Pelvic fracture‐related injuries of the bladder neck and prostate: their nature,cause and management

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To report our experience of bladder neck injuries, which are a well recognized but rare consequence of pelvic fracture‐related trauma to the lower urinary tract, as we have been unable to find any reference in the English literature to their specific nature, cause and management in adults.

PATIENTS AND METHODS

In the last 10 years we have treated 15 men with bladder neck injuries after pelvic fracture. Two were treated at our centre by delayed primary repair. Thirteen were initially treated elsewhere and presented to us 3 months to 5 years after their injury with intractable incontinence and various other symptoms most notably recurrent urinary infection and gross haematuria. Twelve of the injuries were at or close to the anterior midline and associated with lateral compression fractures or ‘open‐book’ injuries. Five of them were confined to the bladder neck and prostatic urethra; the other seven extended into the subprostatic urethra. Four of these were associated with a coincidental typical rupture of the posterior urethra. All had an associated cavity involving the anterior disruption of the pelvic ring. Two of the injuries, following particularly severe trauma, were a simultaneous complete transection of the bladder neck and of the bulbo‐membranous urethra with a sequestered prostate between. We have seen this in children before but not in adults. Another injury, also after particularly severe trauma, was an avulsion of the anterior aspect of the prostate. We have not seen this described before. Fourteen patients underwent lower urinary tract reconstruction and one underwent a Mitrofanoff procedure. All of the 14 had a layered reconstruction of the prostate and bladder neck and in 13, this was supplemented with an omental wrap.

RESULTS

In all patients with an anterior midline rupture, the primary injury appeared to be to the prostate and prostatic urethra with secondary involvement of the bladder neck and the subprostatic urethra. The Mitrofanoff procedure was successful. Of the 14 patients with a layered reconstruction one, without an omental wrap, broke down but was successfully repaired on a subsequent occasion. The four patients who also had a ruptured urethra had a simultaneous bulbo‐prostatic anastomotic urethroplasty, two of which required further attention. Eight of the 14 reconstructed patients underwent implantation of an artificial urinary sphincter (AUS) for sphincter weakness incontinence, in seven of whom this was successful. Two of these had previously undergone implantation of an AUS with an unsatisfactory outcome and were made continent by bladder neck reconstruction. The other six patients had acceptable urinary incontinence by reconstruction of the bladder neck and urethra alone.

CONCLUSIONS

The primary injury is to the prostate and prostatic urethra. The bladder neck and subprostatic urethra are involved secondarily by extension. These injuries have a particular cause and a particular location with a predictable outcome. They need to be identified and treated promptly as they do not heal spontaneously and otherwise cause considerable morbidity. We also describe two particular types of bladder neck injury that we have not seen described before in adults.