Post-Traumatic Bulbo-Membranous Stricture After Pelvic Fracture
A 32-year-old man was involved in a motorbike collision six months ago, sustaining a pelvic fracture and a urethral injury. A suprapubic catheter was placed after a failed urethral catheterisation. He now attends with the suprapubic catheter in situ and asks when it can be removed. He has no fever or pain. Retrograde urethrogram shows a 2.5 cm stricture at the bulbo-membranous junction with no contrast passing into the bladder; the bladder neck is open. He reports reduced erectile rigidity since the accident but no incontinence. Renal function is normal. He is keen to avoid a permanent catheter and wants to know about surgery. He has a new partner and is concerned about fertility and sexual function. The registrar suggests an endoscopic optical urethrotomy.
1. How would you assess this patient and what imaging or tests are needed before definitive repair?
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I would take a focused history of the injury, the initial management, catheter duration, urine stream, incontinence, erectile function, ejaculation and fertility, and the patient's priorities. Examination should include the suprapubic catheter site, meatus, scrotal and perineal sensation, and a neurological assessment. I would arrange urine culture, renal function and a combined retrograde and antegrade urethrogram through the suprapubic catheter to define the stricture length, the bladder neck and any false passage or fistula. A flexible cystoscopy through the suprapubic tract can help assess the bladder neck and the proximal urethra. I would not perform optical urethrotomy for a 2.5 cm post-traumatic bulbo-membranous distraction defect; it has a high failure rate and can lengthen the stricture, making later reconstruction harder. The patient should be counselled about erectile dysfunction and fertility before any intervention.
2. What are the options for repair and which would you recommend? Explain the timing and reasons.
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For a 2.5 cm bulbo-membranous stricture after pelvic fracture, excision of the scar and tension-free anastomotic urethroplasty is the best option. It has a high success rate and addresses the scar rather than merely incising it. The repair is usually performed after at least 3–6 months from injury, when inflammation has settled and the patient has been fully assessed. A suprapubic catheter should remain until the repair is successful. If the defect were longer or if the urethra were unsalvageable, a staged graft reconstruction or buccal mucosal graft urethroplasty would be considered. Endoscopic urethrotomy is not appropriate for a distraction defect because it does not excise the scar and recurrence is likely. The patient needs a preoperative discussion about the risk of erectile dysfunction, urinary incontinence, recurrence and the possible need for suprapubic catheterisation after surgery.
3. What would you tell him about outcomes, erectile dysfunction and fertility?
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I would explain that anastomotic urethroplasty gives a good chance of restoring voiding without a catheter, but that success is not guaranteed and some patients need further procedures. The risk of new urinary incontinence is low when the bladder neck is competent, but stress incontinence can occur. Erectile dysfunction may already be present from the pelvic fracture and can worsen after surgery; he should be assessed and counselled before repair, and treated later if needed. Fertility can be affected by ejaculatory dysfunction or reduced semen quality after pelvic trauma, and the urethral surgery itself may affect ejaculation. I would offer semen analysis if he is trying to conceive and involve a fertility specialist if abnormal. I would also explain that a suprapubic catheter will stay until the repair has healed and that he needs follow-up with flow rate and possibly urethrography if symptoms recur.