










































Key Words Competing Interests Article Information

Female urethroplasty, pelvic fracture urethral 
injury, fistula, urethra, stricture

None declared.

Patient Consent: Obtained for clinical images.

Received on October 6, 2021 
Accepted on January 5, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(2):77–86

DOI: 10.48083/MBXR6354

77SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

ORIGINAL RESEARCH

Pelvic Fracture Urethral Injury in Females

Pankaj M. Joshi,1 Marco Bandini,1,2,3 Christian Yepes,1 Shreyas Bhadranavar,1  
Vipin Sharma,1 Sandeep Bafna,1 Sanjay B. Kulkarni1

1 Kulkarni Reconstructive Urology Center, Pune, India 2 Unit of Urology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele,  
Vita-Salute San Raffaele University, Milan, Italy 3 Centro Chirurgico Toscano, Arezzo, Italy

P.J., M.B., and C.Y. contributed equally to the manuscript

Abstract

Background Pelvic fracture urethral injuries (PFUI) in females are very rare. The available literature on the 
management of this condition is scarce and not clear, mainly because of limited experience among reconstructive 
surgeons. We present our experience of management of these complex urethral injuries in female patients.

Materials and Methods We collected data, retrospectively and prospectively for 22 female patients referred 
to our center for PFUI repair between 1995 and 2021. During the clinical assessment of these complex injuries, 
following our internal institutional protocol, all patients underwent pelvic MRI (bladder and urethra are filled 
with saline solution and jelly to enhance the urethral lumen and the level of the distraction) before anastomotic 
urethroplasty.

Results PFUI compromised the mid urethra in 10 patients (45.5%). A transabdominal approach was used in  
8 patients (80%), and urethra-vaginal fistula repair was undertaken in 6 patients (60%). After a median follow-up of  
36 months, only 1 patient with proximal PFUI required a surgical revision without compromising urinary continence.

Conclusions The most common site of urethral involvement in pelvic fracture is mid urethral, which is owing 
to avulsion. Urethra-vaginal fistula should be suspected. Treatment consists in anastomotic urethroplasty, mainly 
through the abdominal approach.

Introduction

Urethral injury in females with pelvic fractures is very rare[1–8]. The literature on the management of female urethral 
injuries is sparse and not consistent, largely because of limited experience worldwide. Further, patients include a wide 
spectrum from young girls to adult women, and so the referral may be to a pediatric urologist, a gynecologist, or a 
urologist.

The earliest report of such injures was by Perry and Hussmann in 1992[5]. Injuries reported before this were 
longitudinal injuries, which may go unnoticed. The injuries we see in practice are usually avulsion injuries.

The Kulkarni Reconstructive Urology Center is a unique center with referrals from all over the world. Over last 
2 decades we have treated 22 patients with pelvic fracture urethral injury (PFUI) and have acquired substantial 
experience. We believe these injuries should be classified differently in terms of age, with different management 
algorithms for prepubertal girls compared with adult females.

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We present our experience of management of female 
pelvic fracture urethral injuries, and we note that many 
of our findings have been published in reports on 
complex urethral injuries[9–11].

Materials and Methods
We retrospectively and prospectively collected data on 
girls and women referred to our center for PFUI repair 
between 1995 and 2021. A detailed history was obtained, 
and patients were examined in the outpatient clinic. We 
obtained an ultrasound of the abdomen. Additionally, 
we annotated the position of suprapubic catheter and any 
previous scars on the abdomen, and we performed a local 
examination of the vulva. The female urethra is about 4 
cm in length, and even smaller in young women and girls. 
Retrograde urethrogram and voiding cystourethrogram 
were considered critical for assessment of the urethral 
injury, and all patients received pelvic MRI, in which the 
bladder and urethra were filled with saline solution and 
jelly to enhance the lumen and the level of the urethral 
distraction (Figures 1 and 2)[12].

All patients proceeded to surgery within 1 day of 
coming to the hospital. Patients were admitted and 
received a single dose of preoperative antibiotics. Intraop-
eratively, we used the dorsal lithotomy position. Preoper-
ative endoscopy was a critical part of evaluation, and the 
urethra was best visualized with a 0-degree endoscope. 
The best instrument for this proved to be the 7 Fr mini 
nephroscope or a 4.5 Fr ureteroscope, which was passed 
retrograde from the meatus to assess the distal urethra.

