AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

Background

Injury to the urethra is usually associated with severe pelvic trauma in males. The results of such an injury can have enduring consequences that include stricture, impotence, and incontinence.

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Bladder Control Problems.

Pathophysiology

Trauma to the urethra can be attributed to guns, knives, surgical or urologic instruments, blunt trauma, straddle injuries, or penile fracture (Goldman, 1996; Hernandez, 1999; Koraitim, 1996; Tsang, 1992). Most male posterior urethral injuries, however, are the result of blunt pelvic trauma most often associated with a vehicular accident or a fall from a height (Koraitim, 1996; Sandler, 2000). Most cases of anterior urethral trauma result from straddle injuries (Hernandez, 1999; Sandler, 2000).

The male posterior urethra is entirely encased within the rigid pelvis, a protective structure that must be disrupted before the posterior urethra can be damaged by blunt external trauma (Koraitim, 1999). The potential for urethral trauma is thus influenced by the extent of the pelvic injury, and this potential has been classified as no risk, low risk, and high risk (Koraitim, 1996). Examples of no risk injuries include isolated fractures of the acetabulum, ilium, or sacrum; low-risk injuries include single ischiopubic ramus or ipsilateral rami fractures; and high-risk injuries include straddle fractures or Malgaigne fractures. Overall, disruption of both the anterior and posterior sides of the pelvic ring introduces greater risk of urethral trauma.

Damage of the posterior urethra is thought to occur as its support mechanism becomes disrupted. As soft tissue becomes compressed, the puboprostatic ligament ruptures, disconnecting the prostate from the anterior pubic arch. This mobilizes the prostate and bladder. In many cases, a hematoma develops inferior to the prostate from sheared periprostatic vessels. The prostate is then driven cephalad by the growing hematoma. The posterior urethra, however, is firmly attached to the pubic arch by the perineal membrane. The resultant shearing force stretches or ruptures the urethra in varying locations as described by radiographic findings (Koraitim, 1999; Sandler, 1998).

Anterior urethral injuries are seen in a small minority of patients because of the mobility of the anterior urethra compared with the posterior urethra. Most cases are the result of straddle incidents, in which the patient falls on the crossbar of a bike or the top of a fence. Force from the structure on the perineum compresses the corpora spongiosum and bulbous urethra against the pubic symphysis, disrupting the urethra. In some mild cases, the resulting injury will go untreated; however, a stricture develops over time. The patient presents at this time with an inability to void. In some cases, the patient is unaware of the relationship to the past straddle injury (Hernandez, 1999).

If the Buck fascia remains intact, the injury will be limited to the space between the fascia and the tunica albuginea. If, however, the Buck fascia is also disrupted, a hematoma may spread within the confines of the Colles fascia (Hernandez, 1999; Sandler, 1998). Thus, blood or contrast material extravasation may extend to the scrotum, perineum, or anterior abdominal wall. Contrast would not extend into the thigh because of the insertion of the Colles fascia into the fascia lata of the thigh (Sandler, 2000).

Penile fracture results only when the penis is erect, and the injury results in disruption of the corpora and tunica albuginea (Forman, 1989). Of the 180 cases of penile fracture that have been reported in literature, only 10% of these cases have reported accompanying urethral disruption. Of these, only 3 cases have reported a complete urethral tear (Tsang, 1992).

Among women, the most common types of urethral injuries described are longitudinal tears and avulsion-distraction injuries, with the later attributed to more severe lateral compressive pelvic trauma (Venn, 1999; Koraitim, 1999).

Frequency

United States

Most posterior urethral trauma cases in males result from pelvic injury. Among male pelvic traumas, the reported frequency of urethral injury varies widely from 1-25% with an average of approximately 10%. Urethral injury in women with pelvic trauma is considered a less common event; however, some studies have reported incidences as high as 4-6% (Koraitim, 1999). Anterior urethral trauma is thought to occur less frequently due to its higher mobility, but the frequency of occurrence has not been established.

Mortality/Morbidity

The 3 most common morbidities associated with urethral trauma are stricture, incontinence, and impotence.

