International Journal of Urology (2019) 26, 596--607 doi: 10.1111/iju.

13947

Review Article

Management of male pelvic fracture urethral injuries: Review and

current topics
Akio Horiguchi
Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan

Abbreviations & Acronyms
AUA = American Urological
Association
EAU = European
Association of Urology
ED = erectile dysfunction
MRI = magnetic resonance
imaging
PDS = polydioxanone
PFUI = pelvic fracture
urethral injury
PR = primary realignment
QOL = quality of life
SPT = suprapubic tube
Correspondence: Akio
Horiguchi M.D., Ph.D.,
Department of Urology,
National Defense Medical
College, 3-2 Namiki,
Tokorozawa, Saitama 359-8513,
Japan. Email:
impreza@ndmc.ac.jp
Received 31 January 2019;
accepted 22 February 2019.
Online publication 20 March
2019
Abstract: Pelvic fractures from high-energy blunt force trauma can cause injury to
the posterior urethra, known as pelvic fracture urethral injury, which is most
commonly associated with unstable pelvic fractures. Pelvic fracture urethral injury
should be suspected if a patient with pelvic trauma has blood at the meatus and/or
difficulty voiding, and retrograde urethrography should be carried out if the patient is
stable. Once urethral injury is confirmed, urinary drainage should be established
promptly by placement of a suprapubic tube or primary realignment of the urethra
over a urethral catheter. Although pelvic fracture urethral injury is accompanied by
subsequent urethral stenosis in a high rate and it has been believed that primary
realignment can reduce the risk of developing urethra stenosis, it also has a risk of
complicating stenosis and its clinical significance remains controversial. Once
inflammation and fibrosis have stabilized (generally at least 3 months after the trauma),
the optimal management for the resulting urethral stenosis is delayed urethroplasty.
Delayed urethroplasty can be carried out via a perineal approach using four ancillary
techniques in steps (bulbar urethral mobilization, corporal separation, inferior
pubectomy and urethral rerouting). Although pelvic trauma can impair continence
mechanisms, the continence after repair of pelvic fracture urethral injury is reportedly
adequate. Because erectile dysfunction is frequently encountered after pelvic fracture
urethral injury and most patients are young with a significant life expectancy, its
appropriate management can greatly improve quality of life. In the present article, the
key factors in the management of pelvic fracture urethral injury are reviewed and
current topics are summarized.
Key words: erectile dysfunction, incontinence, pelvic fracture, stenosis, urethra,
urethroplasty.

Introduction
Pelvic fracture is usually caused by a high-energy injury, such as a traffic accident or fall
from heights, and places patients at risk of associated urethral injury, which is known as
PFUI.1,2 PFUIs are relatively rare and are much more common in males, because the female
urethra is shorter and more mobile than that of a male, and is almost completely protected by
the pubic bone.3,4 PFUIs can cause urinary outflow obstruction, extravasation and secondary
sepsis in the acute setting, and can also result in significant morbidity, such as urethral steno-
sis, ED and urinary incontinence, which can be associated with lifelong disability.2,5 Because
most patients with PFUIs are young, inappropriate treatment and/or delay in management not
only leads to low QOL, but can also negatively influence social productivity.6–8 Early identifi-
cation and appropriate management are therefore of utmost importance in preventing signifi-
cant long-term morbidity and providing better QOL outcome. All clinicians who take care of
patients with pelvic fractures need to know the presenting signs of PFUI and be familiar with
its treatment. In the present article, the key factors in the management of PFUI are reviewed
and current topics are summarized.

Pathophysiology and mechanism of PFUI

Pelvic fractures are generally categorized according to the direction of the force of injury,
such as anteroposterior compression, lateral compression, vertical shear (Malgaigne

