The diagnosis of PFUI is based on anamnesis, symptoms and urethrogram. A patient presenting at the emergency room after a road-traffic accident or fall from heights, with inability to void and blood at the urethral meatus or gross hematuria, should raise the suspicion of PFUI. Urethrogram represents the cornerstone for the diagnostic appraisal of PFUI.

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In PFUI the key responsibilities are: i) stabilization of the patient; ii) assessment of associated injuries; iii) assessment of urethral injury. Diagnostic measures of urethral injury should be delayed until higher priority systems have received appropriate attention. Only when the patient is hemodynamically stable and no other surgery is imminent that management of urethral injury can be undertaken.

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Immediate management of patients with PFUI

The major concern surrounding the immediate management of PFUI is the potential risk of three major complications: stricture, incontinence, and erectile dysfunction. These complications may result directly from initial trauma and/or iatrogenic trauma induced by the immediate treatment.   

Initial treatments:

• Suprapubic cystostomy alone: In local anesthesia, a suprapubic catheter is placed to drain the urine, and no attempt is made to explore or manipulate the urethra. This option accepts the inevitability of stricture formation (89-94%) following complete urethral rupture which is repaired electively several months later. A gentle urethral catheterization can be attempted before suprapubic cystostomy, but only by experienced hands. 

• Primary realignment: Includes endo-urological and fluoroscopy-guided techniques to establish primary realignment of the urethra 1-19 days after injury, in patients who are hemodynamically stable. This includes different techniques of “railroading” to manipulate a catheter across the urethral gap. The aim of realignment is to pull the proximal urethra down snugly against the distal stump so that healing will occur with minimal stricture. Open surgical realignment can be performed only during surgery for other reasons. Instead, it is contraindicated if the surgery is perform for urethral purpose only.

• Delayed urethroplasty: it is usually performed 3 to 6 months after trauma when the paraurethral hematoma has been reabsorbed. It is a challenging operation that requires a dedicated team of reconstructive urologists.

 

Delayed management of patients with PFUI

After PFUI, a stenosis of the posterior urethra is likely to occur. The stenosis usually involves the bulbomembranous junction, and it is frequently completely obliterative. Indeed, patients usually need suprapubic catheter for draining out the urine from the bladder. Three investigations are usually performed to assess the status of patients after PFUI.

1. Combined retrograde (RGU) and micturition (MCU) urethrography: It is used to estimate the gap of the urethral stenosis, a combined RGU and MCU is necessary before planning surgery. The exam is also crucial to exclude the presence of rectourethral fistulae that are a potential concomitant condition in patients with PFUI

2. Penile color doppler of cavernosa and dorsal penile arteries: Both the cavernosa and dorsal penile arteries might be involved in pelvic trauma, thus resulting in erectile dysfunction of vascular origin. Also, the nervi erigentes can be compromised or damaged resulting in a neurogenic erectile dysfunction, or combined vascular and neurogenic erectile dysfunction. The doppler of the penis after papaverine injection allows a comprehensive evaluation of vascular and neurological function. The examination is usually performed in outpatient setting and it does not require any specific preparation.

3. Urodynamic investigation is also recommended after PFUI. The aim of the examination is to assess the bladder contractility and sensibility that can be lost after pelvic trauma if pelvic nerves had been damaged. The exam presents some technical difficulties in PFUI patients because the urethra is blocked and it does not allow the trans-urethral catheter to be placed. Here, the suprapubic catheter can be transduced instead and also used to fill the bladder. The examination requires high expertise and should be performed only by trained urologists.

4. Small caliber anterograde and retrograde urethroscopy: The proximal and distal urethral ends should be visualized before surgery to assess the status of the mucosa and the caliber of the urethral ends. Here, distal urethra should be assessed with retrograde urethroscopy, proximal urethra with trans-vesical cystourethroscopy.

5. Pelvic MRI: The use of MRI is still investigational in this setting. However, MRI has shown to improve the characterization of the stricture in PFUI patients, especially to predict the need for pubic bone osteotomy (inferior pubectomy).

 

Surgery

In patients with PFUI, surgery is usually carried in a stepwise fashion (as described by Webster in 1986). By definition, PFUI strictures are secondary to trauma, thus anastomotic urethroplasty is the preferred option. Patient is accommodated in a social lithotomy position with legs supported by the Allen’s stirrups. Under spinal or general anesthesia, a perineal vertical incision is taken and the urethra is circumferentially dissected, from the two corpora cavernosa, from the level of peno-scrotal junction down to the distal limit of the stricture. The urethra is transected at the distal limit of the stricture, and the proximal urethral end is identified by the gentle passage of a urethral bougie through the suprapubic cystostomy. Sharp dissection into the tip of the sound identifies the normal proximal urethra, which is dissected from 3 to 9 o’clock positions and spatulated anteriorly (Step 1). When the proximal and distal urethral ends cannot be easily approximated or when the proximal urethral stump cannot be identified by the urethral bouge maneuver, the field of dissection should be extended higher above. In these circumstances the corporeal bodies should be separated distally from the level of the crus (Step 2). Here, care must be taken to preserve the deep dorsal penile vein. If required, pubic osteotomy can be performed removing a wedge of pubic bones after periosteum elevation (step 3). This step allows a deeper access of the proximal urethra and facilitate the removal of the scar surrounding the proximal urethral stump. Once the two urethral ends have been spatulated, the anastomosis can be performed. In some cases, the length of the gap does not allow a tension-free anastomosis. Here, supracrural rerouting is advised to reduce the distance between the two urethral ends (step 4). In complex cases, direct anastomosis cannot be achieved with the perineal approach. Here, the transpubic/abdominal approach with posterior pubectomy is necessary to dissect the proximal urethra (step 5). The interposition of omentum (omentoplasty step 6) may facilitate the healing and reduce the risk of recto-urethral fistulae. After PFUI repair, a 14-16Ch silicone urethral catheter is used to support the repair and it is kept for 4 or 6 weeks.