Vol. 114, J uly Printed in U.S .A.


Copyright © 1975 by The Williams & Wilkins Co.





n··1 'I



From the Division of Urology , Department of Surgery, University of Colorado Medical Center, Denver, Colorado



Two cases of non-penetrating distal urethral trauma are reported to illustrate the potential routes of urinary extravasation. The nature and management of suc h injuries are discussed to emphasize that the t):pically incomplete rupture of the qistal urethra responds satisfactorily to catheter diversion of the urinary stream , antibiotic coverage, drainage of extravasated ur and delayed debridement of n ecrotic tissue . Primary surgical repair of the urethra is rarely indicated in this injury.

I '



Genitourinary trauma most commonly involves the kidneys and less frequently the bladder and proximal or posterior urethra (fig . 1). Trauma involving the prostatic and/or membranous ure thra is almost always associated with multiple severe injuries of the bony pelvis and other organs. 1- 3 In contrast, trauma to the distal or anterior urethra is far less common and usually occurs as an isolated injury. 3 • • Distal urethral injury most often involves the bulbous portion secondary to straddle accidents in which the bul bous urethra is violently compressed against an inferior pubic ramus or the symphysis pubis. After a distal urethral injury in which a rupture or complete sep..ar.alion the uret hra is sustained, urinar extravasation occurs durin voiding. The boundaries of extravasation are determine by anatomically well defined fascia! planes (fig. 2). We nerein present 2 cases of distal urethral trauma, which clinically illustrate the 2 routes of potential extravasation determining the principles of management of such injuries.



.I j j -'r




l j




Case 1. H . H., a 52 -year-old white man, was seen in the emergency room 72 hours after he had been kicked in the groin. He had noticed a few drops of blood at the meatus and experienced mild dysuria and hesitancy during the first 24 hours after the injury. Thereafter, the urinary symptoms abated but progressive swelling and discoloration of the penile shaft developed . On admission to the hospi tal his temperature was 38C, blood pressure 100/80 and pulse rate 140. Physical examination revealed the penile shaft to be markedly edematous with several areas of obvious necrosis (fig. 3, A). The area of involvement was well demarcated at the base of the penis, with no involvement of the scrotum or abdominal wall. A single attempt to pass a 16F catheter was unsuccessful. Urinalysis showed several white and red blood Accepted for publication October 25, 1974 .



cells, and the urine culture was subsequently negative. He was given aqueous penicillin , intravenous keflin and intramuscular kanamycin. Several hours later he was taken to the operating room for insertion of a s~ ic catheter and drains (fig. 3, B and C) . Cultures of the penile drainage yielded hemolytic Streptococcus. Keflin and kanamycin were discontinued after 3 days but the penicillin was continued for 3 weeks. By 2 weeks the area of necrosis was well demarcated with eschar formation aml....de.finitfaz.e..d.e.brideroent was accomplished. This procedure was followed by ¼ per cent acetic acid wet-to-dry dressing debridement and povidone iodine* solution sitz baths. Because of the large area of skin loss a split thick~ skin graft from thigh to penile shaft was done after 20 days. The suprapubic catheter was discontinued 1 week later and the patient voided normally. A retrograde urethrogram was unremarkable. A year later the patient had no voiding difficulties, was uninfected and had a satisfactory cosmetic result. Case 2. M. L ., a 53-year-old man , was working on a car motor when it fell against him, com pressing his penis against the symphysis. He noticed minimal swelling and bruising of the penis but was able to void without difficulty. Swelling and dis comfort increased on the following day. He contin ued to void with a clear stream and did not seek medical attention until 72 hours after the injury. On admission to the hospital his scrotum and penile shaft were markedly edematous and ery thematous. Skin necrosis of the penis was a pparent and the erythema extended to the lower abdomen (fig. 4, A). He was septic with shaking chills, temperature of 40.2C and white count of 23,600. A 16F silastic catheter was easily passed into the bladder. Intravenous keflin , aqueous penicillin and intramuscular kanamycin were started . Several hours later the patient was taken to the operating room for drain placement (fig. 4, B) . Cultures of the

* Betadine, The Purdue Frederick Co., Norwalk, Connecticut.







FIG. 1. Diagrammatic illustration of divisions of urethra. Proximal or posterior urethra consists of that portion which passes through prostate and urogenital diaphragm. Distal or anterior urethra consists of bulbous and pedulous portions.







