Pednekar R*, Parulekar SV**.
(* Assistant Professor, ** Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & K E M Hospital, Mumbai, India.)
We present a case of a periurethral tear due to trauma secondary to a fall which dislocated the urethra posteriorly, thus making it difficult for a patient to pass urine. The patient was a primigravida with 20 weeks of gestation, had a history of fall in a ditch and presented to the emergency room with complaints of bleeding per vaginum, pain and inability to pass urine.
Injuries to vulva are common and most commonly occur secondary to birth trauma & less commonly due to any other trauma secondary to fall astride a hard object, a road traffic accident or sexual violence. Periurethral injuries may occur due to obstetric trauma, by misdirection of expulsive forces. Correct anatomical orientation of structures is very important in identifying the injury and for its correct anatomical repair to avoid any future symptoms related to urinary stream or urethral strictures. We present an unusual case in which there was injury to epithelium all around the urethra extending to labia minora laterally resulting in posterior dislocation of the distal urethra and external urethral meatus.
A 21 years old, gravida 2 para 1 living 1 with previous full term normal delivery, with 24 weeks of gestation, presented to the emergency room with history of fall in the ditch and complaints of bleeding per vaginum, pain over the perineum, and inability to pass urine. She had no history of pain in abdomen or any injury anywhere else over the body. She had no history of any high risk medical or surgical illness. On examination her vital parameters were normal. General and systemic examination revealed no abnormality. Per abdominally the uterus was relaxed and corresponding with her gestational age. Fetal heart rate was normal on auscultation. On local vulvar examination there was a bleeding laceration around 3 cm extending from external urethral meatus anteriorly to the clitoris and 4 cm laterally to labia minora which led to posterior dislocation of the urethra. On per speculum examination, there was no injury to the vaginal mucosa or cervix. There was no active bleeding from the cervical os. Anal sphincters were intact. An obstetric ultrasonographic scan was done. It showed normal fetal cardiac activity and no evidence of placental abruption. The patient was taken to operation theater for repair of the tear. A saddle block anesthesia was given. Urinary bladder catherized with 14 French silicone catheter. There was no evidence of hematuria. The tear was sutured from urethral meatus anteriorly to clitoris and laterally to labia minora in simple inturrupted manner with polyglactin 3-0 on round body needle, after occlusion of all dead space underneath and achieving hemostasis. A continuous metronidazole and gentamycin irrigation was continued throughout the procedure to decrease the chance of wound breakdown postoperatively secondary to infection. Postoperatively a course of antibiotic was completed and urinary catheter was kept in situ for 21 days. The 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. Injury to the vagina and perineum are classified as first to fourth degree perineal tears. First degree includes laceration involiving the fourchette, perineal skin and vaginal mucosa . Periurethral tears are also included in first degree tears. Second degree includes laceration involving, in addition, fascia and perineal body muscles. Third degree extends to anal sphincters and a fourth degree involves the rectal mucosa. Risk factors for perineal tear may include nulliparity, Asian race, second stage arrest of labor, operative vaginal delivery including forceps and ventouse delivery and use of local anaesthetics. Timing of episiotomy is also important, if performed too late, lacerations will not be prevented. An episiotomy has to be given with crowning of the presenting part. Tears of the labia and around the urethra are more common in women when episiotomy is not given when required. According to Carrolli and Mignini, the incidence of injury to anterior perineam was lower in the routine-use episiotomy group. Such tears also occur when there is premature extension of the fetal head during childbirth. Hence modified Ritgen’s maneuver is performed to prevent this premature extension of fetal head. Positioning of parturient’s legs during labor is also important. Legs should not be separated too widely or one leg should not be higher than the other. This uneven positioning of the legs exerts pulling forces on the perineum which may increase the chances of perineal injury. Laine et al suggest that head should be delivered slowly while advising the laboring woman not to push, to reduce the perineal injury. A case of periurethral tear of similar nature and subsequent posterior dislocation of distal urethra secondary to obstetric trauma was reported by us in the past.
Apart from the obstetric trauma other trauma can also inflict similar injuries. Such injuries were witnessed in our patient antenatally at 24 weeks due to a fall. While the obstetric injury is due to a misdirection of the force of expulsion of the fetal head during childbirth, the non-obstetric injury is due to an application of a trauma directly to the local area. As there is no underlying bone in the vestibular area, direct trauma causes contused lacerated wounds, which may disrupt the attachments of this soft tissue to surrounding bone. In the case presented, the anterior pubourethral ligament was torn and hence the distal urethra was dislocated posteriorly. Identifying the anatomical defect and repairing it is very important to avoid future problems related to urinary stream or urethral strictures. Such a tear does not increase the risk of development of urinary stress incontinence, as the provimal urethra is intact, well supported and is in its normal position. Successful and accurate repair of such tears in antenatal period does not increase the chance of their recurrence during a vaginal delivery. Hence a cesarean section is not indicated solely for this purpose.
We thank Dr. Girija Swaminathan for taking intraoperative photographs.
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Pednekar R, Parulekar SV. Traumatic Periurethral Tear And Posterior Dislocation Of External Urinary Meatus. JPGO. 2018 Vol 5 No. 9. Available from: http://www.jpgo.org/2018/09/traumatic-periurethral-tear-and.html