Urethrovaginal fistula should be suspected in every 
female patient with PFUI, and we found a urethrovag-
inal fistula in most of our patients. If possible, a guide 
wire was passed through the urethra into the bladder 
with the outside end brought out through the introi-
tus. Subsequently, we performed a vaginoscopy, which 
usually showed a normal vagina with visualization of 
the cervix (Figure 3), a post-traumatic transverse vagi-
nal septum preventing visualization of the cervix, or 
stenosis of the vagina at the site of trauma.

The next step was to perform endoscopy from the 
suprapubic catheter tract to visualize the bladder, the 
bladder neck, and the urethra proximal to the site of 
injury.

We typically saw urethral avulsion at the bladder 
neck, in the proximal urethra, or in the mid urethra. 
Some patients also exhibited meatal stenosis and/or 
accompanying urethrovaginal fistula and/or vaginal 
stenosis.

Approach
The approach in prepubertal girls was always abdominal 
(Figure 4). In adult women, a vaginal approach was 
possible in some cases.

 

FIGURE 1.

MRI in female patient with pelvic fracture urethral injury

FIGURE 2.

MRI showing grossly dilated vagina and hematocolpos 
in a patient with prior repair of pelvic fracture urethral 
injury

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Transection at bladder neck
Injury at the bladder neck can result in transection 
of the bladder neck. When suprapubic endoscopy 
was performed in these cases, we could usually see a 
dimple that suggested the position of the bladder neck. 
Identification of the ureteric orifices and trigone also 
helped to locate the position of transected bladder neck.

Surgical repair was performed through a lower 
abdominal incision. The extraperitoneal space was 

entered and the bladder was released from its anterior 
attachments. A posterior and superior pubectomy was 
then performed (Figure 5). Scar tissue at the site of 
injury was excised. The urethra distal to the injury was 
incised over a dilator passed through the urethra from 
the meatus (Figure 6).

A 12 Fr mini nephroscope was passed through the 
suprapubic catheter site to guide the incision of the blad-
der. The anastomosis between the bladder neck and the 

FIGURE 3.

Vaginoscopy demonstrating cervix 

FIGURE 4.

Clinical picture of a girl after surgical revision of a 
pelvic fracture urethral injury 

FIGURE 5.

Abdominal approach with posterior and superior 
pubectomy 

FIGURE 6.

Abdominal approach with posterior and superior 
pubectomy 

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urethra was performed with six 5-0 polydiaxone sutures. 
The posterior sutures were tied down (Figure 7) before 
passing a 14Fr silicon catheter across the anastomosis 
and tying down the anterior sutures. The omentum was 
mobilized and transposed onto the anastomosis. A drain 
was not usually required.

Transection at proximal urethra
In cases with a proximal urethral injury a short length 
of intact urethra remained attached to the bladder. The 
surgical steps were the same as for a bladder neck injury, 
except that the anastomosis was performed between the 
2 urethral ends. This was more challenging than bladder 
neck repair, as there is very narrow space to work in the 
female pelvis.

Transection at mid urethra
The mid urethra was the commonest site of female PFUI. 
This type of injury is almost always associated with a 
urethrovaginal fistula, which can be missed (Figure 8). 
In these cases, transection of the mid urethra allows the 
distal urethra to connect to the anterior vaginal wall to 
form a fistula.

Intraoperative endoscopy, preferably with a 7 Fr or 
12 Fr mini nephroscope, depending on the age of the 
patient, was more important in these cases. Endoscopy 
through the meatus into the distal urethra showed the 

urethrovaginal fistula. A guide wire was passed through 
the fistula and back through the vagina. A confirmatory 
vaginoscopy was performed.

The surgical steps were similar to the previously 
described procedure but more challenging. A more 
extensive posterior and superior pubectomy was neces-
sary to expose healthy edges of the proximal and 
distal urethra. The distal urethra was opened, and the 
previously inserted guide wire was pulled through the 
abdominal wound. The vaginal fistula was then clearly 
visible. The edges were freshened, and the fistula closed 
with interrupted polydiaxone sutures. A long stay suture 
was placed and used to tuck the omentum between the 
urethral anastomosis and the anterior vaginal wall to 
create an intervening layer.

Transection at meatus
Rarely, the injury was observed at the level of meatus 
(Figure 9), and this was usually associated with a vaginal 
injury. The meatus became hypospadic. The vaginal 
injury healed with scarring leading to vaginal outlet 
stenosis. These patients voided through the vagina, 
where urine accumulated, and the patients presented 
with intermittent incontinence. The diagnosis was 
confirmed by vaginoscopy with small caliber endoscope. 
These patients needed to be treated with vaginotomy.

