UROGENITAL TRAUMA

Recent advances in management of female lower urinary tract trauma
Hartanto VH, Nitti VW
Department of Urology, New York University, NY 10016, USA
Curr Opin Urol. 2003; 13: 279-84

• Purpose of Review: Abdominal and pelvic injuries are often associated with devastating lower urinary tract injuries. The literature is replete with studies involving male lower urinary tract trauma, however the diagnosis and management of similar injuries in women is not as well covered. In this article we will review recent advances in the diagnosis and management of female lower urinary tract trauma.
• Recent Findings: The recent literature emphasizes the importance of diagnosing and managing female lower urinary tract injuries, both of the bladder and the urethra, caused by blunt or penetrating trauma to the lower abdomen, pelvis and perineum. Successful management of these injuries is based upon accurate diagnosis, recognition of associated injuries, and prompt treatment. Diagnosis and treatment of female bladder perforation have been well established. Reports of female urethral injuries are scarce, however, and subsequently the management is not standardized.
• Summary: High suspicion, accurate diagnosis and prompt treatment are key for the successful management of female lower urinary tract injuries associated with lower abdominal, pelvic and perineal trauma. A standardized algorithm for management of female urethral injuries would be helpful.
  
  
• Editorial Comment
  Female urethral trauma is sufficiently rare that few of us have any significant individual experience. This analysis nicely encapsulates the diagnosis and treatment of both bladder and urethral injuries in women. While the treatment of bladder injuries will be review for many, several aspects of care for female urethral injury bear emphasis. 1)- Urethral injuries in women are far more common in those less than 17 years old. 2)- Index of suspicion should remain high, and hematuria or vaginal bleeding should be evaluated with cystoscopy, even if that is inconvenient in the multi-injured patient. 3)- MRI may be used in females to delineate anatomy before definitive reconstruction, if required. 4)- Repair of severe urethral injury with subsequent fistula or stricture is not yet standardized in the literature. Transfer to a center with experience in this entity may be warranted. Options include first stage Johanson urethroplasty, two stage Johanson urethroplasty, “cut to the light” urethrotomy and dilation, bladder flap urethroplasty, vaginal flap urethroplasty, buccal mucosal onlay urethroplasty, anastomotic urethroplasty or even bladder neck closure and suprapubic urinary diversion. Surgeons should use the approach they are most comfortable with, awaiting future publications which might better establish the best technique.

Dr. Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA