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Pelvic Fracture Related Urethral Injury

What is a pelvic fracture urethral injury (PFUI)?

A pelvic fracture urethral injury (PFUI) is a condition where the urethra, the tube that carries urine from the bladder out of the body, is damaged as a result of a fracture of the pelvis.

Injuries to the urethra occur in about 10% of pelvic fractures, which occur as a result of trauma, such as from a motor vehicle accident or a fall from a height. The severity of the injury can vary from a tear or bruise in the urethra to a complete rupture of the urethra. In a complete rupture, there is no longer any connection between the bladder and the urethra.

What causes a PFUI?

In males, the urethra runs through the prostate gland. There are ligaments (connective tissue) running from the prostate to the pelvic bones. There are other ligaments connecting the urethra itself to the pelvic bones just below the prostate. When a fracture occurs, the bone pieces move; hence, the prostate and urethra can move in different directions from each other and a tear can happen. In females, the urethra is shorter and located closer to the pelvic bone, making it susceptible to injury in cases of pelvic trauma.

How do I know if I have a PFUI?

Nearly all PFUIs are diagnosed while the person is in the hospital being treated for their acute injuries from the pelvic fracture. There will be blood in the urine or an inability to urinate.

How is PFUI diagnosed?

Cystoscopy: A small flexible camera can show that the urethra has a tear in it.

Urethrogram (X-ray): A urethrogram is an x-ray that involves squirting dye through the urethral opening. At the time of the injury, it may show dye leaking through the tear in the urethra. Weeks later this tear will develop into a scar and the x-ray will show a narrowing or total blackage at the area of injury.

How is PFUI managed?

At the time of the injury it would be unwise to do fancy surgery to repair the hole in the urethra. The tissues are too swollen and there is too much bleeding. It is much better to place a catheter and worry about repair at a later time.

Endoscopic realignment: At the time of injury, or in the first few days after injury, a camera can be used through the urethra to try to get a wire past the injured area and then place a catheter over the wire. As the urethra heals, it will do so over the catheter. Most studies show that simple PFUIs (small tears) may heal very well this way. But, complex PFUIs (such as a complete disruption) are going to scar no matter whether there is a catheter placed through the injured area or not.

Suprapubic catheter: At the time of injury, a suprapubic catheter can be placed through the skin on the lower abdomen directly into the bladder to all ow the bladder to drain. This is an alternative to endoscopic realignment.

Urethroplasty: Urethroplasty is a plastic surgery rebuilding of the urethra. The scar tissue is removed, and the two healthy ends of the urethra are reconnected. This would not be appropriate at the time of the injury and is usually performed 3-6 months after the injury. This is a surgery commonly performed by Dr. Elliott, with success rates over 90%.

 

Below is a link to an article written by Dr. Elliott about outcomes with this surgery.

Cooperberg MR, McAninch JW, Alsikafi NF, Elliott SP. Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25-year experience. J Urol. 2007 Nov;178(5):2006-10; discussion 2010. doi: 10.1016/j.juro.2007.07.020. Epub 2007 Sep 17. PMID: 17869302.

 

https://pubmed.ncbi.nlm.nih.gov/17869302/

What is an example of a urethroplasty? 

Although most injuries are not this severe, below are before and after x-rays of a male patient that Dr. Elliott treated with urethroplasty. He was a pedestrian hit by a car and fractured his pelvis. You can see a long gap between his upper urethra and his lower urethra on the “before” x-ray and how Dr. Elliott was able to reconnect the two ends with surgery. He is now urinating very well. Click here to see diagrams and read a description of the steps involved in a urethroplasty for pelvic fracture urethral injury.  

PFUI Before.png

Before

PFUI After.jpg

After

Surgery for PFUI

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