\ \



I I I / /

FIG. 2. Two major fascia! compartments involved in distal or anterior urethral injury with urinary extravasation . Buck's fascia, represented by heavy solid line, surrounds penile .corpora and is firmly fixed to inferior surface of urogenital diaphragm. Colles' fascia surrounds corpora and is fixed to urogenital diaphragm but also surrounds scrotal contents and is continuous in abdomen with Scarpa's fascia.

urine, and scrotal and penile drainage yielded Staphylococcus epidermides, Streptococcus viridans and pyogenes. Keflin and kanamycin were discontinued after 3 days but penicillin was continued for 2 weeks. Tue patient was returned to ~ e r a ting room for definitive debridement 8 days after hospitalization. T he drains were removed. Wet-to-dry dressing debridement and sitz baths with povidone-iodine solution were started. The catheter was removed after 16 days. A retrograde urethrogram was normal. Six months after

'llji,J s .'

c,,," ~fk,

~ [c,..1,~f ,; ~

the injury the patient had a normal urinary stream and was uninfected. DISCUSSION

In contrast to the patient with proximal urethral trauma classically presentmg m acute urinary retention with blood at the meatus, the patient with a distal injury is usually able to void. oft1ni with an apparently normal stream and grossly clear urine.•.• Proximal injuries often result in compietii" transection of the urethra with displace-

~ l~~ h,ev.•--v--v C4 ,t;L, f-e,

1 ~ - {.'.~






I '

ment of the severed ends by hematoma, while distal trauma usually causes only a rent or partial urethral tear, rarely resulting in complete transection and d isplacement. 3 • '· 7 • 8 Thus, in distal injuries urine can usually pass through the damaged area as well as extravasate into surrounding tissues . The severe, often life-threaten in g injuries commonly a·s sociated with proximal urethral trauma bring the patient to immediate attention . In contrast, the less severe and isolated nature of a distal inJur may lead the patient to procrastinate for liours or even ays unt1 the com me e ec of extravasated urine and superimposed mfect1on are manifested by progressive edema, ~ i n necrosis . Whether extravasated urme is limited by ~ f.ascTaor by Calies' and Scarpa's fasda various principles of management pertain.


1) Adequate drainage of extravasated urine : When Buck's fascia is intact the hematoma and extravasated urine are confined to the penile shaft (figs. 3, A and 5, A). Drainage is effected by multiple incisions through the penile skin and BucPs fascia down to the easily recognizable fibrous tunica albugi®a-These incisions are made transverse to the penile shaft and communicated b blunt finger 1ssec 10n 1g. , s~ a l ¼-inch Penrose drains can be passed through and througbjfig. 3, C) . . ,-When Buck's fascia has been ruptured the extravasation can continue into the scrotlIInwhere the attachments of Colles' fascia to t he mfenor surface of the uro enital diaphragm prev~pread into the erianal and ischiorectal areas . However, spread can continue anterior y onto t e a bdominal w~ nder Scarpa's fascia but 1s irrevented fiom

I '







i J l


j l. ..;; I




l i


FIG. 3. Case 1. A, transverse incision in penile skin down to tunica albuginea being widened with hemostat. Note sharp demarcation of extravasation at base of penile shaft. B, incision in part A being communicated with other incisions by subcutaneous blunt finger dissection. C, final placement of through and through Penrose drains. Numerous transverse incisions have been intercommunicated by blunt finger dissection to allow free placement of drains.



FIG. 4. Case 2. A, extravasation secondary to distal urethral mJury, in which Buck's fascia has been ruptured. Extravasation has continued into scrotum and onto anterior abdominal wall (latter not shown here). B, drain placement has been accomplished. Blunt finger dissection with through and through placement of drains in scrotum has been done with same technique used in placing drains in penile shaft.

FIG. 5. A, schematic representation of urinary extravasation secondary to distal urethral injury, in which Buck's fascia is intact. In this situation extravasation is limited to penile shaft. B, schematic representation of urinary extravasation secondary to distal urethral tear, in which Buck's fascia has been ruptured. Extravasation can continue into scrotum and into anterior abdominal wall.


e terin the thighs by the attachment of S a's fascia to the fascia a a 1gs. 4, A and 5, B). l.!!Jh.i.s case placement of through and through drains must include the scrotum especially its most dependent aspect (fig. 4, B). £.Q_oled urine will not be encountered because it dissects freely through alfscrotal tissue planes . It is not necessary to drain the lower ab _..- vious infection and necrosis have extended here too . lowed ta remai!'.l in place until infection is controlled and edema has subsided, usually 5 to 7 ~


2) Urinary diversion : A gentle attempt should be made initially to pass a smafi( .14 or 16F) silastic or t ~ urethra) catheter. In contrast to proximal urethral injuries the incomplete nature of most distal ruptures permits easy catheterization. • However, if unsuccessful , a suprapubic cystostomy is done. By either technique the site of injury and the extravasation are bypassed. P..!2!._onged, vigorous attempts to pass a urethral catheter and use of catheter guides and hhtorms should he condemned since they only cause further trauma to the injured urethra and may convert a partial tear into a co~lete separation.• If the patient presents immediately after injury beforeclinicaTev1aence of extravasation is present, a -retrograde urethrogram should be done . If a rupture 1s demonstrated a catheter should be inserted and antibiotic coverage instituted. In this circumstance no other treatment may be required . \'

Management of non-penetrating distal urethral trauma.

Two cases of non-penetrating distal urethral trauma are reported to illustrate the potential routes of urinary extravasation. The nature and managemen...
1MB Sizes 0 Downloads 0 Views