PFUI in female is a rare entity, but represents a challenging surgical condition. Compared to the male urethra, the female urethra is shorter and it has greater inherent elasticity and flexibility provided by the vagina. In consequence, the risk of urethral injury after pelvic fracture are lower in femalecompared to men. Nonetheless, they still occur when the trauma is particularly violent. Reported incidence of femalePFUI ranges from 1 to 6%.
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Concomitant vaginal,perineal, bladder or pelvic floor injury is verycommon in most cases of PFUI. The initial management is usually conservative and it require placement of suprapubic catheter to drain the urine. Subsequently, the severity of urethral injury and the assessment of collateral complications can be investigated with local examination, urethroscopy and MRI. Unlike males, (RGU/VCUG) is inadequate for diagnosis of female PFUI, both during acute injury or delayed phase.
The diagnosis
is best carried out via examination under anesthesia with cysto-urethroscopy and vaginoscopy. Cystoscopic examination under anesthesia on suprapubic cystoscopy is highly recommended to assess bladder neck and proximal urethra.
Goals of management in every case should be to restore urethral anatomy for normal voiding and continence. Uro-genital or fecal fistula repair, or vaginoplasty would be necessary in many cases depending upon the types and extent of injuries.
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Surgery
Surgery is usually carried with a suprapubic approach for PFUI that involved the proximal urethra or perineal approach for those involving the distal urethra and vaginal introitus. Sometimes, a combined approach (trans-abdominal and perineal) is required. Genital reconstruction like urogenital fistularepair or vaginoplasty should be an integral
part of any attempts at surgical repair. Lastly,after multiple surgical attempts, salvage options include continent Mitrofanoff’svesicostomy or permanent suprapubic catheter.
To restore the normal urethra many options are possible including anastomotic urethroplasty or non-transecting anastomotic urethroplasty. In some patients presenting with proximal uretro-vaginal fistulae, before the anastomosis, a sheet of omentum is placed over the repaired vagina as an intervening layer.