596 © 2019 The Japanese Urological Association


fracture) or their combinations.9–11 Minor fractures rarely
cause urethral injury, and most PFUIs result from massive
blunt shearing force, and pelvic fractures with disruption of
the pelvic ring.2,12 Although earlier data suggest that the
incidence of PFUI is 10–25% of males with pelvic frac-
ture, later data showed a much lower incidence (1.4–
2%).4,10,13 The male urethra can be subdivided into the
anterior urethra and posterior urethra. The anterior urethra
consists of the fossa navicularis, penile urethra and bulbar
urethra, whereas the posterior urethra consists of the mem-
branous urethra and prostatic urethra. The posterior urethra
passes through the perineal diaphragm close to the pubic
bone, to which it is adhered to the puboprostatic ligaments
and the perineal membrane.2,14 Pelvic ring disruption can
tear the ligaments from the attachments to the urethra at
this level due to its lack of distensibility and the absence
of protective surrounding spongy tissue or prostatic par-
enchyma, and certain fracture locations are associated with
increased risk of urethral injury.2 Aihara et al. reviewed
362 patients admitted with pelvic fracture in a level 1
trauma center in the USA, and reported that widened sym-
physis and fracture of the inferior pubic ramus are signifi-
cant predictors of urethral injury on multivariate analysis.15
Koraitim et al. reviewed 203 patients and found the highest
risk of urethral injury was in cases with straddle fracture
when combined with diastasis of the sacroiliac joint, fol-
lowed by straddle fracture alone and Malgaigne’s frac-
ture.16 A large retrospective cohort of 31 380 pelvic
fracture patients from the National Trauma Data Bank in
the USA showed that the likelihood of urethral injury is
significantly increased with Malgaigne fracture.10 Although
the pattern of pelvic fracture alone does not predict the
presence of urethra injury, prompt further work-up for
assessment of urethral injury is necessary when pelvic ring
disruption has occurred.2
In the past, it has been believed that PFUIs occurred at
the level of the membranous urethra and resulted from tear-
ing the prostate from the membranous urethra.17,18 Actually,
however, injury can occur at the prostatic apex, throughout
the membranous urethra or distal to the membranous ure-
thra (junction between the bulbar urethra and membranous
urethra), and the most common site of injury in adult
patients is distal to the membranous urethra.12,19 A cadav-
eric study showed that the pubic bone and urogenital dia-
phragm are tightly adherent to the urethra proximal to the
striated sphincter, but less adherent distal to the sphincter,
resulting in a tendency toward urethral injury at the weaker,
more distal point; that is, the bulbar urethra.20 In contrast
to what is seen in adult patients, in children the site of
injury tends to be more proximal, including the prostate
and the bladder neck, and severe urethral disruption is more
likely as a result of anatomical characteristics in children,
including the fragile tissues of an immature pelvic structure,
the relative intra-abdominal position of the bladder and an
immature prostate.5,21–23 Furthermore, unstable pelvic frac-
tures, such as Malgaigne fractures and straddle fractures,
are much more common in children, and the incidence of
PFUI after these severe pelvic injuries is higher in children
than in adults.16
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PFUI management
Presentation and assessment of PFUIs
The two classic signs of PFUI are blood at the urethral mea-
tus and a superiorly displaced prostate that is movable during
a digital rectal examination.2,24–26 Blood at the meatus is the
common sign of urethral injury, but it cannot be ruled out
even if it is absent and the degree of bleeding does not corre-
late with the severity of the injury.24,25,27 A rectal examina-
tion should always be carried out to exclude an accompanied
rectal injury, which is noticed by blood on the examination
finger and/or a palpable rectal laceration.2,16,28 A rectal exam-
ination might show a superiorly displaced (“high-riding”)
prostate, which is relatively unreliable in the acute setting of
PFUI, because the pelvic hematoma caused by pelvic frac-
tures often disturb precise palpation of a small prostate, par-
ticularly in young males.27,29,30 Other signs of urethral injury
include difficulty or inability to pass a urethral catheter and a
distended palpable bladder due to the inability to void.2,31 It
should be also noted that the clinical symptoms might
become apparent only >1 h after the injury.30
When a PFUI is suspected in the acute setting, retrograde
urethrography is the standard diagnostic investigation.26,31,32
The site and the extent of urethral injury can be identified by
the urethrography. Several classifications based on the
urethrography findings have been proposed,17,33,34 but none
has achieved widespread acceptance.2 The EAU recently pro-
vided a simple classification of urethral injury based on the
findings of retrograde urethrography (grade 1: stretch injury,
grade 2: contusion, grade 3: partial disruption, grade 4: com-
plete disruption, grade 5: complete or partial disruption of
posterior urethra with associated tear of the bladder neck, rec-
tum or vagina) that is simple and relevant in the treatment of
urethral injuries.28 A PFUI is diagnosed if extravasation of
contrast out of the urethra into the periurethral area or around
the inferior surface of the prostate is seen (Fig. 1). The retro-
grade urethrogram might show partial or complete urethral
disruption, and a typical image for partial disruption shows
extravasation that occurs while the bladder is still filling
(Fig. 1a), and a complete disruption is suggested by extrava-
sation without bladder filling (Fig. 1b). However, the distinc-
tion between a partial rupture and a complete rupture is not
always possible, because some patients with a partial disrup-
tion might have concomitant sphincter spasms preventing
passage of contrast medium into the bladder.28,30
Acute management of PFUI
Although urethral injury itself is not life threatening, pelvic
fracture with genitourinary injury tends to be more severe
than that without genitourinary injury and is associated with
concomitant injuries, such as abdominal organ injuries, and
with longer hospital stay and higher mortality incidence.10,35
Initial medical management, therefore, should concentrate
first on resuscitating and stabilizing the patient, and then on
identifying all associated injuries. Urethral injury can cause
urinary outflow obstruction, extravasation and secondary sep-
sis in the acute phase. Once a urethral injury is identified, the
most important initial goal in the acutely injured patient is to
accomplish bladder drainage promptly for prevention of
597

