Rajadoss, M (2013) Impact of traumatic posterior urethral injury on penile vascular supply and erectile function. Does pre-operative MRI have a role? - A Single centre, prospective observational study. Masters thesis, Christian Medical College, Vellore.
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Abstract
INTRODUCTION: Incidence of non-iatrogenic trauma to urethra is 1:1, 25,000. A steady increase in the incidence of high velocity accidents is contributory. Non-iatrogenic urethral injury is more serious than iatrogenic trauma because the force required to injure is very high. The incidence of concomitant injuries may be as high as 86% and usually dominate the initial evaluation and management of such a patient. Traumatic posterior urethral injury is associated with considerable morbidity. This may range from urethral distraction defect, urinary incontinence, and erectile dysfunction to anorectal fistula formation. Young males <40 years of age form the majority of those who present with traumatic posterior urethral injury. Erectile dysfunction is seen in up to 50% of these individuals. Organic causes of erectile dysfunction would be injury to cavernosal nerves, internal pudendal vessels or both. Recent studies have highlighted the role of pre-operative penile color doppler and MRI pelvis in evaluating these factors. Identifying the organic components of erectile dysfunction would enable cause-specific therapy for post-traumatic erectile dysfunction and identify the subgroup of patients who are likely to benefit from early penile rehabilitation. AIM: To study the impact of traumatic posterior urethral injury on erectile function and the role of penile color doppler and MRI pelvis in pre-operative evaluation. OBJECTIVES: a) To study the prevalence of erectile dysfunction in patients with PFUDD using the validated IIEF questionnaire. b) To evaluate penile vascularity using color doppler c) To correlate penile blood supply with the following physical findings on MRI pelvis: • stricture length, • extent of fibrosis, • prostatic displacement and • corporal injuries. d) To assess the impact of vascular changes and MRI findings on surgical outcome. MATERIAL AND METHODS: This was a single center, prospective observational study. The duration of the study was from Feb 2011 till Dec 2012. The study was carried out under the department of Urology, Christian Medical College and Hospital, Vellore - a tertiary care, referral centre. A small pilot study inclusive of 3 patients was carried out to assess the feasibility of the study. Following this, it was evaluated and approved by the Institutional Review Board and Ethics Committee. Inclusion criteria: Consecutive male patients presenting with traumatic posterior urethral injury for a primary urethral reconstruction were included in this study. Exclusion criteria: Unwillingness to consent Co-morbid conditions like diabetes and hypertension with end organ damage Traumatic spinal cord injury Previous operative intervention Pre-existing erectile dysfunction. Pre-operative evaluation: Following informed consent patients were assessed using a validated questionnaire, International Index of Erectile Function (IIEF). Pre-operative imaging with MRI pelvis and penile color Doppler were carried 3 months following the trauma. RESULTS: The median age at presentation was 34 years age (range of 17-61 years). Majority (14/20 - 70%) of them were <40 years in age. All patients underwent suprapubic catheterization. None of the patients had undergone an attempt at primary realignment. Three patients had associated anorectal injuries. They underwent diversion colostomy. One patient underwent external fixation of pelvic fracture, rest where managed Conservatively. Patients in the age group 17-61 years presented with PFUDD. Eight out of the 19 patients (42%) were ≤30 years. Sanjay Kulkarni et al in their review compared PFUDD in developing and developed countries. They found PFUDD more common in children and adolescents in India when compared to Italy (25.6% Vs 8%).(35) There are a few important differences when PFUDD occurs in children and pre-pubescent boys. Presence of rudimentary prostate and puboprostatic ligaments implies higher chance of injury to prostatic urethra and bladder neck resulting in more complex strictures.(5,36,37) Secondly, smaller glans with fewer vascular connections implies poorer retrograde blood flow to bulbar urethra. CONCLUSIONS: Majority of patients presenting with traumatic posterior urethral injury were younger than 40 years. Erectile dysfunction was present in most of the patients. Severe erectile dysfunction was associated with abnormal peak systolic velocity and poor surgical outcome. MRI findings associated with poor peak systolic velocity was longer urethral distraction defect, prostatic displacement and presence of retropubic scarring. Cavernosal injury, prostatic displacement, retropubic scar and ano-rectal injury had significant correlation with erectile dysfunction. Hence, preoperative evaluation with penile color doppler and MRI pelvis has a pertinent role in management of patients with PFUDD who have severe erectile dysfunction.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Impact ; traumatic posterior urethral injury ; penile vascular supply ; erectile function ; pre-operative MRI ; single centre ; prospective observational study. |
| Subjects: | MEDICAL > Urology |
| Depositing User: | Kambaraman B |
| Date Deposited: | 12 Oct 2017 01:24 |
| Last Modified: | 12 Oct 2017 01:24 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/3473 |
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