the Cochrane, Pubmed and OVID databases for all articles available before 30 June 2016 using the terms 'female pelvic fracture urethroplasty', 'female urethral distraction', 'female pelvic fracture urethral injury' and 'female pelvic fracture urethra girls.' Two authors of this paper independently reviewed the titles, abstracts, and articles in duplicate. We identified 162 individual articles from the databases. Fifty-one articles met our criteria for full review, including 158 female patients with urethral trauma. Of these injuries, 83 (53%) were managed with immediate repair; 17/83 (20%) via primary alignment and 66/83 (80%) via anastomotic repair. The remaining 75/158 (47%) were managed with delayed repair. Rates of urethral stenosis and fistula were highest after primary alignment. Urethral integrity appears to be similar after both primary anastomosis and delayed repair; however, patients experienced significantly more incontinence and vaginal stenosis after delayed repair. Patients who underwent delayed urethral repair were more likely to undergo more extensive reconstructive surgery than those who underwent primary repair. The optimum management of female urethral distraction defects is based on very-low-quality literature. Based on our review of the available literature, primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal.

Reconstruction of Female Urethra with Tubularized Anterior Vaginal Flap

INTRODUCTION

Female urethral injury is a rare disease. Causes of urethral injuries are prolonged obstructed labour, gynaecological surgeries like vaginoplasty and post traumatic urethral injuries. The present study was conducted to evaluate outcome of female urethral reconstruction using tubularized anterior vaginal wall flap covered with fibroadipose martius flap and autologous fascia sling in patients with urethral loss.

AIM

Aim of study was to evaluate outcome of reconstruction of female urethra with tubularized anterior vaginal flap.

MATERIALS AND METHODS

Retrospective analysis of all the patients with complete urethral loss was done from August 2008 to July 2015. Total seven patients were included in study. All patients presenting with total urethral loss were included. These patients were treated with tubularized anterior vaginal flap. Neourethra was covered with Martius labial flap and autologous fascia lata or rectus abdominis fascia sling. Most common cause of urethral loss was obstructed labour (57.1%). Postoperatively patients were assessed for continence, urine flow rate, ultrasound for upper urinary tract and post void residue.

RESULTS

Mean operative time was 180 minutes (160-200 minutes) and Intraoperative blood loss was 220ml (170-260 ml). Mean postoperative hospital stay was eight days (seven to nine days) Mean post surgery maximum urine flow rate was more than 15ml/sec (6.7-18.2ml/sec) and mean post void residual urine was 22.5ml (10-50ml). Median follow-up time was 35 months. All patients were catheter free and continent post three weeks of surgery except one patient who developed mild stress urinary incontinence. One patient developed urethral stenosis which was managed by intermittent serial urethral dilatation.

CONCLUSION

Female neourethral reconstruction with tabularized anterior vaginal flap and autologous pubovaginal sling is feasible in patients of total urethral loss with success rate of approximately 86%. It should be considered in patients of complete urethral loss with adequate healthy vaginal tissue.

Bladder Neck Rupture and Vesicovaginal Fistula Associated with Pelvic Fracture in Female

CASE

Female urethral injury or bladder neck rupture associated with pelvic fracture is rare. The experience of this injury is limited and the management is still challenging. Here we describe a young female patient with urethral injury and vesicovaginal fistula associated with pelvic fracture due to traffic accident. We discuss the recommendation and management about this problem.

OUTCOME

We selected staged surgical management for this case, and fortunately succeeded in the repair of the urethral and vaginal injury and acquired favorable continence.

CONCLUSION

Appropriate management should be selected according to the condition in each patient. But it should be taken into consideration that a patient with pelvic fracture is critically ill, and an experienced urologist of this field is not always available at that time.

The incidence, causes, mechanism, risk factors, classification, and diagnosis of pelvic fracture urethral injury

Background

Pelvic fracture urethral injury (PFUI) is an uncommon but potentially devastating result of pelvic fracture. It ranges in severity based on the cause and the mechanism of injury.

Methods

We reviewed previous reports to identify the incidence, causes, mechanisms of injury and risk factors of PFUI. In addition, we reviewed the current classification systems and diagnostic methods that have been described to assess the severity of PFUI, to identify optimal management strategies and evaluate outcomes.