The incidence of these morbidities is dependent on the severity of the injury and the method of management and repair.

Treatment techniques for urethral tears include suprapubic cystotomy with delayed repair, immediate realignment, and immediate suturing. For suprapubic cystotomy with delayed repair, the incidence of stricture is 97% (see Images 10-11), the incidence of incontinence is 4% (see Image 9), and the incidence of impotence is 19%. With immediate realignment, the incidence of stricture is 53%, the incidence of incontinence is 5%, and incidence of impotence is 36%. For immediate suturing, the incidence of stricture is 49%, the incidence of incontinence is 21%, and the incidence of impotence is 56% (Koraitim, 1996).

Sex

Urethral traumas are more frequent in the male population than in the female population (Sandler, 2000; Venn, 1999). This difference is attributed to the higher elasticity, shorter length, and fewer attachments of the female urethra (Venn, 1999). Approximate male-to-female ratios are unknown, because inconsistency exists in diagnosing female urethral trauma.

Among women, the most common types of urethral injuries described are longitudinal tears and avulsion-distraction injuries, with the later attributed to more severe lateral compressive pelvic trauma (Venn, 1999; Koraitim, 1999).

Age

An age-linked risk of urethral injury associated with pelvic fracture has been shown for children younger than 15 years. The suggested cause for this pattern is the difference in pelvic fracture severity seen between children and adults. For pelvic fractures in children, approximately 56% of cases are at high risk for urethral injury. Among adults, only 24% are at high risk for urethral injury (Koraitim, 1996).

Anatomy

Historically, the male urethra has been divided into anterior and posterior parts, which are demarcated at the urogenital diaphragm. The proximal posterior urethra begins at the interface with the bladder, the internal urethral orifice, and the prostatic urethra. The prostatic urethra is entirely contained within the prostate and is continuous with the membranous urethra at the prostatic apex inferiorly. A principal support structure, the puboprostatic ligament, firmly attaches the prostate to the anterior pubic arch. This anatomy is important for locking the posterior urethra and prostate into their relative positions within the extraperitoneal pelvis.

The membranous urethra is located within the anterior tip of the urogenital diaphragm and becomes the proximal portion of the anterior urethra after passing through the perineal membrane. The principal mechanism of continence, the external urethral sphincter, is located within the urogenital diaphragm around the membranous urethra. The Cowper glands are also located within the urogenital diaphragm adjacent to the urethra.

The bulbous urethra, a swelling in the proximal anterior section, travels within the proximal corpus spongiosum and is continuous with the penile urethra. The ducts to the Cowper glands drain into the bulbous urethra. The penile or pendulous urethra extends the length of the penis where it ends as the fossa navicularis and urethral meatus.

Clinical Details

A diagnosis of urethral trauma should be investigated in the presence of pelvic fracture, straddle injury, penetrating trauma in the vicinity of the urethra, or penile fracture. While there are no findings specific for urethral trauma, there are many that suggest its presence. Findings can include blood at the urethral meatus, gross hematuria, an inability to spontaneously void, and a high riding prostate on rectal examination (Hardeman, 1987; Koraitim, 1999; Sandler, 1998; Sandler, 2000).

For many patients with urethral injury, extravasation of blood contained within different fascial planes is also present. On examination, patients with injuries to the urethra distal to the urogenital diaphragm and not contained by the Buck fascia typically have a butterfly hematoma, which forms as blood collects in the superficial perineum (Hernandez, 1999). Scrotal enlargement is also common in this injury, as extravasated fluids are bound by only the Colles fascia. For patients with anterior urethral trauma with extravasation confined by the Buck fascia, edema and ecchymosis of the penile shaft is common (Sandler, 2000). In some cases, however, a hematoma is not seen until at least an hour after injury (Koraitim, 1999).

Preferred Examination

For most patients with widespread acute trauma, CT scanning is performed as an initial diagnostic tool (Ali, 2003; Kane, 1989). However, these scans are not traditionally used for diagnosing urethral trauma. On the basis of new research, however, it is possible that in the future CT could be used as initial screen for urethral injuries (Ali, 2003).