FIGURE 7.

Anastomosis 

FIGURE 8.

Urethrovaginal fistula seen on CT 

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Vaginal examination (which was difficult in pediat-
ric patients because of narrow introitus) often revealed 
an almost bone-like scar on the posterior vaginal wall. 
Older patients sometimes needed a vaginal pull-through 
surgery, involving mobilization of the healthy edge of 
vagina down to be sutured to the introitus.

Urethral lengthening
In cases of meatal injur y where treatment with 
meatotomy would result in a hypospadiac urethra 
and intravaginal voiding, we usually recommend a 
urethral lengthening procedure. This can be done with 
a pedicled inner labial skin flap which is sutured to 
the urethra. We performed this in 1 patient, who was 
satisfied with the result.

Vaginal injury
As stated earlier, urethrovaginal fistula was commonly 
seen in mid-urethral injuries.

Occasionally, the vagina was also transected. Resul-
tant scarring sometimes led to the formation of a vagi-
nal septum. As a result, the proximal vagina and uterus 
could become compartmentalized and separated from 
the distal vagina. Affected patients presented with 
amenorrhea and hematocolpos. Diagnosis was made 
by demonstrating these findings on ultrasound. Intra-
operative vaginoscopy was very important in such 
cases. Inability to visualize the cervix during intraop-
erative vaginoscopy confirmed the presence of a vaginal 
septum. These cases were treated with either laser inci-
sion of the septum or vaginal pull-through.

Complete urethral loss
This is the rarest ty pe of injur y and requires a 
vascularized f lap for repair. This is most easily 
accomplished by making a bladder wall f lap and 
tubularizing it to form a neo-urethra. There remains a 
high risk of incontinence. We carried out this procedure 
in only 1 patient.

Uroflow was performed after surgery to assess the 
success of the operation. Urinary continence was also 
assessed after surgery using a voiding diary.

Results
We retrieved the data of 22 patients: 10 girls (median 
age 9 years) and 12 women (median age 25 years). 
Median time from injury to surgery was 10 months. 
Urethral injury was in the proximal urethra in 5 cases 
(22.7%, 4 prepubertal girls and 1 adult woman), in the 
mid urethra in 10 cases (45.5%, 4 prepubertal girls and 
6 adult women), and in the distal urethra in 6 cases 
(27.3%, 2 prepubertal girls and 4 adult women). One case 
presented with complete urethral loss (Table 1).

Of the 10 patients presenting with mid PFUI, 8 were 
approached transabdominally and 6 (2 girls and 4 adults) 
underwent urethrovaginal fistula repair. The approach 
was transvaginal in all 6 distal patients with PFUI. Two 
prepubertal girls with distal injury had vaginal introital 
stenosis and required vaginotomy. We observed a trans-
verse vaginal septum that was attributed to trauma in 
2 patients who both required vaginal pull-through. The 
patient with complete urethral loss needed a bladder 

FIGURE 9.

Distal urethral injury 

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TABLE 1. 
Summary of treatments and outcome

No
Age at 

accident 
(years)

Interval 
to surgery 
(months)

Group Mechanism of trauma Associated injuries
Mode of 

treatment
Location of 

injury
Approach and surgery

Continence
Day

Night 

Uroflow
(mL /s)

Follow-up
(months)

Further 
intervention

Final result

1 5 3 Prepubertal Collapsing wall Urethrovaginal fistula Delayed Proximal
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
No

9 47 None Success

2 2 36 Prepubertal Collapsing wall Urethrovaginal fistula Delayed Proximal
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

0a
36 Redo Success

3 9 4 Prepubertal Road traffic accident Urethrovaginal fistula Delayed Proximal
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
No

14 42 None Success

4 10 6 Prepubertal Road traffic accident 
Urethrovaginal fistula, lower 

limb fractures, degloving injury 
in thigh

Delayed Mid
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

18 46 None Success

5 11 4 Prepubertal Road traffic accident None Delayed Mid Abdominal, anastomotic urethroplasty
Yes
Yes

16 63 None Success

6 10 3 Prepubertal Road traffic accident 
Urethrovaginal fistula, lower limb 

fracture
Delayed Mid

Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

20 80 None Success

7 43 24 Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

16 66 None Success

8 23 6 Postpubertal Road traffic accident Lower limb fracture Delayed Distal Vaginal
Yes
Yes