A HORIGUCHI
(a) (b)
urinary extravasation and infection.28,31 The proper initial
management depends on the severity of the associated inju-
ries and the hemodynamic status. The flow chart of PFUI
management according to the EAU and AUA guidelines is
shown in Figure 2.28,31 There are two treatment options to
accomplish bladder drainage. The most convenient way is to
place a SPT into the bladder, which can be carried out either
in the emergency room or during laparotomy for the repair of
concomitant injuries. In unstable patients, retrograde urethrog-
raphy should be delayed until the patient has become stabi-
lized, and the patient should be treated in the first instance by
placement of SPT unless a urethral injury can be dis-
counted.31 Blind urethral catheterization before urethrography
should be avoided, because it can be associated with the
potential risks of introducing infection and of making the ure-
thral injury worse, although no definitive studies have shown
that it actually does.2,31 The other option is to carry out early
PR either by simple catheterization or by using a cysto-
scope.2,28,31 Primary open realignment should be avoided,
unless there are concomitant bladder or rectal injuries for
which there is the risk of subsequent urinary incontinence or
pelvic abscess if not treated, because of the risk of entering
the pelvic hematoma with subsequent decompression, loss of
tamponade, uncontrolled bleeding, poor visualization, incapa-
bility to accurately evaluate the degree of urethral disruption,
and increased risks of ED and incontinence.2,36,37 Although
both the EAU and AUA guidelines give PR as a choice for
patients who are hemodynamically stable, it remains a contro-
versial issue.28,31 PR has a lower rate of subsequently devel-
oping stenosis than SPT placement alone, with which the
development of stenosis is almost inevitable.38,39 A recent
meta-analysis showed that the rate of developing subsequent
598
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Fig. 1 Retrograde urethrography immediately
after trauma in (a) a patient with partial disruption
and (b) a patient with complete disruption.
Arrows indicate contrast medium extravasated
from disrupted sites.
stenosis was significantly lower in the PR group than the
SPT group (OR 0.12), and there was no significant difference
in the risks of having ED or incontinence between the two
procedures.38 Patients with successful PR have been reported
to be able to return to voiding early.40 Even if subsequent
stenosis occurs, the length of stenosis is shorter than when
PFUI is managed by SPT placement alone, and the posterior
urethra and the prostate can be well aligned.41 PR has some
important secondary advantages and might be helpful in the
multidisciplinary treatment of the patients with trauma. Surgi-
cal repairs of pelvic fracture are often required in patients
with PFUI, and placement of SPT has a risk of seeding infec-
tion of an open reduction and internal fixation, and the placed
SPT might affect the surgical plan of orthopedic physicians
for pelvic fracture repair.8 PR, therefore, can avoid such risks
when pelvic fracture repair is required. Gomez suggested that
the acute management of PFUI might be selective, and if
open reduction and internal fixation is thought necessary, PR
might provide urinary drainage and adequate operative field
for the orthopedic surgery.42 From the standpoint of cost-
effectiveness, PR rather than SPT is the more cost-effective
strategy for management of PFUIs.43
In contrast, the existing literature also showed several prob-
lems of PR in the acute management of PFUI. Because PR is
easier to carry out in patients with minor injury that might heal
regardless of the selected managements, such selection bias
could make it appear that the PR is more effective than it actu-
ally is.44 The success rate of PR at a level 1 trauma center in
the USA has been reported to be just 9%, which is lower than
that reported previously.8 PR is technically demanding, and
the degree of urethral damage caused by PR depends on the
skill of the surgeon.45 It should be noted that prolonged
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PFUI management