If any of the clinical findings listed above are present, the possibility of urethral trauma should be properly investigated by retrograde urethrography (RUG) (Koraitim, 1999; Sandler, 1998). This should always be done prior to the insertion of a urethral catheter.

In the past, diagnostic catheterization was used to check for urethral disruption. This has been universally dismissed as an acceptable diagnostic tool (Koraitim, 1999). A urethral catheter risks converting a partial urethral tear into a complete urethral disruption, it can increase the extent of hemorrhaging, and it increases the possibility of contaminating a sterile hematoma (Koraitim, 1999; Sandler, 2000). If, however, a urethral catheter is properly in place prior to evaluation for urethral trauma, it should not be removed in order to perform urethrography. In such a case, a pericatheter urethrogram may be obtained.

After a diagnosis of urethral trauma has been made, management and repair can be planned with the possible aid of other imaging modalities, such as MRI and ultrasonography. MRI has some utility in planning surgical approach for posterior urethral disruptions, and ultrasonography has been used at times to aid in the repair of urethral trauma (Dixon, 1992; Forman, 1989; Narumi, 1993; Pavlica, 2003; Pavlica, 2003).

Limitations of Techniques

While RUG provides clinically valuable information on the presence, location, and severity of urethral extravasation, it provides limited information about the details of surrounding soft tissue damage. Furthermore, imaging of the proximal urethra can occasionally be inadequate. This is usually caused by subpar contrast-agent filling of the proximal urethra or by gross extravasation of contrast blocking visualization of the proximal urethra (Narumi, 1993).

In contrast, MRI has proven clinical utility in its ability to define damage to soft-tissue neighboring the urethral trauma. Alone, however, MRI should not be used to investigate urethral extravasation or to define urethral trauma as partial or complete (Dixon, 1992; Narumi, 1993).

DIFFERENTIALS

Section 3 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

Other Problems to be Considered

Urethral stricture
Penile fracture
Bladder-neck injury
Prostate injury
Pelvic fracture

RADIOGRAPH

Section 4 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

Findings

Technique

The standard imaging method used to diagnose urethral trauma is RUG (Koraitim, 1999; Sandler, 1998). While various techniques have been described to implement RUG, the most common utilizes a Foley catheter (Hernandez, 1999; Pavlica, 2003). With this method, the patient is ideally positioned for imaging in an approximate 45° oblique angle with the penis stretched so that the meatus points cephalad. This produces a C configuration from the bladder level to meatus tip. If the penile shaft points caudad, the femur may obscure the opacified urethra. For some patients with multiple injuries, this position is unobtainable. In this case, the patient should be supine with the penis stretched perpendicular to the leg. When the image is obtained in this anteroposterior projection, however, the urethra can appear foreshortened, allowing for possible errors in interpretation of extravasation (Hernandez, 1999; Sandler, 2000).

The Foley catheter is then placed inside the urethra with the balloon inflated in the fossa navicularis. Approximately 20-30 mL of 30% contrast material are injected into the urethra, with the exposure being made during the active injection of the last few mL of contrast. Obtaining the image during the injection allows for maximum filling of the deeper bulbar, membranous, and prostatic urethral sections (see Image 1) (Sandler, 2000). In the most ideal conditions, the entire procedure should be performed under fluoroscopic control; however, in the emergent environment this is often impossible.

Classification of RUG findings

The most accepted and unified classification of RUG findings for urethral injuries is the Goldman classification, with its foundation in the earlier system developed by Colapinto and McCallum (Colapinto, 1977; Goldman, 1997). The Goldman classification of urethral trauma is defined entirely on the anatomical findings of the injury and not on its mechanism. This system defines five major types of urethral injuries as seen in RUG.

Type I urethral injury results when the puboprostatic ligament is ruptured, and the prostate is allowed to move superiorly. The urethra remains intact however, and is only severely stretched by the movement of the prostate. No extravasation of contrast material is seen with radiography, and continuity is maintained with the bladder (see Image 2). True cases of Type I urethral injury are uncommon (Sandler, 1998).