19 112 None Success

9 35 3 Postpubertal Road traffic accident None Delayed Mid Vaginal
Yes
Yes

20 132 None Success

10 30 0b Postpubertal Road traffic accident 
Vaginal injury,

lower limb fracture
Primary Mid Vaginal

Yes
Yes

22 156 None Success

11 22 10 Postpubertal Road traffic accident Vaginal injury Delayed Distal Vaginal, meatoplasty
Yes
Yes

18 72 None Success

12 5 11 Prepubertal Road traffic accident Vaginal stenosis Delayed Distal
Vaginal,

meatoplasty, vaginotomy
Yes
No

11 60
Vaginal  

 pull-through
Success

13 21 3 Postpubertal Road traffic accident 
Lower limb fracture, complete 

urethral loss
Delayed

Proximal, 
Mid, Distal

Abdominal,
bladder flap

Yes
No

6 37 None Success

14 6 24c Prepubertal Road traffic accident 
Lower limb fracture, anterior 

vaginal wall loss
Delayed Mid

Abdominal, closure of UVF, anastomotic 
urethroplasty, Martius flap with skin forming 

the anterior vaginal wall

Yes
Yes

12 12 None Success

15 26 37d Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid
Abdominal, closure of UVF,
anastomotic urethroplasty

Yes
Yes

22 14 None Success

16 24 10 Postpubertal Road traffic accident 
Lower limb fracture, vaginal 

stenosis
Delayed Distal Vaginal, pedicled labial flap, vaginotomy

Yes
No

14 48 None Success

17 27 14 Postpubertal Road traffic accident None Delayed Distal
Vaginal, urethroplasty with laser incision  

of vaginal septum
Yes
Yes

14 24
Vaginal  

pull- through
Vaginal septum

Amenorrhea

18 21 11 Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid
Abdominal, closure of UVF, 
anastomotic urethroplasty

Yes
Yes

22 32 None Success

UVF: urethro-vaginal fistula aFailed; bImmediately; c14 prior interventions before referral; dPrior Mitrofanoff

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TABLE 1. 
Summary of treatments and outcome

No
Age at 

accident 
(years)

Interval 
to surgery 
(months)

Group Mechanism of trauma Associated injuries
Mode of 

treatment
Location of 

injury
Approach and surgery

Continence
Day

Night 

Uroflow
(mL /s)

Follow-up
(months)

Further 
intervention

Final result

1 5 3 Prepubertal Collapsing wall Urethrovaginal fistula Delayed Proximal
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
No

9 47 None Success

2 2 36 Prepubertal Collapsing wall Urethrovaginal fistula Delayed Proximal
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

0a
36 Redo Success

3 9 4 Prepubertal Road traffic accident Urethrovaginal fistula Delayed Proximal
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
No

14 42 None Success

4 10 6 Prepubertal Road traffic accident 
Urethrovaginal fistula, lower 

limb fractures, degloving injury 
in thigh

Delayed Mid
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

18 46 None Success

5 11 4 Prepubertal Road traffic accident None Delayed Mid Abdominal, anastomotic urethroplasty
Yes
Yes

16 63 None Success

6 10 3 Prepubertal Road traffic accident 
Urethrovaginal fistula, lower limb 

fracture
Delayed Mid

Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

20 80 None Success

7 43 24 Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid
Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

16 66 None Success

8 23 6 Postpubertal Road traffic accident Lower limb fracture Delayed Distal Vaginal
Yes
Yes

19 112 None Success

9 35 3 Postpubertal Road traffic accident None Delayed Mid Vaginal
Yes
Yes

20 132 None Success

10 30 0b Postpubertal Road traffic accident 
Vaginal injury,

lower limb fracture
Primary Mid Vaginal

Yes
Yes

22 156 None Success

11 22 10 Postpubertal Road traffic accident Vaginal injury Delayed Distal Vaginal, meatoplasty
Yes
Yes

18 72 None Success

12 5 11 Prepubertal Road traffic accident Vaginal stenosis Delayed Distal
Vaginal,

meatoplasty, vaginotomy
Yes
No

11 60
Vaginal  

 pull-through
Success

13 21 3 Postpubertal Road traffic accident 
Lower limb fracture, complete 

urethral loss
Delayed

Proximal, 
Mid, Distal

Abdominal,
bladder flap

Yes
No

6 37 None Success

14 6 24c Prepubertal Road traffic accident 
Lower limb fracture, anterior 

vaginal wall loss
Delayed Mid

Abdominal, closure of UVF, anastomotic 
urethroplasty, Martius flap with skin forming 

the anterior vaginal wall

Yes
Yes

12 12 None Success

15 26 37d Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid
Abdominal, closure of UVF,
anastomotic urethroplasty

