What is the initial management for traumatic urinary incontinence?

Initial Management of Traumatic Urinary Incontinence

The initial management for traumatic urinary incontinence should prioritize obtaining urinary drainage as soon as possible via urethral or suprapubic catheter to stabilize the patient and prevent further complications. 1

Assessment and Diagnosis

• Perform retrograde cystography in stable patients with gross hematuria and mechanism concerning for bladder injury, or in those with pelvic ring fractures and clinical indicators of bladder rupture 1
• Conduct IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images when renal or upper urinary tract injury is suspected 1
• Evaluate for associated injuries that may contribute to incontinence, including pelvic fractures, which are commonly associated with urethral trauma 2

Initial Management Based on Injury Type

Urethral Injuries

• Obtain urinary drainage immediately via urethral catheter if possible, or suprapubic catheter if urethral injury is suspected 1

• For blunt anterior urethral injuries:

  • Initial conservative management with urinary drainage (urethral or suprapubic catheter) 1
  • Attempt endoscopic realignment before considering surgical repair 1
  • Consider delayed surgical repair if conservative treatment fails 1

• For partial blunt injuries of the posterior urethra:

  • Initial conservative management with urinary drainage 1
  • Attempt endoscopic realignment 1
  • Delay definitive surgical management for 14 days if no other indications for laparotomy exist 1

• For posterior urethral injuries with hemodynamic instability:

  • Immediate urinary drainage and delayed treatment 1
  • When associated with complex pelvic fractures, perform definitive surgical treatment with urethroplasty after healing of pelvic ring injury 1

Bladder Injuries

• For bladder contusion: No specific treatment required beyond observation 1
• For intraperitoneal bladder rupture: Surgical exploration and primary repair 1
• For extraperitoneal bladder injuries: Non-operative management with urinary drainage via urethral or suprapubic catheter if no other indications for laparotomy 1
• For complex extraperitoneal bladder ruptures (bladder neck injuries, lesions associated with pelvic ring fracture, vaginal or rectal injuries): Surgical exploration and repair 1

Follow-up and Monitoring

• Perform urethrography every two weeks until complete healing in cases of urethral injury 1
• For bladder injuries, CT scan with delayed phase imaging is the method of choice for follow-up 1
• In patients with fixed/immobile urethra due to trauma, consider long-term management options including:
  • Pubovaginal sling for completely non-mobile urethras 3
  • Urethral bulking agents as an alternative, though patients should be counseled about potential need for repeat injections 3
  • Artificial urinary sphincter for severe incontinence with fixed urethra 3

Cautions and Pitfalls

• Avoid placing synthetic mesh slings in patients with poor tissue quality, significant scarring, or history of radiation therapy 3
• Avoid transobturator midurethral slings in patients with fixed urethras as they may require additional tension, increasing complication risks 3
• Be aware that urethral injuries can result in erectile dysfunction in up to 50% of male patients and is often associated with urinary incontinence that significantly affects quality of life 2
• Recognize that the management of traumatic urinary incontinence requires a multidisciplinary approach involving urologists, trauma surgeons, and other specialists 1