RADIOLOGICAL EVALUATION OF URETHRAL TRAUMA

1. URETHRAL INJURIES
Dr.I.Gurubharath MD PhD Dr.Pooja

2. • Urethral injuries can result in long-term
morbidity and most commonly result from trauma.
• The male urethra is much more commonly injured
than the female urethra.

3. Clinical presentation
The classic triad of
• Blood of the external urethral meatus or vaginal
introitus
• Inability to void
• Examination may reveal blood on digital rectal exam
and perineal ecchymossis.
• Dysuria, urinary urgency and suprapubic discomfort

4. Pathology
Male urethral injuries are divided into
• Anterior (penile/bulbar)
• Posterior (membranous/prostatic) urethral injuries.
Injuries may be
• Partial
• Complete.

5. Causes:
Blunt trauma:
Due to shearing or straddle injuries
• Usually affects prostatic or membranous urethra
• Associated with pelvic fractures(occurs in ~10%)
• Often associated with bladder injury
Penetrating trauma:
e.g. stab wounds, gunshot wounds, dog bites
• More commonly affect the anterior urethra
Iatrogenic
• catheterisation, Foley catheter removal without
balloon deflation,
• cystoscopy
• post-surgical

7. Goldman classification of urethral injuries
Classification
Type I stretching of the posterior urethra due to disruption of
puboprostatic ligaments, though the urethra is intact
Type II posterior urethral injury above urogenital diaphragm
Type III Injury to the membranous urethra, extending into the proximal
bulbous urethra (i.E. With laceration of the urogenital
diaphragm)
Type IV bladder base injury involving bladder neck extending into
the proximal urethra
Internal sphincter is injured, hence the potential for
incontinence
Type iva bladder base injury, not involving bladder neck (cannot be
differentiated from type IV radiologically)
Type V anterior urethral injury (isolated)

8. Type I Injury: Rupture of the puboprostatic ligaments. Posterior urethra is
intact but stretched (Type I **)

9. Type II urethral
injury
Posterior urethral
rupture above the
intact urogenital
diaphragm
following blunt
trauma.

10. (a) Partial Type II urethral injury. Retrograde urethrogram demonstrates
confined contrast extravasation above the normal cone-shaped proximal
portion of the bulbous urethra. Contrast material, however, flows through
the prostatic urethral lumen into the bladder. Fracture of the left pubic rami.

11. Complete Type II urethral injury. Large amount of contrast material
extravasation without flow into the prostatic urethra or bladder.
Fracture of the right pubic rami.

12. Type III Injury:
Posterior urethral rupture
extending though the
urogenital diaphragm to
involve the bulbous
urethra following blunt

13. (a) Retrograde urethrogram reveals contrast extravasation at the membranous
urethra extending below the urogenital diaphragm surrounding the proximal
bulbous urethra.

14. Signs of proximal bulbous and membranous urethra disruption and
contrast extravasation into surrounding veins and soft tissue space. The
contrast reached the urinary bladder (Grade III incomplete urethral injury).

15. Type IV Injury: Bladder neck injury with extension into the urethra where
the primary continence sphincter lies . The patient with bladder neck
injuries may become incontinent if injury of the internal urethral sphincter is
not appreciated.

16. Retrograde
urethrogram reveals
extraperitoneal
periurethral
contrast material
extravasation at the
bladder neck. The
bladder is pear
shaped, indicative
of perivesical
hematoma.
Diastasis of the
pubic symphysis.

17. Type IVa* Injury:
Extraperitoneal bladder
rupture at the base of the
bladder, which does not
extend into the bladder
neck. Periurethral
extravasation from type
IVa injury simulates a
true type IV urethral
injury on retrograde
urethrogram. Therefore, it
is difficult to distinguish
a Type IVa bladder base
injury from a true Type IV
bladder neck and
urethral injury based on
the retrograde
urethrographic findings.

18. Retrograde urethrogram shows extraperitoneal contrast material extravasation
from the elevated bladder base surrounding the proximal urethra. Fracture of
the superior and inferior pubic rami bilaterally.

19. Type V* Injury:
Straddle pure anterior
urethral injury. The
bulbous urethra and
corpus spongiosum are
compressed between
the hard object and the
inferior aspect of the
pubic bones. This may
result in urethral
contusion with an
intact urethra or partial
or complete rupture of
the sump of the
bulbous urethra. Not
generally associated
with a bone injury.

20. (a) Retrograde urethrogram demonstrates complete disruption of the proximal
bulbous urethra with extensive venous intravasation.

21. Radiographic features
Fluoroscopy
Retrograde urethrography is the modality of choice.
The extent of injury can be categorised:
Contusion
Radiographically normal
Partial disruption
Extravasation of contrast with maintenance of
normal urethral continuity
Complete disruption
Extravasation of contrast with loss of urethral
continuity and lack of proximal urethral filling

22. CT
CT cystography can be performed but this is much less
specific for urethral vs. bladder injury.
Other features of urethral injury include retropubic and
perivesical haematoma and obscuration of the urogenital
fat plane.

23. Post-stress cystogram, shows contrast extravasation
into the right extraperitoneal space

24. Treatment and prognosis
• Treatment consists from urinary diversion to primary
or delayed urethral anastomosis depending on the
severity (i.e. tear vs. complete rupture) of the injury.
• Urethral stricture is the most common long-term
complication.

25. Summary
Urethral injuries most commonly result from trauma.
Causes:
• Blunt trauma
• Penetrating trauma
• Iatrogenic
Classified based on Goldman classification of urethral injuries into 5
types
Radiographic features
Fluoroscopy
Partial disruption
Extravasation of contrast with maintenance of normal urethral
continuity
Complete disruption
Extravasation of contrast with loss of urethral continuity and lack of
proximal urethral filling
CT cystography
It is much less specific for urethral vs. bladder injury
Treatment
urinary diversion to primary or delayed urethral anastomosis
Complication
Stricture

26. References
1. Kawashima A, Sandler CM, Wasserman NF, LeRoy AJ, King BF, Goldman
SM. Imaging of urethral disease: Pictorial review. InAMERICAN JOURNAL
OF ROENTGENOLOGY 2005 Jan 1 (Vol. 184, No. 4, pp. 99-99). 1891
PRESTON WHITE DR, SUBSCRIPTION FULFILLMENT, RESTON, VA
22091 USA: AMER ROENTGEN RAY SOC.
2. Adam A, Dixon AK, Gillard JH, Schaefer-Prokop C, Grainger RG, Allison
DJ. Grainger & Allison's Diagnostic Radiology E-Book. Elsevier Health
Sciences; 2014 Jun 16.
3. Dahnert WF. Radiology review manual. Lippincott Williams & Wilkins;
2017 Mar 9.
4. https://radiopaedia.org/articles/urethral-injury-1