Results

PFUI occurs more commonly in men, but is more likely to be severe in children. The most common cause is motor vehicle collisions, and the mechanism is typically a ligament rupture at the attachment to the urethra. There is no reliable classification system to differentiate partial and complete PFUI. Retrograde urethrography is the standard imaging method but it has its limitations.

Conclusions

Despite many reports describing this injury, there is still a need to further clarify the incidence, aetiology and mechanism of injury to better determine optimal management strategies and evaluate outcomes. Consensus in the diagnosis of PFUI is lacking, and outcomes of primary realignment and the role of flexible cystoscopy as a diagnostic method are still to be determined.

Long-Term Continence Outcomes After Immediate Repair of Pediatric Bladder Neck Lacerations Extending Into the Urethra

PURPOSE

Traumatic bladder neck lacerations extending into the urethra are devastating injuries that occur more commonly in children than in adults. It is unclear whether immediate repair of these injuries decreases long-term complications, such as urinary incontinence. We report our long-term results with immediate operative repair of these injuries.

MATERIALS AND METHODS

Since 1986, we have primarily repaired all individuals sustaining traumatic longitudinal bladder neck lacerations extending into the urethra within 24 hours of injury. All patients were followed a minimum of 2 years.

RESULTS

A total of 12 patients 2 to 16 years old sustained longitudinal bladder neck lacerations extending into the proximal urethra. Median followup was 7 years (range 2 to 13). Postoperatively none of the 12 patients recovered complete urinary continence. Periurethral bulking agents were attempted in all 12 patients with no long-term improvement. Eight patients (75%) pursued additional surgery. Three boys underwent artificial urinary sphincter placement, of which all subsequently eroded. Three girls underwent bladder neck reconstruction with fascial sling procedures, of whom 2 became continent but experienced urinary retention, while 1 became partially continent. Five patients, including the 3 boys with artificial urinary sphincter erosion, ultimately underwent bladder neck closure and continent diversion.

CONCLUSIONS

Traumatic longitudinal bladder neck and proximal urethral lacerations are devastating injuries fraught with long-term complications and the need for additional surgery despite immediate surgical repair. Bladder neck closure and continent diversion should be considered in girls with substantial traumatic urethral loss and in boys with persistent urinary incontinence following primary repair.

[Urethral trauma]

Urethral lesions may be caused by blunt or penetrating objects in the course of accidents, or can be iatrogenic resulting from invasive measures such as catheterization or other major surgical measures (prostatectomy or sling operations for continence). They can also be caused by foreign bodies deliberately introduced into the urethra. Injuries may primarily affect the anterior or posterior urethra. Urethral reconstruction presupposes knowledge of the precise anatomy of the pelvic region. The surgical techniques used and the timing of reconstructive procedures will depend on the cause and nature of the urethral injury. A definitive surgical intervention in most cases of lesions resulting from accidents is not generally recommended, especially when the lesion is in the posterior urethra. A treatment algorithm should prevent post-surgical complications such as incontinence, impotence, recurring urinary tract infections, etc., necessitating multiple operations, and assure an adequate quality of life. Diagnostic clarification of the exact nature of urethral injuries requires high quality imaging studies by specialists in the field.

Urethral and Bladder Neck Injury Associated With Pelvic Fracture in 25 Female Patients

PURPOSE

We describe the presentation, diagnostic evaluation, management and outcome of female urethral trauma.

MATERIALS AND METHODS

All female patients treated at Harborview Medical Center between 1985 and 2001 with urethral injury were identified by International Classification of Diseases 9th revision code. Approval of the Human Subject Division was obtained and patient charts were reviewed. The Urogenital Distress Inventory Short Form, the Incontinence Impact Questionnaire Short Form and the Female Sexual Function Index were sent to the patients.