Suspicion of PFUI

Stable patient Unstable patient

Extravasation on SPT alone and

retrograde urethrography concentrate on resuscitation

Accompanying rectal or bladder injury

No Yes

Open realignment and repair

SPT or PR
of rectal and/or bladder injury

Urethrography at 3-6 months after injury

No stenosis Stenosis

Follow-up for at least 1 year Delayed urethroplasty

Fig. 2 Flowchart for PFUI management.

attempts at PR must be avoided, because the process might
increase injury severity.45 Arora et al. reported a case of a ter-
rible complication of PR and raised the alarm that widespread
use of PR is not recommended for everyone (Fig. 3a).45 If a
urethral catheter is successfully introduced, the correct place-
ment of the Foley balloon catheter inside the bladder has to be
confirmed radiographically or with ultrasound to exclude the
possibility of an inappropriately inflated balloon in the disrup-
tion site (Fig. 3b).28
Several authors pointed out that most patients managed by
PR have their acute urethral injury changed to an unstable
chronic condition state that requires repeated dilations and
urethrotomies.39,46,47 Most patients managed by PR are prone
to having some degree of urethral patency and can void with
a weak stream, but it could trigger the introduction of numer-
ous futile and harmful dilations and urethrotomies required to
maintain urethral patency.47 Tausch et al. reported that most
patients managed by PR who underwent repeated urethro-
tomies showed iatrogenic urethral trauma that was never
found in patients managed only by SPT placement (Fig. 4).47
In contrast to the opinion claiming the positive impact of PR
on subsequent urethroplasty, some authors claimed that PR
did not make urethroplasty easier in regard to stenosis length,
required ancillary techniques or operative time and blood
loss, and that there was no significant difference in postopera-
tive erectile function or continence.39,46,47 Some investigators
have found that PR and subsequent dilations and urethro-
tomies have a negative impact on the surgical outcome of
delayed urethroplasty.48,49 These reports suggest that PR is a
double-edged sword.39 As just described, acute management
of PFUI remains a controversial issue mainly due to the lack
of high-quality evidence. A prospective multicenter cohort
trial by the American Association for Surgery of Trauma is
designed to compare outcomes between PR and SPT place-
ment, which will clarify this issue.44 Because PFUI is associ-
ated with urethral stenosis at a high rate within a year
whether initially managed by either PR or SPT placement, it
is necessary to monitor the patients closely for at least 1 year
after injury (Fig. 2).31
Delayed management for PFUI
Three major complications resulting from PFUI are urethral
stenosis, ED and urinary incontinence. Because most patients
with pelvic fractures are young with a significant life expec-
tancy, their management can significantly improve QOL and
allow recovery of function.
Urethral stenosis
Strategy of urethral stenosis management
PFUI is associated with high rates of urethral stenosis, even
in patients with successful PR, and its gold standard manage-
ment is delayed urethroplasty.2,28,32 Delayed urethroplasty
should not be attempted within 3–6 months of the initial
trauma, because the local healing reaction has not been com-
pleted before this time, and the surgical dissection will be
more difficult and the chance of a successful result might be
less.26,32,50 Although some experts wait just 3–6 weeks
before urethroplasty,51 no others suggest that a delay of
<3 months is appropriate.26 Although transurethral proce-
dures, such as urethrotomy or office- and self-dilation, are
commonly utilized in general urological practice as delayed
management and most urologists persevere with them for as
long as possible, they are applicable only for short and non-
obliterative stenosis and should not be repeated.52 Repeated

