Urology //urinary tract infection 2 //Dr. Omar M.

Shakir

Urethra, congenital anomalies &injuries

Urethra
The male urethra is a tubular structure extending from the bladder
neck to the external urinary meatus at the tip of the glans penis. The
urethra is contained within the corpus spongiosum and the glans
penis. The male urethra divided into :
1. The anterior urethra begins at the perineal membrane and
continues distally to the urethral meatus.
2. The posterior urethra begins distal to the bladder neck and the
transition to anterior urethra is made at the perineal
membrane.
The urethral epithelium is transitional in type until the urethral
epithelium becomes squamous where it traverses the glans penis at
the fossa navicularis.
The arterial supply to the urethra is from the internal pudendal
artery whose bulbourethral branches supply the urethra the corpus
spongiosum, and glans penis.
The verumontanum is formed by the widening and protrusion of the
urethral crest from the posterior wall.
The prostatic utricles (müllerian remnants) orifice appears
like a slit at the apex of the verumontanum.

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

Congenital abnormalities
Posterior urethral valves
PUV are derived from an abnormal congenital membrane arising
from the verumontanum and attaching obliquely to the anterior
urethra (beyond the external urethral sphincter).
Posterior urethral valves occur in around 1: 5000–8000 live male
births cause obstruction to the urethra of boys. They are flap valves
and so although they are obstructive to antegrade urinary flow, a
urethral catheter can be passed retrogradely without any difficulty.
Diagnosis
Posterior urethral valves need to be detected and treated as early as
possible to minimize the degree of renal failure.
 The diagnosis is commonly made antenatally with ultrasound
which demonstrates bilateral hydronephrosis above a distended
bladder.

 If the diagnosis is not made antenatally, then patients typically

present with urinary infection in the neonatal period or with
uraemia and renal failure.

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

Radiographic imaging
 Ultrasound study revealed hydroureteronephrosis, a thick-walled
bladder .
 Micturating cystourethrography MCUG provides the definitive
diagnosis. the dilatation of the urethra above the valves can be
demonstrated on a voiding cystogram ,The bladder is
hypertrophied and often shows diverticula .
Typically, there is vesicoureteric reflux into dilated upper tracts

Treatment
Initial treatment is by catheterisation to relieve the back pressure and
to allow the effects of renal failure to improve .
Definitive treatment is by endoscopic incision of the valves with
continuing supportive treatment of the dilated urinary tract, the
recurrent urinary infections and the uraemia.

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

Hypospadias
Hypospadias occurs in around 1: 200–300 male live births and is the
most common congenital abnormality of the urethra .
There are three characteristic features
1. the external meatus opens on the underside of the penis
or the perineum.
2. the ventral aspect of the prepuce is poorly developed (‘hooded
prepuce’) .
3. there is a ventral deformity of the erect penis (chordee).

Hypospadias is classified according to the position of the meatus

A. Glanular hypospadias.
B. Coronal hypospadias.
C. Penile and penoscrotal hypospadias.

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

D. Perineal hypospadias. This is the rarest and most severe

abnormality. The scrotum is bifid and the urethra opens between
its two halves. There may be testicular maldescent which may
make it difficult to determine the sex of the child.

Treatment
Hypospadias does not cause either obstruction or urinary tract
infection.
Surgery is indicated to improve sexual function to correct problems
with the urinary stream and for cosmetic reasons.
A variety of plastic surgical procedures have been described to
correct the chordee and to re-site the urethral opening.
Some techniques utilise the foreskin and therefore circumcision
should be avoided before the hypospadias has been repaired.
Surgery before the stage of genital awareness ( before 2 years).

Epispadias
Epispadias is very rare. In penile epispadias, the urethral opening
is on the dorsum of the penis and is associated with an upward
curvature of the penis ,Epispadias often coexists with bladder
exstrophy and other severe developmental defects.

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

Urethral injury
presentation of urethral injury
I . Urethral injury rarely occurs in females.
2.Findings that suggest urethral injury include
 blood at the meatus.
 Distended bladder.
 inability to void .
 Genital or perineal hematoma.
 pelvic fracture, penetrating penile injury,
 Unsuccessful catheterization.
 Triad of pelvic fracture, blood at the meatus and inability to
void are diagnostic of urethral injury (posterior urethra).
Anterior urethral injury
Mechanisms
 External blunt: straddle injury (e.g. forceful contact of perineum
with bicycle cross-bar) most common cause of injury; kick to
perineum.
 penile fracture.
 External penetrating: gunshot; stab .
 iatrogenic: catheter balloon inflated in urethra; endoscopic
surgery; penile surgery.

