Trauma to the pelvis: urethral injury

Currently, discrepancies exist in published reports regarding both the site and the extent of the urethral injury in fractured pelvis, as well as in the incidence of the major postoperative complications, namely, stricture and impotence. There is also debate as to the best method of initial treatment of the injury, this is, primary vs. delayed repair. We believe that much of the controversy is the result of inaccurate diagnosis of the site and extent of the initial injury. In the past, diagnosis has depended upon clinical criteria or on the failure of a catheter to traverse the urethra. These methods fail to pinpoint the site of the injury, nor do they tell us whether the rupture is incomplete, partial or complete. Fortunately, much of this information can be obtained by dynamic retrograde urethrography. Using dynamic retrograde urethrography routinely in the initial diagnosis, we have found that: the urethral rupture occurs most often below the urogenital diaphragm rather than above it as is traditionally believed; the patient may have the clinical criteria for complete rupture when his urethra is actually intact or only partially severed; an incomplete or even a small partial rupture may be present in spite of negative clinical criteria. These new concepts have contributed greatly to clarifying current controversies regarding the incidence of posttraumatic stricture and erectile impotence, and will have an influence on surgical techniques in the future. Unfortunately, the value of dynamic retrograde urethrography is not yet common knowledge. Our aim is to convince the orthopedic surgeon, who usually sees the patient first, to postpone urethral catheterization in patients with fractured pelvis until dynamic retrograde urethrography has been done. The technique is simple, takes little time, and requires no special equipment. In a severe emergency it can be done by the attending staff without the help of a radiologist. Ideally, dynamic retrograde urethrography should be obtained in all severe pelvic fractures regardless of the lack of clinical criteria of urethral injury.