Type II urethral trauma is the classically described posterior urethral injury in which the urethra is torn superior to the urogenital diaphragm. In such an injury, contrast-agent extravasation is seen within the extraperitoneal pelvis, but contrast material is not present within the perineum (see Image 3). Here, the urogenital diaphragm is intact, preventing the spread of contrast material inferiorly. This type exists in approximately 15% of urethral trauma cases resulting from pelvic crush injuries (Sandler, 1998).

The most common type of urethral trauma has proven to be type III urethral injury (Goldman, 1997; Sandler, 1998). Type III urethral injury, like type II, shows disruption above the urogenital diaphragm. Unlike type II, though, this injury extends through the urogenital diaphragm and includes the proximal bulbous urethra. In this injury, extravasation can be found within the extraperitoneal pelvis and within the perineum (see Image 4). The amount of contrast material found above or below the urogenital diaphragm depends upon the exact location of the injury and the degree of disruption to the perineal membrane (Sandler, 1998).

Some investigators believe that type I, II, and III urethral disruptions may be seen as the same mechanism of trauma, with varying degrees of severity (Colapinto, 1977). Indeed, there has been at least one report of a delayed rupture of type I urethral trauma (Jones, 1993).

Type II or III urethral injury can be further classified as a partial or complete urethral tear (Goldman, 1997). With RUG, partial tears are diagnosed when extravasation of contrast material occurs with the presence of contrast material in the bladder. Complete tears are diagnosed when extravasation is present and no contrast agent is present in the bladder or in the proximal torn end of the urethra. The relative frequency of partial tears versus complete tears is highly variable in the literature, and no reason for this variance has been agreed upon (Sandler, 1998).

Type IV urethral trauma is a tear to the bladder neck that extends into the proximal urethra. Contrast-agent extravasation is seen in the extraperitoneal pelvis around the proximal urethra (see Image 5). Such injuries can damage the internal urethral sphincter, resulting in incontinence (Goldman, 1997). Proper diagnosis is therefore essential to ensure adequate patient care.

A related injury, as described in the Goldman classification, is type IVA. This is not a urethral injury; however, it can easily be mistaken for a proximal urethral tear. In this case, the base of the bladder is disrupted, with periurethral extravasation of contrast agent. The resulting radiographs can easily mimic those of a true type IV urethral trauma. Distinguishing the 2 conditions is important because type IV injury is typically treated surgically and type IVA injury is not (Goldman, 1997). Dynamic RUG under fluoroscopic control facilitates the differentiation.

Type V urethral trauma describes all cases that are isolated to the anterior urethra. Such an injury occurs distal to the urogenital diaphragm and is more associated with perineal crush or straddle injuries (Hernandez, 1999). The resulting urethral injury is usually a partial tear of the bulbous urethra, though complete tears can also occur. In this case, contrast-agent extravasation occurs inferior to the urogenital diaphragm (see Image 6). If the Buck fascia remains intact, the extravasation is limited to its confines, ie, the penile shaft. If the Buck fascia is disrupted, the contrast material contained within the limits of the Colles fascia (Hernandez, 1999; Sandler, 1998). In this case, contrast agent might be found in the lower abdomen and in the scrotum (Sandler, 2000).

Under certain circumstances, all of the clinical signs of urethral disruption may be present, but contrast extravasation may be completely absent. In such a case, a diagnosis of urethral contusion is often made (Hernandez, 1999).

Degree of Confidence

Specific degrees of confidence for diagnosing male urethral trauma by RUG are not documented.

With regard to females, contradictory opinions exist about the diagnostic dependability of urethrography, with some believing that diagnosis should be made with urethroscopy (McAninch, 1992).

False Positives/Negatives

As discussed above, type IV urethral injuries involving the proximal urethra can be radiologically indistinguishable from type IVA injuries that do not involve the urethra. Careful evaluation is necessary to distinguish these two injuries.

Similarly, reflux of contrast agent into Cowper ducts, which connects to the bulbous urethra, should not be confused with extravasation of the anterior urethra (Sandler, 2000).