© 2019 The Japanese Urological Association 599


A HORIGUCHI
(a)
(b)
Fig. 3 Consequences of inappropriate PR for PFUI. (a) Bulbar urethra was
inappropriately aligned to the false tract (black arrow). The true proximal
urethral end is indicated by white arrow. (b) Periurethral cavity (arrow) devel-
oped at the disruption site due to a balloon inappropriately inflated there.
transurethral procedures are not only futile, but also have a
risk of complicating stenosis by increasing tissue damage and
making urethroplasty more complex, as above-mentioned
(Fig. 4).32,53 Urethral stents have the highest risk of compli-
cating stenosis among transurethral procedures and are not
recommended for patients with stenosis after PFUI (Fig. 4).53
Urologists should be aware that transurethral procedures are
never acceptable alternatives for delayed urethroplasty.
Assessment of urethral stenosis
Accurate assessment of urethral stenosis is crucial to choose
appropriate surgical procedures and to obtain successful out-
comes. Standard evaluation before delayed urethroplasty
includes retrograde and antegrade cystoscopy to assess the
condition of the bladder neck and disrupted urethral ends,
and retrograde urethrography and combined voiding cysto-
urethrography (so called “up and down urethrography”2) to
determine the urethral stenosis and bladder neck competency
(Fig. 5a).32 The length of the urethral stenosis, however, is
often difficult to estimate accurately because of the possibility
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of poor filling of the posterior urethra with contrast material,
and urethrography might not accurately determine the degree
of three-dimensional displacement of the posterior ure-
thra.54,55 In addition, accompanying conditions, such as false
passages, fistulas and periurethral diverticula, might not be
well detected by the conventional urethrography.55 In order
to overcome the limitations of urethrography, MRI has
emerged as a non-invasive method for the evaluation of PFUI
by measuring the stenosis length correctly, and clearly
describing the degree of scarring, and both the direction and
extent of urethral displacement (Fig. 6a).56–58 In addition, the
greatest advantage of MRI over urethrography is its capability
to evaluate periurethral conditions, such as cavity formation
(Fig. 6b), protrusion of the rectum into the space between the
disrupted urethral ends (Fig. 6c) and the presence of a peri-
urethral fistula (Fig. 6d), that cannot be assessed by conven-
tional urethrography. Although MRI is not always necessary
for preoperative assessment in every case and its cost-effec-
tiveness has to be investigated, MRI could help surgeons rec-
ognize surgical anatomy easily and make urethroplasty
easier.57,59
Procedure of delayed urethroplasty
Currently, most urethral stenosis can be repaired by a single-
stage perineal anastomotic urethroplasty, called delayed anas-
tomotic urethroplasty, that consists of the complete excision
of scar, approximation of normal urethral mucosa from the
two sections of the disrupted urethra and establishment of a
tension-free anastomosis, which was originally pioneered by
Turner-Warwick in the 1970s,60 and subsequently further
developed by Webster and Ramon using four distinct ancil-
lary techniques to establish a tension-free anastomosis.61 Sub-
stitution urethroplasty using skin flaps or ileal grafts is rarely
necessary, except for patients with a long gap and/or limited
residual bulbar length in re-do cases.23,62 In brief, the patient
is in a standard or exaggerated lithotomy position and the
bulbar urethra is exposed by a midline or curved perineal
incision depending on the surgeon’s preference.2,14 The bul-
bar urethra is then circumferentially mobilized from the peno-
scrotal junction distally to the site of the disruption
proximally to use the elasticity of the bulbar urethra, which
can be stretched to overcome the gap between the two ure-
thral ends after excision of the scar tissue to accomplish an
overlapping spatulated anastomosis (first step of ancillary
techniques; Fig. 7a).31 The bulbar urethra is then detached
from the perineal body and transected at the disruption site.
Bulbar arteries are usually ligated and sacrificed during bul-
bar urethral transection, which might compromise spongiosal
blood flow and increase the risk of ischemic failure of the
reconstruction. Gomez et al. reported that a novel bulbar
artery-sparing technique used to avoid such complications
resulted in all of the 26 patients who had undergone the pro-
cedure voiding normally at a mean follow-up period of
20 months.63
The most difficult parts of delayed anastomotic urethro-
plasty are finding the disrupted proximal urethral end and
creating an anastomosis in a limited operative space in the
pelvis.26 To find where the proximal urethral end is, a
curved metallic sound, such as a Van Buren sound, is
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PFUI management

