What is the appropriate management for urethral bleeding?

Management of Urethral Bleeding

Immediate Priority: Secure Urinary Drainage

The immediate goal in managing urethral bleeding is to establish secure bladder drainage as soon as possible, regardless of the underlying injury type. 1 This fundamental principle takes precedence over definitive repair in most scenarios.

Initial Assessment and Diagnosis

When confronted with urethral bleeding, perform retrograde urethrography to establish the diagnosis and characterize the injury. 1 Key clinical findings to assess include:

• Blood at the urethral meatus (present in 37-93% of urethral injuries) 1
• Inability to void 1
• Perineal or genital ecchymosis 1
• High-riding prostate on digital rectal examination 1
• Associated pelvic fracture (present in posterior urethral injuries) 1

In females, suspect urethral injury with labial edema or blood in the vaginal vault during pelvic examination. 1

Management Algorithm by Injury Type

Blunt Anterior Urethral Injuries (Straddle Injuries)

Initial conservative management with urinary drainage via urethral or suprapubic catheter is the standard approach. 1 These injuries carry high risk for delayed stricture formation. 1

• Attempt endoscopic realignment before considering surgery 1
• Reserve delayed surgical repair for failures of conservative and endoscopic approaches 1
• Perform urethrography every two weeks to monitor healing 2

Blunt Posterior Urethral Injuries

For partial injuries, initial conservative management with urinary drainage (urethral or suprapubic catheter) and endoscopic realignment is recommended. 1 Delay definitive surgical management for 14 days if no other indications for laparotomy exist. 1

Avoid immediate sutured repair of posterior urethral injuries as this approach is associated with unacceptably high rates of erectile dysfunction and urinary incontinence. 1 The traditional approach of suprapubic tube placement followed by delayed urethroplasty remains valid, though primary realignment has become more common with improved endoscopic techniques. 1

When posterior urethral injury is associated with complex pelvic fracture, perform definitive urethroplasty only after healing of the pelvic ring injury. 1

Penetrating Urethral Injuries

Conservative treatment is generally not recommended for penetrating injuries. 1

• Anterior urethra penetrating injuries: Perform immediate direct surgical repair if clinical conditions allow and an experienced surgeon is available; otherwise, establish urinary drainage and plan delayed treatment 1
• Posterior urethra penetrating injuries: Treat with primary repair only if clinical conditions permit; otherwise, use urinary drainage and delayed urethroplasty 1

Hemodynamically Unstable Patients

In cases of hemodynamic instability, establish immediate urinary drainage (urethral or suprapubic catheter) and delay definitive treatment. 1 This damage control approach prioritizes life-threatening injuries first. 3

Special Considerations for Massive Hemorrhage

For massive urethral bleeding unresponsive to standard management, consider:

• Catheter balloon inflation technique: Gradually inflate the Foley catheter balloon (up to 4 mL) to tamponade bleeding 4
• Angiographic embolization: For persistent bleeding with pseudoaneurysm formation, coil embolization of the bulbourethral artery may be necessary 5
• Evaluate for coagulopathy: Persistent painless urethral bleeding may indicate underlying bleeding disorders such as von Willebrand disease 6

Associated Injuries

Penile Fracture with Urethral Injury

Urethral injury occurs in 10-22% of penile fractures. 1 Immediate primary surgical management of both the penile fracture and urethral injury is safe and effective with minimal complications. 7

Bladder Injuries

Concomitant bladder injuries are present in 15% of posterior urethral injuries. 1 Perform retrograde cystography to evaluate for bladder rupture when urethral injury is suspected. 2

Follow-Up Protocol

• Urethrography or uretroscopy are the methods of choice for follow-up of urethral injuries 1
• Perform urethrography every two weeks until complete healing 2
• Allow return to sport activities only after microscopic hematuria resolves 1

Critical Pitfalls to Avoid

• Never attempt blind urethral catheterization when urethral injury is suspected based on blood at the meatus or mechanism of injury 1
• Do not perform immediate surgical repair of posterior urethral injuries except in penetrating trauma with favorable conditions 1
• Do not delay establishing urinary drainage while pursuing diagnostic workup in unstable patients 1