Urethral Injury

Clinical assessment

• When urethral injury is suspected — based on the mechanism of injury or the presence of blood at the urethral meatus — a urological consultation should be obtained before any attempt to pass a urethral catheter, as blind catheterization of a disrupted urethra can convert a partial tear into a complete disruption and worsen urethral damage.
• Physical examination of the perineum, genitalia, and abdomen is performed. In the setting of major trauma, assessment follows Advanced Trauma Life Support (ATLS) protocols, with attention to associated life-threatening injuries.

Retrograde urethrogram (RUG)

• Retrograde urethrography is the definitive initial diagnostic test for suspected male urethral injury. Contrast material is instilled directly into the distal urethra using a catheter-tipped syringe, and fluoroscopic or plain radiographic images are obtained. The pattern of contrast extravasation identifies the site, length, and degree of urethral disruption. This investigation is mandatory before urethral catheterization in any male patient with blood at the meatus following pelvic trauma.

CT with intravenous contrast

• In the polytrauma setting, a CT scan of the abdomen and pelvis with intravenous contrast is routinely performed to evaluate associated injuries to the kidneys, ureters, bladder, and other pelvic structures. CT cystography or CT urography may further characterize the extent of injury.

Voiding cystourethrogram (VCUG)

• A voiding cystourethrogram — performed after suprapubic catheter placement — can provide additional information about the posterior urethra and bladder neck in the delayed management phase.

Urethroscopy / cystoscopy

• Endoscopic assessment of the urethra may be performed by an experienced urologist to assess injury extent, confirm the presence of urethral continuity, and guide catheter placement in selected cases of partial posterior urethral injuries.

Treatment strategy is individualized based on injury location (anterior vs. posterior), degree of disruption (partial vs. complete), mechanism, and patient clinical status.

Urinary diversion — suprapubic cystostomy

• The immediate management priority for most significant urethral injuries is to establish safe urinary drainage by placing a suprapubic catheter (a drainage tube inserted percutaneously through the skin above the pubic bone directly into the bladder). This allows the bladder to drain without placing any further stress on the injured urethra, provides time for associated injuries to be stabilized, and permits the acute inflammatory process to resolve before definitive urethral reconstruction.

Endoscopic primary realignment (EPR)

• In selected patients with posterior urethral disruption who are hemodynamically stable and have appropriate expertise available, primary endoscopic realignment — using flexible cystoscopes to align and bridge the disrupted urethral ends over a catheter under fluoroscopic or endoscopic guidance — may be attempted within the first few days of injury. If successful, this approach may reduce the need for later open reconstruction or reduce the length of any subsequent stricture. However, it carries technical challenges and is not always feasible.

Delayed urethroplasty (definitive urethral reconstruction)

• Definitive surgical reconstruction of the urethra — urethroplasty — is typically deferred for 3–6 months after injury to allow the surrounding hematoma and inflammation to resolve and the tissues to mature. Open surgical urethroplasty — in which the scarred or disrupted urethral segment is excised and the ends are spatulated and re-anastomosed (end-to-end anastomosis), or a tissue graft is interposed — is the definitive treatment for most significant urethral injuries and achieves high success rates in experienced hands.

Anterior urethral injuries

• Minor anterior urethral contusions are often managed conservatively with urethral catheterization (or suprapubic catheterization) and resolve with appropriate drainage. More significant anterior urethral lacerations may require immediate repair or staged urethroplasty depending on the degree of injury.

Urethral stricture management

• Urethral stricture — narrowing of the urethra from post-injury scarring — is the most common late complication of urethral injury. Treatment options include:
  • Urethral dilation: Gradual mechanical dilation of the stricture using dilators of progressively increasing size; provides symptomatic relief but does not address the underlying scar
  • Direct vision internal urethrotomy (DVIU): Endoscopic incision of the stricture under direct vision; appropriate for short, non-obliterative strictures, though recurrence rates are high for longer or denser scars
  • Open urethroplasty: Surgical resection and reconstruction of the strictured segment, using an end-to-end anastomosis or a buccal mucosal (oral mucosa) graft; considered the gold standard for recurrent or complex strictures