134 © 2 0 0 4 B J U I N T E R N A T I O N A L | 9 4 , 1 3 4 – 1 3 6 | doi:10.1111/j.1464-410X.2004.04874.x Original Article PELVIC FRACTURE URETHRAL INJURIES IN GIRLS DORAIRAJAN ET AL. Pelvic fracture-associated urethral injuries in girls: experience with primary repair LALGUDI N. DORAIRAJAN, HARENDRA GUPTA and SANTOSH KUMAR Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India Accepted for publication 22 March 2004 catheter was removed after 3 weeks and a voiding cysto-urethrogram taken. Thereafter they were followed with regular urethral calibration. RESULTS All patients voided satisfactorily with a good stream; three were fully continent and the fourth had transient stress urinary incontinence. One patient needed dilatation at 2 months and another visual internal urethrotomy at 5 months. At a mean (range) follow-up of 33 (9–60) months all the patients had a normal voiding pattern and were continent; none developed vaginal stenosis. CONCLUSION Primary repair of the urethra, and if that is impossible, simple urethral realignment over a catheter, is the procedure of choice for managing female urethral injury associated with a pelvic fracture. The procedure has the additional advantage of reducing the risk of vaginal stenosis. KEYWORDS paediatric urethral injury, staged repair, pelvic fracture OBJECTIVE To present our experience with four urethral injuries in females accompanying a pelvic fracture, managed with primary repair or realignment of the urethra. PATIENTS AND METHODS There were three teenage girls and one adult (22 years old). All the patients had complete urethral injuries associated with a pelvic fracture from accidents. They were managed by immediate suprapubic cystostomy followed by repair or realignment of the urethra over a catheter on the same day. The INTRODUCTION Injury to the female urethra after a pelvic fracture is rare; the experience of any one centre in the initial management of this problem is limited. Most cases are managed initially by general or trauma surgeons and their management is based on principles developed from treating male urethral injury, i.e. initial suprapubic cystostomy and deferred referral to the urologist 3–6 weeks later, by which time the options for management are very few. As a result of this management the patient may have substantial loss of an already short urethra. Not surprisingly most reports, especially recent, have focused on the challenges of managing the destroyed female urethra [1–3]. They suggest recommendations on acute management based on the difficulties in correcting these late sequelae. Some of them have suggested a two-stage approach of initial suprapubic cystostomy (SPC) followed several weeks later by definitive repair by a urologist experienced in reconstructive surgery for the resulting stricture or fistula [1], while others have suggested primary repair or realignment of the injured urethra. However, the results of primary repair, and the nature of continued urological care after surgery, have not been well elucidated. We managed four such cases by primary repair or realignment of the urethra, and herein discuss the nuances in management, both during and after surgery, with the outcome of these procedures. PATIENTS AND METHODS Since 1998 four cases of urethral injuries associated with pelvic fracture in females were managed in our institution by primary repair. The case records of these patients were assessed for clinical details and are described. CASE 1 A 17-year-old girl presented 2 h after a wall collapsed on her, with genital bleeding and unable to stand. On examination she was in shock; an abdominal examination revealed a pelvic fracture and a suprapubic haematoma. The bladder was palpable up to the umbilicus. Blood was trickling from the vagina and the anterior vaginal wall was torn, exposing the posterior surface of the pubic bones. There was blood oozing from the urethral meatus. A catheter passed through the urethra came out of the vagina. A SPC was placed and a cystogram taken after resuscitation, which showed the bladder floating high in the pelvis. Exploration under general anaesthesia (GA) by a combined retropubic and perineal approach showed complete avulsion of the urethra just distal to the bladder neck. A cystotomy was made and a 16 F Foley catheter passed through the bladder neck and retrieved through the vagina; a similar catheter was passed from the external urinary meatus. The two catheters were tied together and a finger placed in the vagina by the assistant to guide the distal catheter into the proximal segment across the tear and into the bladder. The position of catheter was confirmed under vision. The two urethral ends were then approximated with a few interrupted sutures of 3/0 polyglycolic acid. No traction was applied on the catheter. A SPC was placed and the vaginal tear was repaired. Voiding cysto- urethrography (VCUG) after 3 weeks showed mild narrowing of the mid urethra but the patient had a normal stream and continence. Three months later she required urethral dilatation for the stricture and thereafter she has been on regular calibration, initially every 3 months and now every year, for the last 2 years. CASE 2 A 17-year-old girl presented with a history of being run over by a lorry, 4 h before presentation, followed by vaginal bleeding, and unable to void or stand. The clinical presentation was similar to that of the first case, except that her vaginal tear was larger and the broken fragments of pelvic bone were