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Posterior urethral injuries and management

Author
Andrew Peterson, MD
Section Editor
Jerome P Richie, MD, FACS
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

Any blunt or penetrating trauma to the penis, scrotum, perineum, or pelvis may cause injury to the urethra. The male urethra is divided into the anterior (bulbous and pendulous) and posterior (prostatic and membranous) urethra at the level of the urogenital diaphragm (figure 1). Anterior urethral injuries may be caused by direct blows, straddle injuries, instrumentation, or penile fracture. By contrast, posterior urethral injuries usually occur in the setting of significant pelvic fractures, often caused by motor vehicle collisions (table 1). Urethral injuries are much less common in women because the female urethra is short, relatively mobile, and lacks significant attachment to the pubis.

In this topic, we will concentrate on posterior urethral injuries, including their etiology, clinical manifestations, diagnostic evaluation, and management. A discussion of anterior urethral injuries and other genitourinary traumas can be found in other UpToDate topics. (See "Blunt genitourinary trauma: Initial evaluation and management" and "Urethral strictures in men" and "Pelvic trauma: Initial evaluation and management" and "Severe pelvic fracture in the adult trauma patient".)

EPIDEMIOLOGY AND ETIOLOGY

Traumatic injury to the posterior (prostatomembranous) urethra occurs in 10 percent of pelvic fractures [1]. Blunt trauma from motor vehicle accidents or occupational injuries account for at least 90 percent of the cases, but penetrating trauma can result in these injuries as well [2,3].

The urethra is most often injured in fractures that disrupt the pelvic region or cause diathesis of the pubic symphysis [4,5]. The risk of urethral injury varies with the types of pelvic fractures [5-9]. High-risk injuries include concomitant fractures of all four pubic rami or fractures of both ipsilateral rami accompanied by massive posterior disruption through the sacrum, sacroiliac joint, or ilium. Low-risk injuries include single ramus fractures and ipsilateral rami fractures without posterior ring disruption. The risk of urethral injury approaches zero with isolated fractures of the acetabulum, ilium, and sacrum [1].

Posterior urethral disruption occurs when a significant pelvic fracture causes upward displacement of the bladder and prostate. Avulsion of the puboprostatic ligament is followed by stretching of the membranous urethra resulting in a partial or complete disruption at the anatomic weak point, the bulbomembranous junction [1].

                  
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Literature review current through: Nov 2017. | This topic last updated: Sep 25, 2017.
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