RESULTS

A total of 25 patients (13 adults, 12 children) with a mean age of 22 years (range 4 to 67) met inclusion criteria. All had pelvic fracture related to blunt trauma. They represented 6% of all female patients treated in the same review period with pelvic fracture. Blood was seen at the introitus in 15 patients and 19 had gross hematuria. Of the injuries 9 were avulsions, 15 were longitudinal lacerations and 1 was not further specified. Primary repair was performed in 21 patients and 4 were treated nonoperatively. There were 5 patients who required secondary procedures including fistula repair in 4 and continent urinary diversion in 1. At a mean followup of 7.3 years (range 1.6 to 14.4) 9 of 21 patients (43%) had moderate or severe lower urinary tract symptoms and 8 of 13 (38%) had sexual dysfunction (FSFI score less than 26.55).

CONCLUSIONS

Female urethral and bladder neck injury occurs with pelvic fracture, presents with gross hematuria and/or blood at the introitus, and requires operative repair for avulsions and longitudinal lacerations. These patients are at risk for significant sexual and lower urinary tract dysfunction.

Pelvic fracture-associated urethral injuries in girls: experience with primary repair

OBJECTIVE

To present our experience with four urethral injuries in females accompanying a pelvic fracture, managed with primary repair or realignment of the urethra.

PATIENTS AND METHODS

There were three teenage girls and one adult (22 years old). All the patients had complete urethral injuries associated with a pelvic fracture from accidents. They were managed by immediate suprapubic cystostomy followed by repair or realignment of the urethra over a catheter on the same day. The catheter was removed after 3 weeks and a voiding cysto-urethrogram taken. Thereafter they were followed with regular urethral calibration.

RESULTS

All patients voided satisfactorily with a good stream; three were fully continent and the fourth had transient stress urinary incontinence. One patient needed dilatation at 2 months and another visual internal urethrotomy at 5 months. At a mean (range) follow-up of 33 (9-60) months all the patients had a normal voiding pattern and were continent; none developed vaginal stenosis.

CONCLUSION

Primary repair of the urethra, and if that is impossible, simple urethral realignment over a catheter, is the procedure of choice for managing female urethral injury associated with a pelvic fracture. The procedure has the additional advantage of reducing the risk of vaginal stenosis.

Endourologic reconstruction of post-traumatic obliterated urethral stricture in a young female: a point of technique

INTRODUCTION

A simple endourologic technique for reconstruction of a post-traumatic obliterated urethra in a young unmarried woman is described as an alternative management to complex open urethral reconstruction.

TECHNICAL CONSIDERATIONS

A 20-year-old woman presented with a post-traumatic obliterated urethra after a road traffic accident. The cystogram at 6 weeks did not reveal a bladder neck or urethra. The examination under anesthesia showed just a dimple at the presumed external urethral meatus. Antegrade cystoscopy revealed a complete block just distal to the bladder neck. A puncture was made from the external urethral meatus into the bladder through the bladder neck under antegrade cystoscopic guidance. The tract was dilated up to 18F using fascial dilators over a guidewire. A 16F Foley catheter was placed for 6 weeks. The operative time was 30 minutes, with no intraoperative complications. The catheter was removed at 6 weeks. Urethroscopy showed a normal urethra. She performed self-catheterization for the initial 3 months. A micturating cystourethrogram at 3 months revealed a normal urethra. She was continent and stricture free at follow-up of 16 months.

CONCLUSION

This technique is simple and easy, with good results in selected cases of post-traumatic complete obliteration of the urethra with an intact bladder neck in young women.

Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management

PURPOSE

Urethral injury in girls accompanying fracture of the pelvis is rare. We present our experience with 5 such complex cases and review the literature to define the types of problem and determine appropriate management.

MATERIALS AND METHODS

We report on 5 girls with posttraumatic urethral injuries and pelvic fracture resulting in stricture as well as management based on the site and length of urethral stricture. Associated injuries and results are discussed.

RESULTS

Of the 5 girls who presented with stricture 4 had undergone suprapubic cystostomy as initial treatment, whereas in 1 primary repair had failed. Urethral reconstruction using a bladder flap tube and distal urethrotomy into the vagina were performed in 3 and 1 cases, respectively. These 4 girls were continent although 1 required clean intermittent catheterization for a short period. The 3 patients with complete urethral loss had a more severe degree of pelvic fracture, including 1 treated with core through internal urethrotomy.