(a) (b)

(c) (d)

Fig. 4 A case of complicated stenosis caused by

repeated transurethral procedures after PFUI. (a)
Despite the short urethral stenosis initially
(arrow), (b) the patient received repeated
transurethral procedures including urethral
stenting. (c) Finally, the stenosis became
obliterative (arrow) and extended to the bulbar
urethra (dotted arrow), necessitating (d) excision
of a long urethral segment during delayed
urethroplasty. Arrow indicates the anastomotic
site.

(a) (b)

Fig. 5 (a) Combined retrograde and antegrade

urethrography 3 months after injury in the same
patient as Figure 1a. Arrows indicate the proximal
and distal urethral ends. (b) Post-urethroplasty
voiding cystourethrography in the same patient.
Arrow indicates the anastomotic site.

advanced through the suprapubic tract into the bladder and found or anastomotic tension is obvious due to a long ure-
then through the bladder neck. The tip of the metallic sound thral gap, the surgeon should consider using further ancil-
can be palpated in the perineum, indicating the site of the lary techniques in steps including developing the intercrural
proximal urethral end. If the proximal urethral end is not space by corporal splitting at the level of the triangular

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A HORIGUCHI
(a) (b)
(c) (d)
ligament and retracting laterally (second step of ancillary
techniques; Fig. 7b), carrying out partial resection of the
inferior pubic arch (third step of ancillary techniques;
Fig. 7c), and rerouting the urethra around one crus (fourth
step of ancillary techniques) to widen the exposure and
facilitate further proximal dissection, and to straighten the
bulbar urethra to further reduce any length between the two
urethral ends. The use of the first two steps alone is catego-
rized as the simple perineal approach, and the inclusion of
steps 3 and 4 is categorized as the elaborated perineal
approach.2 When necessary, usually when adequate access
to the proximal urethral end cannot be obtained by these
four steps (particularly in children, re-do cases, and cases
with complex stenosis accompanying recto-urethral fistula,
periurethral cavity, false passage and/or open bladder neck),
an abdominoperineal approach could be required
(Figs 8,9).23,64–68 It has been highlighted that the final deci-
sion on the type of repair (i.e. which ancillary technique is
required) usually depends not on the preoperative imaging,
but on the findings at surgery.7 Andrich et al. found no sig-
nificant association between the stenosis length and the type
of urethroplasty, and concluded that it is impossible to pre-
dict it by preoperative urethrography.54,69 In order to over-
come this problem, we previously evaluated the role of
MRI in predicting the type of urethroplasty.59 It remains
unclear whether the type of urethroplasty can be predicted
exactly from the preoperative imaging studies, and further
studies are necessary to clarify this issue.2
It is quite important to excise scar tissue covering the ure-
thral end meticulously and thereafter expose the mucosa of
the proximal urethral end. In our practice, the edge of the
urethral mucosa is pulled down and anchored to the sur-
rounding tissue by six sutures of 4-0 PDS to keep the end of
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Fig. 6 Representative preoperative MRI findings
in patients with urethral stenosis after PFUI. (a)
Lateral displacement of the proximal urethral end
(arrow) from the midline (dotted line) in the axial
T2-weighted image, (b) cavity formation just
behind the proximal urethral end (arrow) in the
sagittal T2-weighted image, (c) bulging of
the rectum into the urethral gap (arrow) in the
sagittal T2-weighted image. (d) Periurethral
fistulas (arrow) in contrast-enhanced T1-weighted
image.
the urethra from retracting proximally, as described previ-
ously.66 Scar tissue on the mobilized bulbar urethra is excised
and eight interrupted 4-0 PDS sutures are placed to reapprox-
imate the urethral mucosa (Fig. 7d). We use a 16-Fr silicone
catheter as a urethral stent for the anastomosis, and a SPT is
also kept in the bladder to ensure adequate urinary drainage.
We usually leave a suction drain tube at the end of operation,
which is wise after corporal splitting and partial pubectomy
when there is a dead space.
Post-urethroplasty management and surgical
outcome
The postoperative management differs among surgeons. In our
practice, the urethral catheter is placed for 2–3 weeks after
urethroplasty and peri-catheter retrograde urethrography is car-
ried out to confirm the healing status of anastomosis. If the
anastomotic site is patent and showed no leakage of contrast
medium, the SPT is plugged and voiding cystourethrography
is carried out after removal of the catheter (Fig. 5b). If the
patient can void without difficulty for several days thereafter,
SPT is removed. The urinary flow rate is measured at the time
of SPT removal and used as a baseline reference for further
follow up. We typically monitor the patients by assessing uri-
nary flow rate, and a patient-reported outcome measure at
every visit at 3, 6 and 12 months and thereafter annually, and
by cystoscopy at 6 months.70 If patients have symptoms of
obstructive voiding or show a decreased urinary flow rate,
urethrography along with cystoscope is carried out to assess
recurrent stenosis. Although delayed urethroplasty carried out
by an expert surgeon has a high success rate (nearly 90%) and
low complication rate,6,7,71–77 recurrent stenosis can be
encountered either shortly after removal of the urethral cathe-
ter (usually <48 h after surgery) or several months or years
© 2019 The Japanese Urological Association
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PFUI management