Yes
Yes

22 14 None Success

16 24 10 Postpubertal Road traffic accident 
Lower limb fracture, vaginal 

stenosis
Delayed Distal Vaginal, pedicled labial flap, vaginotomy

Yes
No

14 48 None Success

17 27 14 Postpubertal Road traffic accident None Delayed Distal
Vaginal, urethroplasty with laser incision  

of vaginal septum
Yes
Yes

14 24
Vaginal  

pull- through
Vaginal septum

Amenorrhea

18 21 11 Postpubertal Road traffic accident Urethrovaginal fistula Delayed Mid
Abdominal, closure of UVF, 
anastomotic urethroplasty

Yes
Yes

22 32 None Success

UVF: urethro-vaginal fistula aFailed; bImmediately; c14 prior interventions before referral; dPrior Mitrofanoff

continued on page 84

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wall flap. One child needed a complex reconstruction 
with use of a Martius flap along with the overlying labial 
skin to reconstruct the vaginal wall.

Overall, 17 patients (77.3%) were continent at night 
and during the day. Of those with proximal PFUI, 3/5 
patients (60%) were continent at night and during the 
day. The patient with bladder wall flap was continent 
but voided with low pressure. This patient’s urethra was 
patent on urethroscopy, and there was no obstruction. 
The median postoperative Qmax was 18 mL/s. After a 
median follow-up of 36 months, 1 patient with proxi-
mal PFUI required a surgical revision but was continent 
thereafter.

Discussion
Management of female PFUI is evolving slowly, and only 
a few reports are available in the literature. Ours is one of 
the largest reported series of such patients to date.

Usually, the injury goes unnoticed in the acute post 
trauma evaluation. It is recognized by the inability to 
catheterize the patient or the presence of acute urinary 
retention. Examination of the vulva needs the lithot-
omy position, which is challenging in the acute setting 
of trauma. In the series by Perry and Husmann[5], the 
patients presented with extravasation and persistent 
incontinence, which suggests that the urethral injuries 
were overlooked on initial evaluation.

The favored management strategy for PFUI is to place 
a suprapubic catheter in the acute setting, stabilize the 
patient, and perform a definitive repair after 3 months. 
Rarely, if there is an acute transection that is accessible, 
and no other injuries, a primary repair can be attempted 
in an adult female.

The true incidence of female urethral injuries is 
unknown. Pelvic fracture urethral injuries are generally 
less common in females[8]. Factors likely include the 
flexibility provided by the vagina, as well as the inher-
ent elasticity of female urethra in adults. Podestá et al. 
reported a concurrent vaginal laceration in 75% to 87% 
of cases[13], which is consistent with the experience of 
Venn et al.[8]. Singh et al. described a case of urethral 
distraction defect causing complete urethrovaginal 
avulsion[14].

Venn et al. reported 12 female patients, aged 7 to 51, 
with urethral injuries[8]. Four had concomitant rectal 
injuries. In 5 cases urethral continuity was preserved 
because the urethral injury was longitudinal. Two of these 
12 patients presented in follow-up with stress urinary 
incontinence. Although the cause of incontinence is 
unclear, the authors suggested a mixed etiology including 
direct urethral damage and damage to innervation.

In our study, the majority of patients were continent 
after urethroplasty, although 5 had nocturnal inconti-
nence. The fear of incontinence should not deter the 
urologist from performing anastomotic urethroplasty in 
women with PFUI. An artificial urinary sphincter can 
even be considered[8], although this was not needed in 
our patients.

Over the last 2 decades, we have gained the greatest 
experience of male PFUI[10], and our experience with 
female PFUI has simultaneously grown. Female PFUI is 
particularly challenging to manage because of the diver-
sity of urethral injuries observed. Venn et. suggested 
that it was difficult to produce recommendations on 
treatment of these injuries based on their patients. After 
operating on 22 such patients we are able to provide a 

TABLE 1. 
Summary of treatments and outcome

No
Age at 

accident 
(years)

Interval 
to surgery 
(months)

Group Mechanism of trauma Associated injuries
Mode of 

treatment
Location of 

injury
Approach and surgery

Continence
Day

Night 

Uroflow
(mL /s)

Follow-up
(months)