CONCLUSIONS

Posttraumatic urethral injury accompanying pelvic fracture in young girls results in challenging management situations. More severely displaced pelvic fracture is associated with greater urethral loss and requires more complex repair. Cases of partial urethral injury or urethral transection without much displacement are better managed by primary repair of the transected urethra, which decreases morbidity. Primary repair may not be feasible in patients with extensive injury, who should be treated with secondary appropriate reconstruction after preliminary suprapubic cystostomy. Complete urethral loss may be managed by bladder flap tube neourethra creations with effective continence and excellent outcomes. Short segment distal urethral strictures may be treated with meatotomy or core through internal urethrotomy.

Pelvic fracture injuries of the female urethra

OBJECTIVE

To review pelvic fracture urethral injuries in women, generally regarded as rare and thus discussed infrequently.

PATIENTS AND METHODS

Twelve patients (age range 7-51 years) with such injuries were reviewed; most had associated injuries, generally more severe than seen in males with urethral injuries.

RESULTS

Patients with milder injuries, perhaps damaging just the innervation of the urethra, presented with incontinence; more severe injuries seemed to cause a longitudinal tear in the urethra but again patients presented mainly with incontinence problems. The most severe injuries were associated with complete rupture of the urethra and a distraction defect suggesting an avulsion injury. These problems were difficult to treat both reconstructively and in providing continence.

CONCLUSIONS

Pelvic fracture urethral injuries occur in females, but less often than in males. The female urethra seems relatively resistant to injury; differing degrees of severity of pelvic trauma cause different types of urethral injury but in general, a more severe injury is needed to damage it than is necessary in males.

Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function

OBJECTIVES/HYPOTHESIS

To evaluate the impact of a pelvic fracture on a woman's physical, sexual, and reproductive functioning.

DESIGN

Retrospective review.

SETTING

Level one trauma center.

PATIENTS

Two groups of female multitrauma patients: those with pelvic fractures (subjects) and those with extremity fractures but no pelvic fracture (controls).

MAIN OUTCOME MEASUREMENTS

Of the 302 women eligible for participation in this study, 255 (80%; 123 subjects, 118 controls) were interviewed by blinded professional interviewers regarding genitourinary symptoms, sexual function, and reproductive history.

RESULTS

Urinary complaints occurred significantly more frequently in subjects than in controls (21 versus 7%, respectively; p = 0.003), in subjects with residual pelvic fracture displacement > or = 5 mm than in those without displacement (33 versus 14%, respectively; p = 0.018), and in subjects with residual lateral (60%) or vertical (67%) displacement than in those with medially displaced fractures (21.4%) (p = 0.04). Although both groups reported increased rates of cesarean section, this increase was statistically significant only in the subject group: 14.5% preinjury versus 48% postinjury (p < 0.0001). Adjusting for previous cesarean sections, cesarean section was significantly more frequent in subjects with fractures initially displaced > or = 5 mm (80%) than in those with fractures initially displaced < 5 mm (15%) (p = 0.02). There was no difference in the incidence of miscarriage or infertility between the groups. Problems with physiologic arousal or orgasm were rare. Pain during sex (dyspareunia) was more common in subjects with fractures displaced > or = 5 mm than in those with nondisplaced fractures (43 versus 25%, respectively; p = 0.04).

CONCLUSIONS

We found that pelvic trauma negatively affected the genitourinary and reproductive function of female patients. The increased rate of cesarean section in women after pelvic trauma may be multifactorial in origin and warrants further investigation.

Incidence of urethral disruption in females with traumatic pelvic fractures

According to the National Center for Health Statistics, in 1986 1.4 million female patients in the United States were admitted to inpatient and short-stay nonfederal hospitals as a result of injuries acquired secondary to trauma. Of these, 45,000 had traumatic pelvic fractures. Rupture of the urethra is the most important lower urinary tract injury associated with traumatic pelvic fracture because of the high incidence of serious complications, such as urethral stricture and incontinence. To our knowledge, there are no satisfactory studies in the English literature documenting the incidence of urethral disruption in females with traumatic pelvic fractures. The records of all women patients with pelvic fractures registered in the Latter Day Saints Hospital trauma registry between July 1, 1981 and August 31, 1987 were reviewed. Of 146 female patients with traumatic pelvic fractures who were hospitalized during this period, none was found to have an urethral injury. Two patients (1.4%) had bladder contusions, and one (.7%) had a bladder rupture. This was the first large series attempting to identify the true incidence of urethral disruption in females with traumatic pelvic fracture, and it was found to be a rare occurrence.