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

 Internal, self-inflicted: foreign bodies inserted into urethra.

History and examination

The patient usually presents with difficulty in passing urine and
frank haematuria in the context of a straddle injury. Blood may be
present at the end of the penis and a haematoma around the site of
the rupture.
If Buck’s fascia is intact, bruising from a urethral rupture is confined
in a sleeve-like configuration along the length of the penis.
If Buck’s fascia has ruptured, the extravasation of blood, and thus
the subsequent bruising is limited by the attachments of Colles’
fascia which forms a ‘butterfl y’-like pattern in the perineum and is
continuous in the upper abdomen and chest with Scarpa’s fascia.
Extravasation of urine can create a collection of urine around the
urethra (a urinoma) and generates an inflammatory reaction, with
subsequent stricture formation. Superadded infection can lead to
abscess formation which may burst onto the surface of the skin,
leading to a urethrocutaneous fistula. More rarely, Fournier’s
gangrene supervenes.
Radiographic imaging
Retrograde urethrography delineates the extent of urethral injury.
This can divided

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

1. Anterior urethral contusion

Typical history: blood at meatus, no extravasation of contrast on
retrograde urethrogram. Pass a small gauge urethral catheter (12 Ch
in an adult) and remove a week or so later.

2. Partial rupture of anterior urethra

Leak of contrast from urethra with retrograde flow into bladder.
Most can be managed by a period of suprapubic urinary diversion.
Seventy percent heal without stricture formation (primary closure
can be difficult because of oedema and of haematoma at the site of
injury and can convert a short area of urethral injury into a longer
one). Give a broad-spectrum antibiotic to prevent infection of
extravasated urine and blood. If a voiding cystogram 2 weeks later
confirms urethral healing, remove SPC. If contrast still extravasates,
leave it in place a little longer . Suprapubic catheterization
(percutaneously) is preferred over urethral catheterization because a
partial rupture can be converted to a complete rupture.

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

3. Complete rupture of anterior urethra

Leak of contrast from the urethra on retrograde urethrogram, no
filling of the posterior urethra or bladder. The urethra may either be
immediately repaired (if a surgeon with sufficient experience is
available) or an SPC can be placed with delayed repair.
Immediate surgical repair of anterior urethral injuries is only done in
the context of penile fracture or where there is an open wound.

Posterior urethral injury

Mechanisms
 External blunt - : pelvic fracture—road traffic accidents, falls
from a height, crush injuries—most common cause.
 External penetrating - : gunshot—rare; stab—rare.
 iatrogenic - : endoscopic surgery; radical prostatectomy; TURP.
 Internal, self-inflicted - : foreign bodies inserted into urethra.

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 Urology //urinary tract infection 2 //Dr. Omar M. Shakir

The great majority of posterior urethral injuries are an associated

injury following pelvic fracture, and their diagnosis and initial
management are Immediate (within 48h) open repair of posterior
urethral injuries is associated with a high incidence of urethral
strictures 70%and subsequent restenosis after stricture repair,
incontinence 20% and impotence 40%. The surrounding haematoma
and tissue swelling make it difficult to identify structures and to
mobilize the two ends of the urethra to allow tension-free
anastomosis.
In the majority of male posterior urethral injuries, treatment should
be deferred for 3 months to allow the oedema and haematoma to
completely resolve. As this occurs, the two distracted ends of the
urethra come closer together, thereby reducing the amount of
mobilization that the surgeon has to do. Most such injuries can be
repaired by an anastomotic urethroplasty.
Immediate repair is indicated where there is an open wound as long
as the urethral ends are close(i.e. not distracted by alarge haematoma)
Urethral injuries in females
Rare because the female urethra is short and its attachments to the
pubic bone are weak such that it is less prone to tearing during pubic
bone fracture. When they do occur, such injuries are usually
associated with rectal or vaginal injuries. In developing countries,
prolonged labour can cause ischaemic injury to the urethra and
bladder neck, leading to urethrovaginal or vesicovaginal fistula
formation.

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