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30 Diagnosis ofUrethral Injury: Symptoms, Signs, andImaging Studies
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30.2 Imaging Investigations
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Fig. 30.2 (a–e) Delayed retrograde urethrography performed in ve different patients: (a) Very
short bulbar urethra. (b) Two bulbar strictures that collectively measure 3cm long. (c) Long bulbar
stricture. (d) Residual membranous urethral stricture after PFUI in RTA treated initially with pelvic xation and SPC. (e) Panurethral stricture. (Courtesy Ashraf Abdelsalam Al Ozeni, Urology,
The Royal Hospital, Muscat, Oman)
243
solution at the fossa navicularis to prevent reux and leak of the contrast
out the external meatus.
– Rotate the uoroscopic C-arm 30° left or right anterior oblique position
to demonstrate the full urethra.
– Place the penis laterally over the thigh, and slowly inject 20–30mL of an
iodinated contrast agent with uoroscopic recording. Continue injecting
until the contrast material is seen owing past the external urethral
sphincter and entering the bladder. Continuous pressure is advised to
overcome the external sphincter spasm that tends to prevent the lling of the membranous and prostatic urethra.
Retrograde or ascending urethrography is contraindicated in patients
with allergy or hypersensitivity to the contrast medium, urinary infection,
and recent urethral instrumentation. Its complications are very rare and
include anaphylaxis, urinary tract infection, extravasation, urethrovenous intravasation, and possible sepsis. The urethro-venous intravasation results from a forceful push of contrast against an obstructed urethra
resulting in mucosal tear and a contrast escape into the penile venous
plexus [10–12] (Fig.30.3a, b). A case of Fournier’s gangrene has been
described after retrograde urethrography and extravasation [13].
(b) Antegrade or descending urethrography [8].
– Adequately ll the bladder with 350–400mL of the contrast agent through
the SPC.
– Instruct male patients to micturate into a bottle while in an oblique stand-
ing position.
The expression “Pie-in-the-sky bladder” was rst used by TurnerWarwick referring to the radiological image of an upward-pushed bladder on antegrade or retrograde urethrocystography [14–16] (Fig.30.4).
He did mention at the same time that the bladder dislocation is due to the
intervening pelvic hematoma and advocated an observation over months
to allow shrinking of the hematoma and descent of the bladder neck
toward the urethra. With this expectant management, an initial gap of
10–15cm might reduce to 3–4cm after 1year.
Well before Turner-Warwick coined the above expression, Prather and
Kaiser invented the expression “tear-drop bladder” in 1950, which is a
synonym of “pear-shaped” bladder deformity [17]. The bladder appears
vertically elongated due to extrinsic compression, either as the consequence of a pelvic hematoma or of other entities such as pelvic
lipomatosis, inferior vena cava occlusion, lymphoceles, enlarged pelvic
lymph nodes [18, 19] (Fig.30.5).
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30 Diagnosis ofUrethral Injury: Symptoms, Signs, andImaging Studies
ab
Fig. 30.3 (a) Retrograde urethrography in a 37-year-old man showing an obstructing bulbar ure-
thral stricture with contrast intravasation in the corpus spongiosum, periurethral, circumex, and
pelvic (pudendal) venous plexus. (Courtesy Qais Al Hooti, Urology, The Royal Hospital, Muscat,
Oman). (b) Another retrograde urethrography in a 26-year old man with severe stricture at the
bulbar urethra demonstrating extensive intravasation into the corpus spongiosum and periurethral,
cicumex, and pelvis veins. St Stricture, UR Urethra distal to the stricture, CS Corpus spongiosum
(superposed with proximal urethra), VI Venous intravasations
Combination of an antegrade with a retrograde urethrogram
The combination of a suprapubic antegrade cystourethrography with
an ascending urethrogram is sometimes referred to by the funny name
“up- and- downogram.” It is the investigation of choice in assessing the
site, the severity, and the length (gap) of urethral injuries, and should be
performed within a week from the time of injury if one considers a
delayed primary repair, or at 3months when a deferred or late repair is
contemplated [1] (Fig.30.6)
(c) Pericatheter Urethrography
In patients who have already an indwelling urethral catheter, this should
be kept in position as long as the entire urethral integrity is not ascertained.
Therefore, one should perform the pericatheter ascending technique
whereby the contrast is instilled at the external meatus through a smallgauge pediatric catheter (4–6Fr), or a small-bore (4–6Fr) feeding tube, or a
20-gauge (1.1 mm) 1-inch (25 mm) long angiocatheter alongside the
indwelling catheter [8, 20] (Figs.30.7, 30.8, and 30.9). Once the bladder is
lled with contrast, the descending pericatheter urethrography is simply
performed by removing the small-gauge catheter, deating or pushing the
indwelling catheter balloon into the dome of the bladder, and asking the
patient to void around the indwelling catheter [8, 20].