(a)

(b)

(c)

Fig. 7 Images and scheme of operative (d)

procedures of delayed urethroplasty. (a) The
bulbar urethra is circumferentially mobilized from
the penoscrotal junction distally and to the
departure of the anterior urethra proximally. (b)
Corporal bodies are split and (c) the inferior pubis
is resected in steps if the proximal urethral end
cannot be found or urethral tension is observed.
(d) After complete removal of the covering
fibrotic scar, eight interrupted anastomotic
sutures are placed to reapproximate the urethral
mucosa.

after surgery.78,79 Early recurrent stenosis is more common,
and patients present with an inability to void that is caused by
ischemia due either to severe vascular damage at the initial
injury, to tension at the anastomosis because of inadequate
bulbar urethral mobilization or to inadequate excision of scar
tissue, which usually require salvage urethroplasty.23,78–80 In
contrast, late recurrent cases present with a weak urinary
stream due to narrowing of the anastomosis and are usually
corrected by a single urethrotomy.78,79
Erectile dysfunction
PFUI is associated with a high incidence of ED, and a recent
meta-analysis estimated its incidence is 34% on average,
which is higher than that in patients with pelvic fractures
alone.81,82 Urethral injury alone is unlikely to be the direct
cause of ED in pelvic fracture patients, but rather a surrogate
for extensive pelvic injury involving the neurovascular struc-
tures central for erectile function,82 and ED is due to a conse-
quence of the original pelvic fracture rather than its
treatment.7,83 Different possible mechanisms contribute to the
pathophysiology of ED, including nervous damage, arterial
inadequacy, veno-occulusive dysfunction, and direct crural or
tunica albuginea injury, resulting in intracorporal fibrosis or
venous leakage.81,84 Koraitim et al. reported that the presence
of pubic diastasis, lateral prostatic displacement and long ure-
thral stenosis were significant predictors of ED after PFUI,
and that, among them, the risk of ED was highest for pubic

