What is the treatment for an exposed bulbar urethra with hyperemic genital skin?

Treatment of Exposed Bulbar Urethra with Hyperemic Genital Skin

For exposed bulbar urethra with hyperemic genital skin, prompt urinary drainage should be established followed by appropriate surgical repair, with the specific approach determined by the nature and extent of the injury.

Initial Management

• Establish immediate urinary drainage via suprapubic catheter or urethral catheter if possible 1
• Evaluate for extent of urethral injury using retrograde urethrography 1
• Assess for associated injuries, particularly to the penis, scrotum, or perineum 1
• Control local infection with appropriate antibiotics if signs of infection are present 1

Surgical Management Options

For Penetrating Injuries:

• Prompt direct surgical repair is recommended for uncomplicated penetrating trauma of the anterior urethra 1
• Spatulated primary repair offers excellent outcomes superior to delayed reconstruction 1
• Primary repair should not be undertaken if:
  • Patient is hemodynamically unstable
  • Surgeon lacks expertise in urethral surgery
  • There is extensive tissue destruction or loss 1

For Blunt/Straddle Injuries:

• Conservative management with urinary drainage is the initial treatment of choice 1
• Avoid immediate operative intervention to repair or debride the injured urethra due to the indistinct nature of the injury border 1
• Endoscopic realignment should be attempted before surgical repair 1
• Delayed surgical repair should be considered if conservative treatment fails 1

For Large Defects:

• When anastomotic urethroplasty is not feasible due to a large anatomic defect (typically lesions > 2–3 cm in the bulbar urethra):
  • Perform temporary suprapubic urinary catheter placement
  • Plan for delayed anatomic reconstruction with graft or flap (interval urethroplasty at > 3 months) 1

For Cases with Extensive Genital Skin Loss:

• Perform exploration and limited debridement of non-viable tissue 1
• Consider staged repair with:
  • First stage: Placement of buccal mucosa graft to the tunica albuginea 1
  • Second stage: Urethral tubularization 6-12 months later 1
• For extensive tissue loss, wound management options include:
  • Gauze dressings with frequent changes
  • Silver sulfadiazine or topical antibiotic with occlusive dressing
  • Negative pressure dressings 1

Follow-up Care

• Monitor patients for complications (stricture formation, erectile dysfunction, incontinence) for at least one year following urethral injury 1
• Perform urethrography every two weeks until complete healing 1
• Use surveillance strategies with uroflowmetry, retrograde urethrogram, and/or cystoscopy 1
• Stricture formation after urethral injury is very high, requiring vigilant follow-up 1

Special Considerations

• If lichen sclerosus is suspected as the underlying cause (particularly with hyperemic skin changes), biopsy for histological confirmation is recommended 1, 2
• For cases with severe tissue loss or infection, consider gracilis myocutaneous flap for coverage of post-infective raw areas 3
• Be vigilant about vascular complications such as pseudoaneurysm of the bulbar artery, which may occur with urethral trauma 4
• When using buccal mucosa grafts for reconstruction, extragenital tissue is preferred in cases with compromised genital skin 1, 5