In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.

Objective To determine the risk factors and mechanism of urethral injury associated with pelvic fractures. Patients and methods A total of 203 consecutive male patients with pelvic fracture were studied prospectively, including a clinical examination, radiographic examination of the pelvis, excretory urography and retrograde urethrography. Results Thirty‐nine (19%) patients had urethral injury, five (2.5%) had bladder injury and 12 (6%) had combined urethral and bladder injuries. Urethral injury was by stretching of the intact membranous urethra in 13 patients (25.5%), partial rupture in 13 (25.5%) and complete rupture in 25 (49%). Injury involved the prostatic urethra and bladder neck in three children. Urethral injury was consistently associated with pubic arch fractures. Involvement of the posterior pelvic arch, with fractures of the anterior arch, considerably increased the risk of urethral injury. Also, the risk was greater with an increase in the number of broken rami. Conclusion The highest risk of urethral injury was found in cases with straddle fracture when combined with diastasis of the sacroiliac joint (24 times more than the rest of pelvic fractures); this was followed by straddle fracture alone (3.85 times) and Malgaigne's fracture (3.4 times). Stretching of the membranous urethra usually precedes its rupture, which classically occurs at the bulbomembranous junction.

Of the operative details 3 constitute the gold triad that assures a successful outcome, namely complete excision of scarred tissues, fixation of healthy mucosa of the 2 urethral ends and creation of a tension-free anastomosis. When the bulboprostatic urethral gap is 2.5 cm or less, restoration of urethral continuity may be accomplished with a perineal procedure after liberal mobilization of the bulbar urethra. For defects of 2.5 cm or greater the elaborated perineal or perineo-abdominal transpubic procedure should be used. In the presence of a competent bladder neck, anastomotic surgery does not result in urinary incontinence. Impotence is usually related to the original trauma and rarely (2%) to urethroplasty itself.

The male urethral sphincter complex is composed of an inner lissosphincter of smooth muscle and an outer rhabdosphincter of skeletal muscle. It extends in the form of a cylinder around the urethra from the vesical orifice to the perineal membrane. While the rhabdosphincter is most marked around the membranous urethra and becomes gradually less distinct toward the bladder, the lissosphincter has its main part at the vesical orifice and is thinner in its further course in the urethra. The lissosphincter is primarily concerned with the function of continence at rest. On the other hand, the rhabdosphincter has a dual genitourinary function, namely active continence during stress conditions and antegrade semen propulsion.

Urethral strictures were most commonly associated with Malgaigne's fracture (35% of cases) and straddle fracture with or without diastasis of the sacroiliac joint (26%). Strictures were almost invariably inferior to the verumontanum with prostatic displacement in 44% of cases. Length of the strictured segment may be overestimated or underestimated on urethrography as a result of incomplete filling of the prostatic urethra or a urinoma cavity connected with the proximal segment, respectively. Perineal or transpubic bulboprostatic anastomosis is the best treatment for posttraumatic strictures, while internal urethrotomy should be avoided since it may compromise the chance of subsequent anastomotic urethroplasty. Repair of associated bladder neck incompetence may be deferred until the resumption of urethral voiding after urethroplasty, when incontinence can be documented.