There have been some investigators that have questioned the accuracy of RUG in distinguishing partial and complete urethral tears. They have suggested that contrast material proximal to a partial rupture could be prevented by spasm of the external urethral sphincter (Koraitim, 1999).

CT SCAN

Section 5 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

Findings

Despite the prevalent use of CT as the initial screening modality for general acute trauma, the literature has historically described few applications of CT in diagnosing urethral injuries. In one small study of CT and the ability to identify patients with bladder and posterior urethral injuries, CT identified only 1 of 3 patients with urethral trauma (Kane, 1989). The authors of the study suggested that the presence of a Foley catheter might have prevented adequate contrast-agent extravasation in the undiagnosed cases.

One report has shed new light into the important potential clinical value for CT in diagnosing urethral trauma (Ali, 2003). In this retrospective review, Ali et al reviewed 97 patients examined over an 11-year period. Seventeen patients had pelvic fractures and urethral injury (confirmed during urethroscopy or surgery), 30 patients had pelvic fractures with no associated urethral injury, and 50 patients had neither pelvic fracture nor urethral injury. As a result of their investigation, the authors were able to identify findings specific for type I, II, and III urethral injuries as well as findings highly associated with general urethral trauma.

A distance of 2 cm between the prostatic apex and urogenital diaphragm was specific for type I urethral injuries. The CT findings specific for type II and type III urethral trauma were contrast-agent extravasation above the urogenital diaphragm and extravasation below the urogenital diaphragm, respectively (see Images 7-8, Image 12). CT findings associated with but not specific for urethral trauma were distortion or obscuration of the urogenital fat plane, hematoma of the ischiocavernosus muscle, distortion or obscuration of the prostatic contour, distortion or obscuration of the bulbocavernosus muscle, and hematoma of the obturator internus muscle (Ali, 2003).

Because many patients with generalized trauma undergo CT before a specific evaluation for urethral trauma, CT might serve as an initial screening examination for such injuries. Presently, no test supersedes RUG for the confirmation of urethral trauma (Ali, 2003; Kane, 1989). With information from reports such as that by Ali et al, CT might help exclude unnecessary RUG. Such a screening would require a thorough understanding of the relevant and intricate pelvic anatomy.

Degree of Confidence

Because few studies have been conducted to evaluate the accuracy of CT in identifying urethral trauma, further investigation is necessary for a well-defined degree of confidence.

In the study by Ali et al described above, all specific findings were found only in patients with urethral trauma. Among associated findings, distortion and obscuration of the urogenital fat plane was found in 88% of those with urethral trauma and in 3% without urethral trauma. Hematoma of the ischiocavernosus muscle was found in 88% with urethral trauma and in 17% without urethral trauma. Distortion or obscuration of the prostatic contour was present in 59% with urethral trauma and in 7% without urethral trauma. Distortion or obscuration of the bulbocavernosus muscle was present in 47% with urethral trauma and in 10% s without urethral trauma. Hematoma of the obturator internus muscle was found in 53% of patients with urethral trauma and in 13% without urethral trauma (Ali, 2003).

False Positives/Negatives

False-positive and false-negative results have not been thoroughly studied. It has been suggested that the presence of a Foley catheter in the urethra could produce false-negative findings for urethral trauma on CT studies (Kane, 1989).

MRI

Section 6 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

Findings

Traditionally, MRI has not been used as an initial diagnostic tool for urethral traumatic injuries; nevertheless, some researchers have demonstrated the advantage of using MRI as a preparatory tool when planning surgical repair of urethral disruption (Dixon, 1992; Narumi, 1993).

One of the most common methods of treatment for urethral injury is delayed reconstruction after 3-4 months of suprapubic cystotomy (Koraitim, 1996). After the initial delay, the surgical reconstruction is usually done with a transperineal or combined transperineal and transpubic approach with pubectomy. The approach chosen is dependent on the length of the urethral disruption, the degree of prostatic dislocation, and the amount of scar tissue present.

