Pelvic fracture urethral distraction injury four months after the crash
A 30-year-old man is referred 4 months after a motorcycle crash with a pelvic fracture and a straddle injury. At the time, he had blood at the meatus and could not void; a suprapubic catheter was placed, and a retrograde urethrogram showed a 4-cm distraction of the bulbar urethra with no contrast reaching the bladder. No primary realignment was attempted. He now voids only through the suprapubic catheter, has no erections, and reports numbness in the glans and shaft. He is keen to "get rid of the bag". Examination shows a suprapubic catheter, a healed perineal scar, and a palpable 3-cm gap between the prostate and the bulbar urethra on rectal examination. He has normal renal function and no other injuries. He asks about the chance of normal voiding and sexual function after repair.
1. What preoperative assessment would you perform before urethral reconstruction?
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I would confirm the anatomy with a combined retrograde urethrogram and antegrade cystogram through the suprapubic catheter. This defines the length of the distraction, whether the bladder neck is competent, and whether there is a false passage. I would also perform urethroscopy and cystoscopy to assess the proximal urethra and bladder neck. MRI is optional but can help define the degree of prostatic displacement and scar tissue.
The neurological and erectile history matters: he has no erections and penile numbness, suggesting cavernous nerve or vascular injury. I would document this with a validated erectile function score and baseline testosterone. Renal function and urine culture should be checked, and any infection treated before surgery. The key judgement is to define the defect and bladder neck status before committing to a perineal repair; a bladder neck injury changes the reconstruction and continence counselling.
2. When and how would you repair the urethra?
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I would perform a delayed excision and primary anastomosis through a perineal approach, typically 3–6 months after injury once the scar has matured. A 4-cm distraction in the bulbar urethra is at the limit of a simple perineal anastomosis; I would be prepared for corporal separation, inferior pubectomy, or rerouting to gain length. The suprapubic catheter is left in place until a voiding trial.
The key steps are to excise all scar, mobilise the bulbar urethra, and perform a tension-free spatulated anastomosis. I would avoid grafting in this contaminated, scarred field. Success rates exceed 90% in experienced hands. If the bladder neck is incompetent, continence may remain a problem after repair. The timing should not be rushed: operating too early on immature scar increases recurrence.
3. How do you counsel him about erectile dysfunction and incontinence after surgery?
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I would be honest that his absent erections are unlikely to recover fully after urethroplasty. Pelvic fracture urethral distraction injury damages the cavernous nerves and blood supply, and erectile dysfunction affects up to half of patients. Urethroplasty restores voiding but does not reliably restore erections. I would offer phosphodiesterase-5 inhibitors, a vacuum erection device, and referral to a sexual medicine specialist; intracavernosal injections are an option if oral therapy fails.
Incontinence is less common unless the bladder neck was injured. If the bladder neck is incompetent, he may need an artificial urinary sphincter after the urethra has stabilised. Retrograde ejaculation is possible. I would also warn him about a 10–15% risk of stricture recurrence and the need for surveillance. The overall message is that voiding has a high chance of success, but sexual function and continence need separate assessment and treatment.