If the male pelvis is fractured or crushed, it is considered a very serious and drastic injury. However, to make matters worse, a pelvic fracture can lead to an associated injury in which the urethra in the area under the prostate is torn. In some cases, this can be a partially torn urethra, but more often a pelvic fracture can lead to a completely torn urethra. A pelvic fracture urethral injury (PFUI) most commonly occurs as a result of a motor vehicle accident, but can also be caused by pelvic crush injuries such as work-related falls or other trauma. This urethral trauma is most commonly called a pelvic fracture urethral injury (PFUI), however, the injury has also been referred to as a prostatomembranous urethral injury or a pelvic fracture urethral distraction defect (PFUDD). Regardless of the name of the injury, patients simply think of it as a torn urethra that they want to be fixed!
Fortunately, these injuries can be effectively repaired. The Center for Reconstructive Urology has a 21-year history of successfully repairing torn urethras with a 99+% technical success rate. Our incredibly high success rate even includes more complex cases in which patients have had one or more failed surgeries by other Reconstructive or General Urologists, and then came to us for a successful re-do surgery. Detailed information about our approach and the development of specialized, cutting edge instrumentation by Dr. Gelman to facilitate a successful repair, can be found in his most recently published surgical textbook chapters on the subject:
Posterior Urethral Strictures article in Advances in Urology volume 2015
This section of our educational website is for men who suffered a pelvic fracture urethral injury or tear. It details the best way to have a pelvic fracture urethral injury effectively evaluated and permanently fixed so they can go back to living a happy and healthy life. It is essential to learn as much information as possible to make for informed consent to any and all treatment. An inexperienced surgeon may attempt treatment and fail, and it is important to know what options remain after ineffective treatment. We are seeing more and more men with one or more failed repairs who are mistakenly told that their only option is to repeatedly insert catheters into their urethras to keep the area of injury open. This is simply not the case, as there are various other treatment options.
Initial Evaluation and Management of Pelvic Fracture Urethral Injury
Patients who suffer pelvic bone fractures from trauma are immediately transported by ambulance to the nearest Emergency Room. In general, many of these patients are found to have blood at the tip of the urethra, which is a sure sign of a pelvic fracture urethral injury. If this is the case, the next step is to confirm the diagnosis, and an appropriate diagnostic evaluation is performed using a urethral imaging X-ray study retrograde urethrogram (RUG).
This image is a retrograde urethrogram (RUG) obtained after pelvic trauma caused a urethral injury. A contrast fluid was injected through the urethra, and in the image, the contrast did not remain contained within the urethra. Instead, it escapes through the area of the tear into the surrounding tissues, confirming the diagnosis. This is called contrast extravasation.
Men who suffer a complete tear of the urethra are unable to urinate, requiring the placement of an emergency suprapubic tubes immediately after the injury. A suprapubic tube is a catheter that enters the bladder directly through the area between the penis and belly button, commonly known as the lower midline abdomen. This allows for urine in the bladder to pass through the tube and then drain into a collection bag, letting the bladder successfully empty of all fluids. Since this bladder drainage tube is what allows the bladder to empty as the urethra is stabilizing, it is important that this tube be of proper size and location.
The suprapubic tube is placed through a small hole in the skin between the penis and umbilicus (belly button) to allow for direct access to the bladder. A small balloon is inflated at the tip of the catheter inside the bladder to keep the catheter from sliding out.
If the urethra is completely torn, a Urologists may choose to perform a surgery called Primary Realignment. The objective of this surgical procedure is to push a catheter through the penis and the area of injury, leading it into the bladder. The idea behind a Primary Realignment is that as healing occurs and the blood surrounding the injury (hematoma) gets reabsorbed back into the body, the presence of a stenting catheter will allow the severed ends of the urethra to come together. Therefore, when the catheter is removed, the hope is that the urethra will remain open. If not, this “realignment” will lead to subsequent surgery.
The relative effectiveness of a Primary Realignment is the subject of some controversy among Urologists. At the Center for Reconstructive Urology, we do not consider this technique to be effective when treating a complete urethral tear that developed as a result of a pelvic fracture. What is not controversial is that if a urologist completes a Primary Realignment and the catheter eventually comes out, under no circumstances should the urethra be repeatedly catheterized to “keep it open” in an effort to avoid surgical repair. This will not be curative and will instead result in an unnecessary delay of actual curative treatment.
Delayed Repair of Pelvic Fracture Urethral Injury
While most men with urethral tears and suprapubic tubes yearn for immediate surgical repair, they will usually have to wait for treatment. We advise that they wait approximately 3 months with the suprapubic tube before undergoing surgical repair, called posterior urethroplasty. If a patient is healing from other issues, such as other bone fractures, they will need to wait even longer. All other injuries need to first heal before we are able to do urethral surgery. During this crucial healing time, the torn severed urethra seals off and the swelling in the surrounding tissues goes down. As the patient waits for surgery, the suprapubic tube allows for the bladder to empty.