Urethrography is the most commonly used preoperative evaluation; however, with this technique, information on prostatic displacement and the degree of scarring can be limited. Further, the exact length of the urethral defect can be inaccurately determined when the prostatic urethra is not optimally filled with contrast material (Dixon, 1992; Narumi, 1993).

MRI has shown positive results in evaluating the anterior-posterior, superior-inferior, and lateral displacement of the prostate; the degree of scar tissue around a urethral defect; and the precise length of a posterior urethral defect. In one study, the results of MRI preoperative evaluations changed the surgical repair approach in 26% of the patients studied (Narumi, 1993). Because of its superiority in defining local disruption to adjacent tissues, MRI can be an important tool in combination with RUG in evaluating urethral trauma for management.

Degree of Confidence

In the study mentioned above, the displacement of the prostatic apex was accurately measured by MRI to within 5 mm in 90% of patients. The length of the urethral defect was accurately identified within 5 mm in 85% of patients (Narumi, 1993). Large studies to determine a consensus degree of confidence are not available.

False Positives/Negatives

No false-positive or false-negative results have been discussed.

ULTRASOUND

Section 7 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

Findings

Like MRI and CT, ultrasonography alone has not yet proven adequate and is not typically used for the primary diagnosis of urethral trauma (Pavlica, 2003; Riccabona, 2003). However, a few reports suggest that ultrasonography can be used for defining the extent of urethral damage in certain cases and for preparing for surgical repair (Bearcroft, 1994; Forman, 1989).

High-frequency probes used in sonourethrography provide a high spatial resolution; therefore, details of urethral anatomy can be studied after the injection of a saline solution. This saline solution technique uses a Foley catheter in a similar manner as described for RUG to promote distension of the urethra. The presence of saline in the urethra produces high contrast relative to the urethral mucosa. Thus, this technique allows accurate visualization of the urethral wall as well as the urethral lumen (Pavlica, 2003).

Only a limited number of reports exist in the literature regarding the usage of sonourethrography. Such cases include the use sonography for the diagnosis of urethral trauma associated with penile fracture and in evaluating anterior urethral trauma prior to delayed urethroplasty. Sonourethrography has been shown to accurately depict trauma to soft tissues surrounding the urethra, such as the tunica albuginea (Forman, 1989). Other investigators have shown that sonourethrography can more accurately measure stricture length than RUG (Pavlica, 2003). This information could prove useful for planning surgical repair for specific cases.

Authors have also suggested that sonography demonstrates hematoma size and the extent of fluid extravasation better than RUG (Pavlica, 2003).

Degree of Confidence

Further studies are necessary to compare sonourethrography with RUG and to investigate the sensitivity and specificity of sonourethrography for diagnosing urethral trauma.

False Positives/Negatives

False-positive and false-negative results have not been described.

INTERVENTION

Section 8 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

Interventional radiology has played only a small role in the treatment of urethral injuries. In a few situations, delayed realignment of the urethra following suprapubic diversion has been accomplished under radiological guidance (Clark, 1992).

Fluoroscopic guidance for percutaneous suprapubic cystotomy has also been suggested for clinical use when the bladder is distorted by a retroperitoneal hematoma or when the bladder has been displaced superiorly (Kantor, 1989).

Patient Education:

For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education article Understanding the Male Anatomy.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

Media file 1:  Urethra, trauma. Normal retrograde urethrogram. Pericatheter retrograde urethrogram is negative for urethral trauma and shows continuous filling of contrast material through the extent of the urethra and into the bladder without extravasation.
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Media file 2:  Urethra, trauma. Retrograde urethrogram reveals a type I urethral injury with minimal stretching and slight luminal irregularity of the posterior urethra. No extravasation of contrast material is present.
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Media type:  X-RAY

Media file 3:  Urethra, trauma. Retrograde urethrogram demonstrates a less common type II urethral disruption. Extravasation of contrast material (solid arrow) from the posterior urethra is seen superior to an intact urogenital diaphragm (dashed arrow).
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Media type:  X-RAY

Media file 4:  Urethra, trauma. Retrograde urethrogram demonstrates a type III urethral injury. Extravasation is located in both the extraperitoneal pelvis and in the perineum (above and below the urogenital diaphragm).
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Media type:  X-RAY

