Posterior Urethral Stricture: What Should Be Done for Urethral Stricture After Pelvic Fracture?

Pelvic fractures caused by severe trauma, such as traffic accidents or falls from height, may rarely lead to complications that deeply affect the patient’s life. One of the most important of these complications is posterior urethral stricture, which is characterized by rupture or injury in the section of the urethra, the urinary canal, near the prostate. In the acute period, the most prominent findings are inability to urinate, bleeding from the urethral opening, the penis, and bladder fullness. In this article, we will discuss the roadmap from emergency intervention to long-term repair in posterior urethral stricture that develops after pelvic fracture.

Emergency Period: What Should Be Done First?

At the time of trauma, the most important goal is to protect the patient’s life and safely empty the bladder. In the emergency approach to pelvic fracture urethral injury, blind catheter placement after trauma should definitely be avoided, as this procedure may worsen the existing injury.

In suspicious cases such as inability to urinate or bleeding, the first step is retrograde urethrography, a contrast X-ray of the urinary canal, and CT evaluation. If urethral injury is confirmed, a catheter is placed directly into the bladder through the lower abdomen, called cystostomy or suprapubic catheter.

The answer to the question “When should cystostomy be performed?” is clear: it is the priority in every case where urethral integrity is disrupted. Although early endoscopic realignment may provide advantages in suitable cases, safe drainage with cystostomy is recommended instead of primary, immediate open repair. This method safely ensures urine drainage while protecting the injured urethra.

Delayed Repair: Why Is It Necessary to Wait?

After the initial healing process, scar tissue develops between the ruptured urethral ends, resulting in a complete posterior urethral stricture. After cystostomy, it is generally recommended to wait between 3 and 6 months before definitive surgery.

This waiting period has vital purposes: allowing the borders of periurethral fibrosis, or scar tissue, in the trauma area to become clear, completing tissue organization, and allowing the pelvic hematoma to be absorbed. During this period, patients should adapt to living with cystostomy and be meticulous about catheter care and infection prevention.

In addition, during the waiting phase, detailed evaluation is performed to determine whether there is any additional injury to surrounding organs such as the bladder neck, prostate, or rectum due to the initial trauma.

Definitive Treatment: Open Repair

Posterior Urethroplasty

Once the waiting period is completed, the gold standard treatment is open surgery. Delayed posterior urethroplasty provides the highest success rate.

The surgery is usually performed through the perineal area. The main steps are:

Complete removal of scar tissue.

Identification of healthy urethral ends.

Tension-free end-to-end connection of the tissues, called anastomosis.

For a successful repair, it is very important that the tissues are not under tension and that the anatomical alignment of the prostate and bladder is preserved. This procedure permanently restores urethral integrity.

Postoperative Period, Risks, and Follow-Up

The hospital stay after surgery is usually 2–3 days, and the urinary catheter remains in place for approximately 3 weeks. In experienced hands, the long-term success rate is quite high, around 85–90%.

Possible Risks

Urinary Incontinence:When performed with the correct technique, the risk is generally low, on average below 5%.

Erectile Dysfunction:There is already a risk of nerve damage due to the initial severe trauma. The risk of new erectile dysfunction after surgery is between 5% and 15%, and in many cases it may be temporary.

How Is Follow-Up Performed?

According to EAU recommendations, patients are called for follow-up visits in the 3rd, 6th, and 12th months after surgery. During follow-up, uroflowmetry, which measures urine flow rate, is mainly performed and the patient’s complaints are evaluated.

A decrease in urine flow rate may be the earliest sign of recurrence of the stricture, so these measurements are critically important. When necessary, additional imaging methods are used to keep the process under control.

Frequently Asked Questions

1. Why is my urinary canal not repaired immediately after the accident? Why do we wait for months?

After an accident, serious tissue damage and bleeding occur around the urinary canal. Waiting for 3 to 6 months is generally the safest approach so that the borders of the injury become clear, swelling subsides, and the tissues become healthy and suitable for repair. This waiting period significantly increases the chance of success of the definitive reconstructive surgery.

2. Can I continue my daily life with the catheter placed through my abdomen, cystostomy, during the waiting period?

Yes, you can. Although it may take some time to get used to this situation at first, you can hide the urine bag under your clothes, carry out your daily activities, go outside, and take a shower by following the hygiene rules recommended by your doctor.

3. Can this stricture be opened with closed, endoscopic methods? Why is open surgery necessary?

After pelvic fracture, the urinary canal is usually completely ruptured, and hard scar tissue forms between the two ends. Closed methods cannot permanently eliminate this hard tissue. For a permanent and definitive solution, this damaged tissue must be completely removed and the healthy ends must be sutured together. Therefore, open surgery, or open repair, is the gold standard and the most successful treatment method.

4. Will I experience urinary incontinence or erectile dysfunction after surgery?

The risk of urinary incontinence is quite low in surgeries performed with the correct technique, below 5%. Erectile dysfunction, on the other hand, may usually occur not because of the surgery itself, but because of the damage caused by the severe accident to the nerves in the region. Even if such problems occur after surgery, they may often be temporary.

5. What is the success rate of the surgery? Can the stricture recur in the future?

After an appropriate waiting period, open repair surgeries performed by an experienced surgical team have a very high long-term success rate, around 85–90%. Your condition will be closely monitored with urine flow tests, uroflowmetry, in the 3rd, 6th, and 12th months after surgery to make sure that everything is progressing well.