Further 
intervention

Final result

19 38 22 Postpubertal Road traffic accident 
Urethrovaginal fistula, limb 

fracture
Delayed Proximal

Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

21 18 None Success

20 9 11 Prepubertal Road traffic accident Urethrovaginal fistula Delayed Bladder neck Abdominal, anastomotic urethroplasty
Yes
Yes

19 12 None Success

21 10 10 Prepubertal Road traffic accident None Delayed Distal Meatoplasty, vaginal pull-through
Yes
Yes

11 12 None Success

22 24 9 Postpubertal Fall from train Urethrovaginal fistula Delayed Mid Abdominal, anastomotic urethroplasty
Yes
Yes

22 12 None Success

UVF: urethro-vaginal fistula aFailed; bImmediately; c14 prior interventions before referral; dPrior Mitrofanoff

, Cont’d 

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clear algorithm to assist reconstructive urologists in the 
management of these injuries (Figures 10 and 11). We 
suggest categorizing patients in 2 groups: young females 
and adult females.

Always suspect a urethrovaginal fistula in urethral 
injuries, especially in prepubertal girls. Anastomotic 
urethroplasty through an abdominal approach is the 
favored procedure. The urethra can be accessed with 
posterior and superior pubectomy keeping the rim of 
pubic bone intact. Incontinence is rare in such patients. 

FIGURE 10, FIGURE 11. 

Algorithm for management of female pelvic fracture urethral injury

Mid Urethral

Mid

• Look for associated
 Urethrovaginal �stula
• Commonest injury
• Can have vaginal septum

Proximal
• Posterior pubectomy
• Scar excision
• Anastomotic urethroplasty

Bladder
Neck / Proximal

Distal
• Meatal stenosis
• Vaginal introital stenosis
 Vaginotomy / Pull through

Algorithm

Distal

Female PFUI

History, clinical examination

MRI with our protocol: full bladder and 
lignocaine jelly in urethra

Preoperative urethroscopy
Look for urethrovaginal �stula

 

Anastomotic urethroplasty (urethrovaginal �stula closure)

Vaginoscopy
(Look for cervix) 

If cervix not visualized, 
suspect traumatic vaginal septum

 

TABLE 1. 
Summary of treatments and outcome

No
Age at 

accident 
(years)

Interval 
to surgery 
(months)

Group Mechanism of trauma Associated injuries
Mode of 

treatment
Location of 

injury
Approach and surgery

Continence
Day

Night 

Uroflow
(mL /s)

Follow-up
(months)

Further 
intervention

Final result

19 38 22 Postpubertal Road traffic accident 
Urethrovaginal fistula, limb 

fracture
Delayed Proximal

Abdominal, closure of UVF,  
anastomotic urethroplasty

Yes
Yes

21 18 None Success

20 9 11 Prepubertal Road traffic accident Urethrovaginal fistula Delayed Bladder neck Abdominal, anastomotic urethroplasty
Yes
Yes

19 12 None Success

21 10 10 Prepubertal Road traffic accident None Delayed Distal Meatoplasty, vaginal pull-through
Yes
Yes

11 12 None Success

22 24 9 Postpubertal Fall from train Urethrovaginal fistula Delayed Mid Abdominal, anastomotic urethroplasty
Yes
Yes

22 12 None Success

UVF: urethro-vaginal fistula aFailed; bImmediately; c14 prior interventions before referral; dPrior Mitrofanoff

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Few patients need a tai lored approach to eit her 
lengthen the urethra if short or a full reconstruction 
in case of complete urethral loss. For these cases blad-
der or vaginal flaps are harvested for reconstruction. 
A bladder pubovaginal stenosis should be suspected 
in dista l injuries. Such patients can present with 
amenorrhea and hematocolpos in the adolescent age. 
Scar excision, good tension-free anastomosis, and 
omental interposition are key steps in performing the 
anastomotic urethroplasty.

Conclusions
Female pelvic fracture urethral injuries are uncommon. 
When they occur, the commonest PFUI is the mid 
urethral avulsion. Urethrovaginal fistula should be 
suspected. The injury is best repaired with anastomotic 
urethroplasty, mostly through the abdominal approach, 
which we show leads to excellent outcomes. This surgery 
requires specialized expertise. We present here our 
experience of management of these injuries with an 
operative algorithm.

References

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2. Antoci JP, SchiC MR Jr. Bladder and urethral injuries in patients 
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86 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

 ORIGINAL RESEARCH

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https://dx.doi.org/10.4103%2Fiju.IJU_118_17
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