Media file 5:  Urethra, trauma. Retrograde urethrogram reveals a type 3 urethral tear at the urogenital diaphragm (solid arrow) and a type 4 urethral disruption at the bladder neck (dashed arrow).
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Media type:  X-RAY

Media file 6:  Urethra, trauma. Straddle injury. Retrograde urethrogram shows a type 5 urethral injury with extravasation of contrast material from the distal bulbous urethra.
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Media type:  X-RAY

Media file 7:  Urethra, trauma. CT scan demonstrates extravasation of contrast material in the pelvic floor after complete disruption of the bladder base and posterior urethra.
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Media type:  X-RAY

Media file 8:  Urethra, trauma. CT scan shows contrast material in the perineum (same patient as in Image 7). This patient had extensive trauma to the bladder with injury extending to the membranous urethra.
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Media type:  X-RAY

Media file 9:  Urethra, trauma. After delayed repair for urethral trauma, this patient remained incontinent. Retrograde urethrogram confirms lack of constriction at the internal and external urethral sphincters.
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Media type:  X-RAY

Media file 10:  Urethra, trauma. Retrograde urethrogram reveals a tight stricture, a common morbidity of urethral injuries treated with delayed repair.
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Media type:  X-RAY

Media file 11:  Urethra, trauma. Cystogram reveals stricture of the urethra in a patient treated with delayed repair (same patient as in Image 10). The cystogram and retrograde urethrogram together help define the length of the stricture.
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Media type:  X-RAY

Media file 12:  CT scan demonstrates fluid and a slight presence of contrast material in the perineum; this is indicative of a urethral tear. Retrograde urethrography should be used to confirm the location of a urethral injury.
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Media type:  CT

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Intervention
• Multimedia
• References

• Ali M, Safriel Y, Sclafani SJ, Schulze R. CT signs of urethral injury. Radiographics. Jul-Aug 2003;23(4):951-63; discussion 963-6. [Medline].
• Bearcroft PW, Berman LH. Sonography in the evaluation of the male anterior urethra. Clin Radiol. Sep 1994;49(9):621-6. [Medline].
• Clark WR, Patterson DE, Williams HJ Jr. Primary radiologic realignment of membranous urethral disruptions. Urology. Feb 1992;39(2):182-4. [Medline].
• Colapinto V, McCallum RW. Injury to the male posterior urethra in fractured pelvis: a new classification. J Urol. Oct 1977;118(4):575-80. [Medline].
• Corriere JN Jr, Sandler CM. Mechanisms of injury, patterns of extravasation and management of extraperitoneal bladder rupture due to blunt trauma. J Urol. Jan 1988;139(1):43-4. [Medline].
• Dixon CM, Hricak H, McAninch JW. Magnetic resonance imaging of traumatic posterior urethral defects and pelvic crush injuries. J Urol. Oct 1992;148(4):1162-5. [Medline].
• Forman HP, Rosenberg HK, Snyder HM 3rd. Fractured penis: sonographic aid to diagnosis. AJR Am J Roentgenol. Nov 1989;153(5):1009-10. [Medline].
• Godec CJ. Genitourinary trauma. Urol Radiol. 1985;7(4):185-91. [Medline].
• Goldman HB, Dmochowski RR, Cox CE. Penetrating trauma to the penis: functional results. J Urol. Feb 1996;155(2):551-3. [Medline].
• Goldman SM, Sandler CM, Corriere JN Jr, McGuire EJ. Blunt urethral trauma: a unified, anatomical mechanical classification. J Urol. Jan 1997;157(1):85-9. [Medline].
• Hardeman SW, Husmann DA, Chinn HK, Peters PC. Blunt urinary tract trauma: identifying those patients who requireradiological diagnostic studies. J Urol. Jul 1987;138(1):99-101. [Medline].
• Hernandez J, Morey AF. Anterior urethral injury. World J Urol. Apr 1999;17(2):96-100. [Medline].
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Article Last Updated: Aug 10, 2004