A Monthly Journal of Practical Medicine.

VOL. XXXVI. ST. LOUIS, Mo., MARCH, 1908.

No. 3.

TRAUMATIC RUPTURE OF THE URETHRA.

BY EDWARD J. ANGLE, A. M., M. D.,

Professor of Genito-Urinary Surgery and Skin Diseases, Nebraska College of Medicine,
Lincoln, Neb.

[Written for the MEDICAL BRIEF.]

In reviewing the literature, one can not fail to be impressed with the paucity of detailed information on this subject. Many works on surgery dismiss it with a few paragraphs, while in others the discussion is so general and indefinite as to be valueless to the general practitioner.

Occurring, as it does, in the rural districts as well as in the city, the general practitioner is first called, and the final result in a patient, the subject of ruptured urethra, will depend upon an accurate, early diagnosis, and proper treatment.

Therefore, it behooves the practitioner to be familiar with the mechanism of the injury, its symptoms, and results, and, if necessary, summon a surgeon before hemorrhage and urinary extravasation threaten the vitality of the tissues, and sepsis the life of the patient.

I quote from Lydston, who says to the point: "The subject of urethral traumatisms, while strictly surgical, is very important to the general practitioner. He is usually first upon the scene after injuries, and may be led to believe that certain cases are of trifling importance, when they urgently demand the immediate attention of an expert surgeon. It is by no means serious swelling, pain, and retention of urine alone that require careful surgery. A knowledge of the possible immediate dangers, ultimate results, and proper treatment of traumatisms of the urinary canal is of the greatest importance, not only because of the immediate gravity of many cases, but of the possible remote, yet serious, results."

Rupture of the pendulous urethra seldom occurs, except during erection. It is usually the result of breaking a chordee, "fracture of the penis," or forcible manipulation of the erect organ. The flaccid penis is so movable that it usually escapes the force of blows and kicks.

Rupture is most commonly found in the perineal urethra, and it is to this portion that my remarks will be directed. The seat of the rupture is usually the bulb. The membranous or posterior urethra is torn in cases of fracture of the pelvis, or disjunction of the pubic symphysis. The prostatic urethra is involved only in cases of extensive fracture.

Kauffmann, as the result of a statistical study of over two hundred cases, gives as the modus operandi of the injury: Falling astride a beam or similar hard object, eighty per cent; perineal blows, twelve per cent; run over by vehicles, four per cent; jolting of a rider onto the pommel of his saddle, four per cent.

The mechanism of the injury has provoked much discussion and divers contradictory opinions. We can safely say, as a general proposition, that the mechanism of the urethral injury depends upon the shape of the offending body, and the direction in which the force is applied.

When the injury results from falling astride the narrow edge of a plank or similar object, this is forced upward between the ischio-pubic rami, tears the triangular ligament, and forces the urethra to one side, and crushes it against the ischio-pubic ramus.

Kicks from behind, when the pelvis is tilted forward, rupture the membranous and bulbous portion of the urethra.

Dr. Arch Dixon,* in a recent article, sums up concisely the seat of the lesion: "According to Franc and Reybard, a rupture, resulting from a contusion of the perineum, is most frequently situated in the portion of the urethra which extends between the triangular ligament and the suspensory ligament of the penis. From information gathered at autopsies, and examinations made at the moment when perineal incisions had been practiced, Cras came to the following conclusion: Every time that the examination was made carefully, the bulbous region was found involved. Guyon, in his report on the paper of Cras, adopts the same opinion. Finally, Terillon, relying upon the results of autopsies, upon explorations carried out by surgeons during operations of urethrotomy, and upon his own experience, arrives at altogether analogous conclusions. In contusions of the perineum, ruptures are situated most frequently at the level of the middle or anterior portion of the bulb. There always remains, in front of the triangular ligament, a strip of the canal, having a length which varies from one to three centimeters."

As previously mentioned, rupture of the membranous urethra usually results from fracture of the pelvis or luxation of the pubic symphysis.

Rupture of the urethra may be partial or complete. In cases of only moderate injury, the spongy tissue of the bulb may only be involved, its fibrous investment and the mucous and sub-mucous layers of the urethra remaining uninjured. However, even in these moderate cases, there may be temporary obstruction of the urethra, due to extravasation of blood in the erectile tissue of the bulb. In cases of more severe character there is a solution of continuity through the spongy body and mucous and sub-mucous layers. In the most severe cases we find, in addition to the above, the injury extending through the fibrous sheath surrounding

* Surgery, Gynecology and Obstetrics, Volume IV, p. 1.

the spongy body, and, consequently, opening up a direct communication from the urethra to the connective tissue of the perineum and scrotum.

The canal may be completely or partially divided, or it may be broken into a number of pieces. More frequently, the injury comprises only the lower and lateral urethral walls. If there is a complete severing of the canal there is marked retraction of its ends, leaving a space between them, from one-half to an inch. The ends may be contused, sharply cut or decidedly disintegrated. At the side of the injury there is always more or less extravasation of blood and urine into the surrounding tissues. If there be extensive extravasation, there will be found a hard, bulging tumor, filling in the loose tissue of the perineum.

Extravasation of the urine, occurring through injury of the bulbous region of the urethra, will follow the space enclosed by the deep layer of the superficial (Colles') fascia. If not relieved, this infiltration extends backward to either side of the rectum, forward into scrotum, and over the body of the pubis: If the injury is confined to the membranous portion alone, the extravasated urine would be confined by the two layers of the triangular ligament and could only invade other structures by sloughing and abscess formation. In all neglected cases there occurs, secondarily, the element of infection, and this may be due to unsuccessful catheterization, or through the use of instruments not surgically clean.

The symptoms of laceration of the urethra are, disturbance of urination, hemorrhage, pain, and the formation of tumor of a greater or lesser extent, at the seat of injury. The pain of ruptured urethra is not in any way characteristic, as there may be intense pain in an injury of moderate extent, and but little complaint in an extensive injury. The act of urination increases the pain, which becomes more intense if retention occurs, and may be due as well to distended bladder as to the direct injury.

The escape of blood from the meatus is always indicative of urethral injury. Blood escaping through the urethra, with the formation of little or no perineal tumor, indicates that the injury is confined to the mucous surface of the urethra. The size and rapidity with which the perineal tumor is formed is indicative of the extent of the hemorrhage. In cases in which the tissues have been contused, rather than sharply cut, it is attended with little loss of blood. If the rupture is posterior to the triangular ligament, hemorrhage will not manifest itself, either at the meatus or in the form of a perineal tumor, but passes backward into the bladder, and involves the deep cellular tissues.

In cases of mild injury and slight laceration of the urethra, the act of urination may be little affected. If the injury is extensive, or urethra is completely severed, with retraction of its proximal end, the patient is unable to void urine naturally. For a time there may be complete retention in the bladder, but, sooner or later, the tenesmus forces urine, in part or entirely, into the peri-urethral cellular tissue.