Pednekar R*, Valvi D*, Warke HS**.
(* Assistant Professor, ** Associate Professor, Department of Obstetrics and Gynecology, Seth G. S. Medical College and KEM Hospital, Mumbai, India.)
We present a case of an unusual periurethral tear due to obstetric trauma which dislocated the urethra posteriorly, thus making it difficult to catheterize the patient. The patient was a second gravida and had come in labor to receiving room with head on perineum already. In spite of making an episiotomy to decrease the birth trauma and attempt at controlled delivery of the fetal head, a periurethral tear and a small perineal tear occurred, which subsequently had to be sutured in the operation theatre.
Trauma to the maternal lower genital tract during childbirth should be preventable with due care. Unfortunately it continues to occur, because of deficiencies in administration of healthcare, and sometimes the patients presenting too late even when adequate healthcare facilities are available. Injuries to the perineum, vagina, and cervix are much more common than those to the area anterior to the vaginal opening, i.e. lateral to the urethra and around clitoris. We present an unusual case in which there was disruption of epithelium all around the urethra resulting in posterior dislocation of the distal urethra and external urethral meatus.
A 26 years old, gravida 2 para 1 living 1, previous full term vaginal delivery, with term gestation, came in labor with head on perineum and delivered a male child of 3.13 kg in vertex presentation. The baby cried immediately after birth and handed over to a neonatologist. Placenta and membranes were delivered intact and completely. The mother had no other high risk factor, her past medical and surgical history was non significant. She had a full term normal vaginal delivery of a male baby weighing 3 kg. On examination, her vital parameters were normal. General and systemic examination revealed no abnormality. On local examination there was a tear of around 3 cm extending from external urethral meatus to clitoris anteriorly. It was bleeding. The external urinary meatus was dislocated posteriorly. The width of the raw area was 2 cm.
Figure 1. Injury to the area anterior to the external urethral meatus (white arrows). Vaginal opening (green arrow) Foley’s catheter (FC) are marked.
Figure 2. The part of the torn portion near the external urethral meatus is sutured.
Figure 3. The torn portion anterior to the external urethral meatus is sutured almost completely. The part near the clitoris is being sutured.
Figure 4. The end result of the repair.
Also there was around 0.5 cm of tear in the epithelium of the vestibule posterior to the external urinary meatus. Thus the external urethral meatus was in the middle of a raw surface without any overlying epithelium. Cervical tracing was normal. Anal sphincters were intact. Episiotomy edges were intact. There was a small first degree perineal tear in the midline. The patient was shifted to operation theatre for vaginal exploration. She was given spinal anaesthesia. A size 16 the urethral meatus was located and Foley’s catheter was passed through the urethra into the urinary bladder. The tear was sutured with interrupted sutures of No. 3.0 polyglactin, first anterior and then posterior to the external urinary meatus. All dead space underneath was occluded while placing the sutures. Patient withstood procedure well and stable. Postoperatively the Foley’s catheter was kept in situ for a week. Patient recovered well.
The lower two third part of the urethra lies immediately above the anterior vaginal wall opening into external urethral meatus which lies in the midline of the vestibule, 1 to 1.5 cm below the public arch just below the clitoris and just above the vaginal opening. Lacerations of the vaginal and perineum are classified as first to fourth degree perineal tears. First degree involves the fourchette, perineal skin and vaginal mucosa . Periurethral tears are also included in this which bleed profusely. Second degree involves , in addition, fascia and perineal body muscles. Third degree involves anal sphincters and A fourth degree extends through rectal mucosa. Risk factors may include nulliparity, second stage arrest of labour, mid or low forceps, use of local anaesthetics and Asian race. Timing of episiotomy is also important, if performed too late, lacerations will not be prevented. Typically, episiotomy is given with crowning of the presenting part, when 3-4 cm of head diameter is visible during a contraction. Anterior tears involving the urethra and labia are more common in women in whom episiotomy is not given. According to Carrolli and Mignini, the incidence of anterior perineal injury was lower in the routine-use episiotomy group. Such tears also occur when modified Ritgen’s maneuver is not performed properly and premature extension of the fetal head is allowed to occur during childbirth. Positioning of the legs during labour is also important. There should not be too wide separation of legs or one leg should not be higher than the other. This exerts pulling forces on the perineum and may increase the chances of perineal injury. Laine et al suggest that slow delivery of the head while advising the parturient not to push may reduce the perineal laceration.
In our patient the various above mentioned factors such as unnecessary pushing, too late episiotomy and sudden delivery of the head, came into play giving rise to anterior perineal injury. What is interesting in this case is that there was epithelial disruption all around the external urethral meatus, so that the meatus got dislocated posteriorly. Such an injury is very rare. Proper repair of such an injury is essential in order to restore normal position of the dislocated urethra and prevent misdirection of the urinary stream in future.
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- Carroli G, Mignini L: Episiotomy for vaginal birth. Cochrane Database Syst Rev 1:CD000081, 2009.
- Laine K, Pirhonen T, Rolland R, Pirhonen J. Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol 2008 May;111(5):1053-7.
Pednekar R, Valvi D, Warke HS. Traumatic Posterior Dislocation Of Urethra. JPGO 2017. Volume 4 No. 5. Available from: http://www.jpgo.org/2017/05/traumatic-posterior-dislocation-of.html