2. Sonourethrography
Ultrasonographic studies are possible by distending the urethra with saline or
lubricant jelly and using ultra-high-frequency linear probes along the penile and
perineal tract [21]. Sonourethrography showed great accuracy in measuring
30.2 Imaging Investigations
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245
a
b
c
Fig. 30.4 (a) Cystography through SPC showing a high-riding or “Pie-in-the-sky” bladder caused
by a large hematoma in the Retzius space. (b) Stretched supra-membranous urethra, being displaced posteriorly and superiorly and compressed laterally. (c) Projectional bladder displacement
occurring with displacement of the anterior pelvic ring. (From Andrich DE etal. [15], with permission from John Wiley and Sons)
stricture length in the bulbar urethra, in diagnosing spongiobrosis (shown as a
lack of distensibility during retrograde instillation of saline solution), and also in
detecting incidental ndings such as calculi, false passage, etc. [22].
3. Magnetic Resonance Imaging (MRI)
MRI can dene the urethral gap very accurately and will add additional infor-
mation about the direction and extent of prostatic displacement, the density of
urethral and periurethral brosis (spongiobrosis), the presence of paraurethral
false tracks, an eventual avulsion of the corpus cavernosum as a possible cause
of impotence for some patients, the presence of periurethral cavity formation,
the eventual protrusion of the rectum between the urethral ends, and the presence
of periurethral stula [9, 23, 24] (Fig.30.10).
Unfortunately, the routine use of MRI is hindered by its cost and unavailability
in many rural and regional hospitals.
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Fig. 30.5 The “pearshaped” bladder, a result of
pelvic hematoma, is
opacied on this image
obtained after intravenous
contrast material
administration for
computed tomography.
Note the diastasis of the
symphysis pubis and right
sacroiliac joint. (From
Triffo W.J etal. [19], with
permission from Springer
Nature)
Fig. 30.6 Combined
antegrade and retrograde
urethrogram (“up-anddownogram”) in a
post-RTA patient with
PFUI showing a complete
rupture of the membranous
urethra with signicant
gapping. (Courtesy Kurian
George, Retiree from the
Urology Department, The
Royal Hospital, Muscat,
Oman)
30 Diagnosis ofUrethral Injury: Symptoms, Signs, andImaging Studies
ab
ab
30.2 Imaging Investigations
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Fig. 30.7 (a, b) Insertion of angiocatheter alongside Foley catheter for pericatheter retrograde
urethrography. (From Sussman RD etal. [20], with permission from Springer Nature)
247
Fig. 30.8 Fluoroscopic results of pericatheter RUG: (a) early lling with minimal leakage from
urethral meatus, (b) late lling with contrast alongside catheter to level of bladder without obvious
extravasation. (From Sussman RD etal. [20], with permission from Springer Nature)
248
ab
cd
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Fig. 30.9 Fluoroscopic results of pericatheter RUG: (a) early lling with gross extravasation, (b)
subsequent image of the same patient after 2 weeks with resolution of extravasation. (From
Sussman RD etal. [20], with permission from Springer Nature)
30 Diagnosis ofUrethral Injury: Symptoms, Signs, andImaging Studies
a
b
Fig. 30.10 Representative preoperative MRI ndings in patients with urethral stenosis after
PFUI. (a) Lateral displacement of the proximal urethral end (arrow) from the midline (dotted line)
in the axial T2-weighted image, (b) cavity formation just behind the proximal urethral end (arrow)
in the sagittal T2-weighted image, (c) bulging of the rectum into the urethral gap (arrow) in the
sagittal T2-weighted image. (d) Periurethral stulas (arrow) in contrast-enhanced T1-weighted
image. (From Horiguchi A [9], with permission from John Wiley and Sons)
References
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30 Diagnosis ofUrethral Injury: Symptoms, Signs, andImaging Studies
Treatment ofUrethral Injury. I:
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ThePosterior Urethra
Before embarking on a very long journey in what looks like the Amazonian forest,
it is important to clarify the exact meaning of certain concepts used in this chapter.
The WHO experts’ consensus recommends the following terminology be used with
regard to the timing of the surgical intervention: “immediate treatment” when the
intervention is undertaken within minutes or hours of the injury, “delayed primary
treatment” when it is performed in 2–14days, and “deferred treatment” for sur-
gery taking place after 3months or more [1].
The preservation of the integrity of the bladder neck is of paramount importance
because urinary continence after posterior urethroplasty mainly depends on the
bladder reconstruction and to a lesser extent on the preserved external sphincter
which is damaged most of the time [2, 3]. A urodynamic study to assess the sphincteric and detrusor function may be necessary before posterior urethroplasty but will
be possible only if there is continuity of the urethral tract. The competence of the
bladder neck not only depends on its anatomical and physiological integrity but also
on the stability of the detrusor. It is important to remember that the functional length
of the bladder neck mechanism extends well beyond its mere anatomical location
encompassing the proximal half of the posterior urethra, up to the level of the verumontanum. The bladder neck function is difcult to study in the absence of urethral
patency, but one can make out a favorable impression through the cystographic
observation of its closure at rest and its opening when the patient tries to void [2].
Herein it was shown that incontinent patients have a signicantly greater average
bladder neck and prostatic urethral opening on the cystourethrogram compared to
continent patients with 1.68cm and 0.9cm, respectively [4].
While only a small number of urologists have enough experience to perform
reconstructive procedures of the injured urethra, it is important for all to master the
principles of its management as this will frequently be encountered in their professional practice. As mentioned in the epidemiology chapter, it should be remembered
that in industrialized countries the prevalence of urethral stricture disease of all etiologies in men is estimated to be 900 per 100,000 population (0.9%), and in the
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© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_31
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