Pelvic fracture urethral injury in males—mechanisms of injury, management options and outcomes

Abstract

Pelvic fracture urethral injury (PFUI) management in male adults and children is controversial. The jury is still out on the best way to manage these injuries in the short and long-term to minimise complications and optimise outcomes. There is also little in the urological literature about pelvic fractures themselves, their causes, grading systems, associated injuries and the mechanism of PFUI. A review of pelvic fracture and male PFUI literature since 1757 was performed to determine pelvic fracture classification, associated injuries and, PFUI classification and management. The outcomes of; suprapubic catheter (SPC) insertion alone, primary open surgical repair (POSR), delayed primary open surgical repair (DPOSR), primary open realignment (POR), primary endoscopic realignment (PER), delayed endoscopic treatment (DET) and delayed urethroplasty (DU) in male adults and children in all major series have been reviewed and collated for rates of restricture (RS), erectile dysfunction (ED) and urinary incontinence (UI). For SPC, POSR, DPOSR, POR, PER, DET and DU; (I) mean RS rate was 97.9%, 53.9%, 18%, 58.3%, 62.0%, 80.2%, 14.4%; (II) mean ED rate was 25.6%, 22.5%, 71%, 37.2%, 23.6%, 31.9%, 12.7%; (III) mean UI rate was 6.7%, 13.6%, 0%, 14.5%, 4.1%, 4.1%, 6.8%; (IV) mean FU in months was 46.3, 29.4, 12, 61, 31.4, 31.8, 54.9. For males with PFUI restricture and new onset ED is lowest following DU whilst UI is lowest following DPOSR. On balance DU offers the best overall outcomes and should be the treatment of choice for PFUI.

Management of male pelvic fracture urethral injuries: Review and current topics

“…A rectal examination should always be carried out to exclude an accompanied rectal injury, which is noticed by blood on the examination finger and/or a palpable rectal laceration . A rectal examination might show a superiorly displaced (“high‐riding”) prostate, which is relatively unreliable in the acute setting of PFUI, because the pelvic hematoma caused by pelvic fractures often disturb precise palpation of a small prostate, particularly in young males . Other signs of urethral injury include difficulty or inability to pass a urethral catheter and a distended palpable bladder due to the inability to void .…”

“…Other signs of urethral injury include difficulty or inability to pass a urethral catheter and a distended palpable bladder due to the inability to void . It should be also noted that the clinical symptoms might become apparent only >1 h after the injury …”

“…b). However, the distinction between a partial rupture and a complete rupture is not always possible, because some patients with a partial disruption might have concomitant sphincter spasms preventing passage of contrast medium into the bladder …”

“…2,16,28 A rectal examination might show a superiorly displaced ("high-riding") prostate, which is relatively unreliable in the acute setting of PFUI, because the pelvic hematoma caused by pelvic fractures often disturb precise palpation of a small prostate, particularly in young males. 27,29,30 Other signs of urethral injury include difficulty or inability to pass a urethral catheter and a distended palpable bladder due to the inability to void. 2,31 It should be also noted that the clinical symptoms might become apparent only >1 h after the injury.…”

“…2,31 It should be also noted that the clinical symptoms might become apparent only >1 h after the injury. 30 When a PFUI is suspected in the acute setting, retrograde urethrography is the standard diagnostic investigation. 26,31,32 The site and the extent of urethral injury can be identified by the urethrography.…”