© 2019 The Japanese Urological Association 603


A HORIGUCHI
(a) (b)
diastasis.83 The spontaneous recovery of potency usually
occurs during the first year as a result of reconstruction of
neural function after a period of neuropraxis and/or establish-
ment of accessory penile arterial supply after arterial occlu-
sive lesions, but might take up to 2 years after injury.83
Thus, the preferable timing for evaluating sexual function and
making a decision on further therapy is 2 years after the ini-
tial trauma. Management is usually oral therapies using phos-
phodiesterase type 5 enzyme inhibitors as the first line, and if
that fails, intracavenousal injection therapy.2
Incontinence
Urinary continence depends on two components in males,
which are the internal sphincter (bladder neck) and the exter-
nal sphincter (the membranous urethra). An old theory is that
the membranous urethra is avulsed from the prostate apex
and the external sphincter is eliminated, and continence is
dependent on the function of the bladder neck.17,18 In reality,
the disruption most commonly occurs at the bulbomembra-
nous junction, just distal to the external sphincter, and in
most cases external sphincter function is preserved to some
extent.19,20,85,86 This theory regarding the site of disruption
has been supported by cystoscope evidence19 and by cada-
ver20 as well as urodynamic studies.86 As a result, the conti-
nence after delayed urethroplasty for PFUI has been reported
to be sufficient in most cases.85 Cooperberg et al. reported
the voiding function in 103 men accessible after delayed
urethroplasty, and found that nearly 90% of them had no
signs of incontinence.71 Fu et al. reported that 88% (447/
510) of the men in a retrospective study at a referral center
were continent after delayed urethroplasty.87 However, the
external sphincter can be damaged in complex urethral dis-
ruptions or during total excision of scars for even a short ure-
thral stenosis. Urinary continence in such cases depends on
bladder neck function.12 It is quite important to note that any
subsequent surgery on the prostate or bladder neck, such as
transurethral resection of the prostate, will pose a great risk
of urinary continence. Staged placement of an artificial
604
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Fig. 8 A case of severe PFUI with secondarily
developed long urethral stenosis requiring an
abdominoperineal approach. (a) Preoperative
sagittal T2-weighted MRI showed a long urethral
gap. Arrow indicates the distal urethral end and
dotted arrow indicates the proximal urethral end.
(b) Postoperative voiding cystourethrography.
Arrow indicates the anastomotic site.
urinary sphincter should be considered for patients who have
severe incontinence after delayed urethroplasty.
Conclusion
Management of PFUI remains a challenging urological issue,
and a source of significant debate in both acute and delayed
settings. Early identification and appropriate management can
prevent significant long-term morbidity for patients, and pro-
vide better QOL. The difficulty of PFUI management is due
to its rarity and the technical difficulty of the procedures
required.
The incidence of both traffic and incidental accidents has
been decreasing, and the injuries they cause have become less
severe because of the improved working environment and
increased inclusion of security devices (airbags) in automo-
biles in developed countries.52,88,89 According to a nation-
wide survey, 60% of Japanese consultant urologists had
experienced fewer than three patients with PFUI, and just 5%
of them had managed >10 in their whole career.52 In the
acute setting, urologists must decide whether to only place a
SPT or carry out PR. PR is technically more demanding than
SPT placement and is associated with significant complica-
tions, and most urologists in Japan are likely to be inexperi-
enced in it.45 The number of patients managed by PR is
limited, even in level 1 trauma hospitals in the USA.8,90 As
suggested by Arora et al., SPT placement alone might still be
the safer option in an acute setting for urologists who are
inexperienced with the management of PFUI.45
Surgical correction of urethral stenosis secondary to PFUI
remains one of the most challenging issues in urology.14,91
The technical inexperience of the surgeon has been reported
to be the most common cause of failed urethroplasty,26,73 and
Mundy has recommended that urologists who are not rou-
tinely carrying out >15 urethroplasties a year should be refer-
ring patients to high-volume centers where the caseload is
enough to maintain surgical expertise.92 The patient’s best
chance of a cure is during the first attempt, and his QOL for
the rest of his life depends on the decisions his surgeon
© 2019 The Japanese Urological Association
 14422042, 2019, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iju.13947 by Nat Prov Indonesia, Wiley Online Library on [04/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PFUI management

(a) (b)

(c) (d)

(e) (f)

Fig. 9 Images and scheme of operative procedures of abdominoperineal urethroplasty. (a) The bulbar urethra (arrow) is circumferentially mobilized perineally. (b)
The superior surface of the pubis is excised to create a space to pass the mobilized urethra (arrow). (c) The bulbar urethra is rerouted around the left side of the
corporal body and is passed on the resected surface of the pubis, and (d) urethral anastomosis is completed. The schemes of (e) coronal and (f) sagittal postoper-
ative images are also shown.

makes.23 No matter what method of initial treatment is cho-

sen, patients with subsequent urethral stenosis after PFUI
Acknowledgment
should be referred to experts as soon as possible without I greatly appreciate Ryuichi Azuma, MD, for technical sup-
being subjected to futile dilations or urethrotomies. port in delayed urethroplasty. This study was supported by a

© 2019 The Japanese Urological Association 605


A HORIGUCHI
grant for scientific research from the Ministry of Education,
Science, Sports and Culture (16H05467).
Conflict of interest
None declared.
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