Definition

Urethral rupture is a condition characterized by the disruption of urethral tissue due to trauma or injury. The urethra serves as the passage connecting the bladder to the external environment, thus any urine leaving the body must pass through it. Although rare, this condition constitutes a medical emergency within the human urinary system and necessitates immediate attention.

Due to the longer length of the male urethra, urethral rupture occurs more frequently in men than in women. Generally, men aged 11-25 years old are at a higher risk of experiencing urethral rupture.

Urethral rupture can manifest in two primary ways:

• Complete rupture, affecting the entire length of the urethra.
• Incomplete rupture, involving only a portion of the urethra.

Furthermore, urethral rupture can be classified based on its location:

• Anterior urethral rupture, occurring in the front portion of the urethra.
• Posterior urethral rupture, occurring in the rear part of the urethra.

These injuries can lead to urethral damage, resulting in urinary flow impairment and posing both quality of life and life-threatening risks. The resultant wounds may impede or obstruct urine flow from the penis. Timely and effective examination and management are essential for mitigating mortality and disability rates associated with urethral rupture.

Causes

Urethral rupture can result from various types of injury, including blunt, sharp, or iatrogenic trauma (injury caused by medical instruments).

• Examples of blunt injuries may involve fractures or cracks in the pelvic and penile bones.
• The most common sharp injuries leading to urethral rupture are typically associated with gunshot wounds and stab wounds.
• Iatrogenic injuries often occur due to the use of endoscopic instruments and catheter placement during medical procedures.

Overall, cases of urethral rupture are most frequently attributed to traffic accidents and falls from heights. Additionally, sexual behavior is recognized as another potential cause of urethral rupture.

Risk factor

The risk factors for urethral rupture can vary, but the most common ones include:

• Male gender
• Pelvic fractures
• Motorcycle accidents
• Penile fractures or fractures of the penis

Symptoms

Urethral rupture may present with the following symptoms: hematuria, characterized by the presence of blood in the urine, or urine appearing red. The bladder may feel palpable and full.

Due to incomplete urethral tissue, urine retention in the bladder can occur. This condition may lead to urinary retention, pain in the groin area, and a painful sensation during urination.

Diagnosis

The diagnosis of urethral rupture typically involves a comprehensive approach, combining a medical interview, physical examination, and diagnostic tests to establish an accurate diagnosis.

During the medical interview, if the patient is conscious, the doctor will inquire about:

• The patient's main complaint and accompanying symptoms
• History of the last urination
• Presence of pain during urination
• History of injury
• Past medical history
• Family medical history

A physical examination will encompass checking the patient's vital signs, including level of consciousness, blood pressure, pulse, and respiratory rate. Subsequently, the doctor will examine the patient's groin area and the region surrounding the urethra.

In cases of anterior urethral rupture, evident bleeding may be observed on the skin around the groin, often in a characteristic pattern resembling a butterfly (butterfly hematoma).

Additionally, a rectal examination will be performed not only to assess the position of the prostate in men but also to aid in determining the location of the urethral injury.

Diagnostic tests will include laboratory tests and imaging examinations to confirm the diagnosis. Laboratory tests are essential to check for any underlying conditions that may require attention. This ensures that the doctor is adequately prepared with relevant laboratory information to prevent deterioration and complications in the patient, especially if surgery is indicated.

For imaging examinations, retrograde urethrography (RUG) is typically recommended. This examination is fast, accurate, simple, and can indicate the severity and location of urethral rupture, which is valuable for determining appropriate management.

CT scans can also be performed as an optimal imaging option for assessing the urinary tract. Meanwhile, MRI is useful as preoperative imaging before urethral reconstruction surgery to correct urethral shape and remove scar tissue.

In summary, retrograde urethrography is the most recommended radiological examination among the mentioned modalities to assist in diagnosing urethral rupture.

Management

Since urethral rupture is considered a medical emergency, the initial treatment focuses on stabilizing the patient's condition, particularly addressing any bleeding. Once the patient is stabilized, the therapy varies based on the type and location of the injury, with treatment tailored to each case according to the patient's condition and the doctor's judgment.

In less severe cases, a urinary catheter may be inserted through the abdomen (suprapubic catheter) and left in place for approximately 14–21 days. Subsequent follow-up examinations will assess the improvement of the urethral condition. If the urethral function improves satisfactorily, urethral reconstruction surgery (urethroplasty) may not be necessary.

However, for posterior urethral rupture cases, a urinary catheter is typically left in place through the abdomen for monitoring for about 3–6 months. Urethroplasty is performed once conditions permit.

If the patient's condition remains unstable or if surgical attempts are unsuccessful, a suprapubic cystostomy procedure may be required. This involves extracting urine through a needle inserted into the skin, connected to the bladder to facilitate urine flow. Urethroplasty should ideally be performed no later than 14 days after the injury to optimize outcome.

Complications

Urethral rupture has the potential to lead to various complications for patients, both in the short and long term.

Short-term complications may include:

• Secondary infection, which can result in the formation of abscesses or pus-filled lumps in the area surrounding the urethra.
• In severe cases, it may lead to Fournier's gangrene, a condition where tissue in the scrotum, penis, and adjacent areas dies due to infection.

Long-term complications can encompass:

• Urethral stenosis, characterized by the narrowing of the urethral canal.
• Urethral stricture, involving the formation of fibrosis or scar tissue in the urethral canal.
• Urinary incontinence, which refers to the inability to control the urge to urinate.
• Erectile dysfunction.

Given the potential for these complications, comprehensive management is essential for patients with urethral rupture.

Prevention

Prevention of urethral rupture entails avoiding activities that pose a risk of injury. Examples include:

• Driving at a safe speed to reduce the likelihood of traffic accidents.
• Avoiding activities such as jumping from heights without appropriate safety measures to prevent potential injuries that could result in urethral rupture.
• For medical personnel, always ensuring the use of a catheter with a size suitable for the patient's urethra. Using an inappropriate catheter size can injure the patient and potentially lead to urethral rupture.

When to see a doctor?

Go to the nearest doctor or health facility promptly if you have an injury around the hip, waist, or groin area. Additionally, seek medical attention promptly if you experience symptoms such as difficulty urinating, blood in the groin after an injury, or blood in the urine. This condition is considered an emergency and needs to be treated promptly.

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