LAUSR

A 17-year-old female was presented to the emergency department following a fall from standing height onto a rocky surface. Examination found marked oedema and bruising superficially with a laceration to the left superolateral aspect of the vagina but no bony point tenderness or rectal injury identified. The patient had significant discomfort due to urinary retention with >1000 mL on bladder scan. She underwent an exploration under anaesthetic for repair of vaginal laceration and insertion of indwelling catheter (IDC). Intraoperatively, a 270 circumferential tear of the mid-urethra was identified with an intact 9–11 o’clock portion associated with a vaginal laceration shown in Figure 1. A tension-free primary repair was performed with 4-0 dissolvable interrupted sutures over a 16-Fr IDC with good mucosal apposition requiring minimal tissue debridement, shown in Figure 2. A Martius interpositional flap was harvested from the left labial fat pad with the superior end of fat pad transected and ligated with 2-0 vicryl stitch tie. It was tunnelled through the vaginal wall and sutured in place with 3-0 vicryl rapide to prevent vaginal fistulation. The flap site closure was performed with 3-0 chromic and 4-0 subcuticular monocryl to skin. A suprapubic catheter was inserted at the completion of the case. A voiding cystourethrogram was performed 4 weeks postoperatively which showed a slight irregularity to the contour at the site of repair with eccentric narrowing, as shown in Figure 3. On the basis of radiological findings and the patient’s ongoing dysuria, a cystoscopy and urethral dilatation were performed. A suture was visible in the distal urethra, with a normal appearance proximally and at the urethral meatus. The patient had a formal urethral dilation, suprapubic catheter replacement and the dissolvable suture was left in situ. Following dilatation, she had an average flow rate of 10.5 mL/s, emptied her bladder completely and reported minimal dysuria. This case is presented with written informed consent from the patient and ethics waiver approval AU201907-01. Female urethral disruption is exceedingly uncommon in blunt trauma, and almost non-existent in the context of low-velocity mechanism. The incidence of urethral injury with pelvic fractures ranges from 0% to 6%, predominantly caused by high-speed motor vehicle accidents. The rarity of urethral injury in the female is attributed to the increased elasticity, shorter length and fewer attachments of the urethra to the pelvic bone. It has been suggested that the trauma required to cause urethral injury in women is greater than males due to the aforementioned protective anatomical features. Most reports of urethral injury are in children or younger women, and several hypotheses for this include: non-ossified pelvic bones are more compressible and the tissues are more fragile in younger females and older females are less likely to survive the trauma required to cause urethral rupture; however, the evidence for these is poor.