Female urethral injury secondary to blunt pelvic trauma

Urethral injury after blunt pelvic trauma is rare in women. We report a case of urethral injury and vaginal laceration secondary to blunt pelvic trauma. Pelvic examination should be performed in any female patient who has sustained blunt pelvic trauma to avoid the morbidity associated with delayed diagnosis of urethral injury.

Blunt pelvic trauma

Blunt pelvic trauma results in significant morbidity and mortality from associated genitourinary, neurological, vascular, and visceral damage. Diagnosis begins in the ED with the initial trauma evaluation. Proper treatment using a multidisciplinary approach and cooperation between orthopedist, urologist, trauma surgeon, and emergency physician should minimize complications.

Delayed retropubic urethroplasty of completely transected female membranous urethra

Injuries to the female urethra, especially in childhood, are rarely seen with pelvic trauma. Complete transection of the membranous urethra was sustained by a ten-year-old girl in a car accident. A delayed retropubic urethroplasty after suprapubic cystostomy drainage was accomplished. The technique of the repair is described. Delayed repair in a female child is an excellent alternative to primary realignment if a primary repair cannot be accomplished.

Indications for retrograde cystourethrography in trauma

Injuries to the lower genitourinary tract may occur with penetrating or severe blunt lower abdominal trauma. Commonly associated findings are pelvic fractures and gross hematuria or a bloody urethral discharge. Retrograde cystourethrography should be performed in all cases of penetrating trauma when lower genitourinary tract injury is suspected. We recommend retrograde urethrography in male patients with a pelvic fracture or significant lower abdominal or perineal trauma without a fracture when associated with gross hematuria, a bloody urethral discharge, inability to void, swelling, ecchymosis or hematoma of the perineum or penis, or a "high-riding" or boggy prostate. Cystography should follow urethrography after a urethral injury has been excluded.

Urethral replacement using ileum with an intussuscepted ileal valve for continence

Numerous techniques for replacing the urethra have been previously described, but attempts to provide continence have rarely been satisfactory. Urethral replacement using ileum with an ileal intussuscepted valve for continence has been successfully performed in ten female dogs. Eight of them were available for a 1 to 6-month followup. This neo-urethra has provided good continence and can be easily catheterized. The clinical usefulness of this technique in the treatment of total urethral loss in humans needs to be further explored.

Blunt pelvic trauma with urethral injury in the female: A case report and review of the literature

A case of blunt pelvic trauma with injury to the urethra in a female is reported. Although uncommon, this type of injury is by no means as rare as previously thought. If the morbidity associated with delayed diagnosis is to be avoided, urethral injury should be a consideration in any case of major pelvic trauma in females.

Traumatic rupture of female urethra

Complete avulsion of the female urethra secondary to blunt trauma is uncommon. It is associated with pelvic fractures, and because of the close association of the urethra and vagina a vaginal laceration also occurs. The paucity of lesions associated with pelvic fracture may be explained by the relative mobility and shortness of the urethra in the female. The treatment of urethral trauma in females has not been established. Vaginal, transpubic, or retropubic approaches have been used successfully. We report on 3 cases of urethral trauma with anterior vaginal lacerations treated by retropubic approach with good results.

Genitourinary tract injuries due to fracture of the pelvis in females: sequelae and their management

The pathophysiology of injury to the female genitourinary tract secondary to a fractured pelvis has been studied in 5 patients. Delayed complications were frequent and their management is described. It is concluded that a transpubic approach to the lower urinary tract facilitates the satisfactory reconstruction of the urinary tract. Long-term follow-up of 4 to 5 years is necessary for the satisfactory management of these patients following their initial injury.

Traumatic avulsion of the lower urinary tract in the female child

We report a rare case of complete avulsion of the proximal urethra from the bladder neck and a urethrovaginal fistula secondary to blunt pelvic injury in a girl. The management consisted of a relatively simple first stage procedure, suprapubic cystostomy, followed 6 months later by transpubic repair of the defect. The child is continent and free of urethral obstruction 10 months postoperatively.