After around three months of healing occurs, the urethra will no longer be torn. However, there will be significant scarring in the area surrounding the urethral tear, and the 2 ends will not be successfully connected. The main purpose in delaying evaluation is so that the exact length and location of the defect can be precisely determined in preparation for surgery.
Evaluation of a Torn Urethra Prior to Surgery
The evaluation process of patients with posterior urethral disruptions consists of simultaneously performing a retrograde urethrogram and a cystourethrogram. A retrograde urethrogram involves injecting contrast through the urethra from below and capturing images of what occurs, and a cystourethrogram involves inserting a scope through the tract established by the suprapubic tube from above. It is our preference to perform these tests in the operating room.
The following slide show provides pictures and information describing the various methods we use to evaluate patients before surgery.
Those patients who suffer traumatic urethral injuries often have associated vascular and nerve damage affecting the penis and urethra, and over half suffer erectile dysfunction as a result of the injury. We evaluate the vascular status prior to urethral reconstruction using an ultrasound test called a Penile Duplex. Most patients, even with some arterial compromise, have enough blood flow to have their urethras repaired without concern about proper healing. This test confirms adequate blood supply to the urethra. Occasionally, we document severe impairment, and in these cases, perform a revascularization procedure prior to urethral reconstruction so that the urethra will then have adequate blood supply at the time of repair. This is very rarely required.
In summary, when a man suffers a urethral tear, the initial management is placement of a bladder drainage tube called a suprapubic tube and patience is required as the tissues heal for at least 3 months. Then, before posterior urethoplasty surgery to repair the urethra, what is needed is:
The suprapubic tube to be at least size 16 and in the middle and at least 1 inch above the bone and for the tube to be in this location for at least 1 month prior to surgery.
All bone fracture damage to the pelvic has healed well enough that the legs can be positioned in stirrups as this position (called lithotomy) is used during surgery. In some cases, more than 3 months of physical therapy is needed before the orthopedic pelvic injuries are healed well enough for the urethral surgery to be scheduled.
Imaging has been performed from above and below at the same time in a very precise way to confirm that the injury is in the typical location and amenable to a surgery where the scar is removed and the severed ends of the urethra can then be re-connected.
The erectile function has been tested by a penile ultrasound (called a penile duplex) which is especially beneficial when there is erectile dysfunction caused by the pelvic fracture injury.
Our patients have the urine tested during the week prior to surgery and appropriate antibiotics are started prior to surgery based on urine culture results. In some cases, patients are admitted to the hospital the day prior to surgery to receive intravenous (IV) culture specific antibiotics. This is done because when patients have suprapubic tubes, the urine is generally contaminated with bacteria, and we want to take every precaution to prevent a wound infection and an associated breakdown of the repair. Although some may consider this “overkill”, we have seen patients who were not managed according to our protocol and suffered this devastating complication, and we have performed hundreds of perineal proximal reconstructive surgeries over the past 20 years without ever having an infection related failure.
The following slide show describes our approach to surgery.
Our patients are maintained with urethral catheters and suprapubic tubes for 3 weeks after surgery, and then return for an imaging test called a voiding cystourethrogram. In general, at that time, both tubes are then removed, and our patients resume normal urination without need for further intervention.
The image on the left was taken of one of our patients prior to surgery to repair his pelvic fracture urethral injury by a posterior urethroplasty. The image on the right was the post-operative imaging called a voiding cystourethrogram. This image after surgery was obtained by easily filling the bladder with contrast and then taking a film during urination. The image shows a wide open urethra and a “water tight” repair.
Posterior urethral reconstruction is a very difficult surgery. However, these injuries are amenable to repair with a very high success rate when properly performed and with custom specialized instruments. The outcomes are highly surgeon dependent. To date our technical success rate has been 99+% with up to 20-year follow-up. To clarify, we define success as a wide-open urethra that stays open when the catheter is removed after surgery without the need for catheters to ever then be inserted to “calibrate” or maintain the opening or “stabilize” the urethra. If any dilation or internal incision (called a urethrotomy) is needed to open back up the urethra after a repair, this means that the surgery failed. While it is true that recurrence of stricture is always a possibility, it should be a very uncommon occurrence. The most common cause of failure is inexperience of a surgeon who is not exclusively specialized in male urethral-genital reconstructive surgery. Patients who come to us for re-do surgery after 1 or more failed surgeries elsewhere can still be successfully fixed with a surgery that is generally even more complex than a first surgery. In general, it is our expectation that just about everyone who has a pelvic fracture urethral injury can undergo a successful repair and resume normal urination without the need for tubes or dilations or other intervention. There are exceptions, but these are very rare.
