What is the management and treatment of a urethral injury?

Management of Urethral Injury

Urethral injuries require immediate urinary drainage followed by injury-specific management: blunt injuries are managed conservatively with delayed repair, while penetrating injuries require prompt surgical repair when feasible. 1

Initial Diagnostic Approach

• Perform retrograde urethrography immediately when urethral injury is suspected based on blood at the meatus (present in 37-93% of cases), inability to void, perineal/genital ecchymosis, or high-riding prostate on exam 1, 2
• Retrograde urethrography remains the gold standard diagnostic modality with 95.9% accuracy 2
• In females with pelvic fractures, suspect urethral injury if labial edema or blood in the vaginal vault is present 1

Management Algorithm by Injury Type

Anterior Urethral Injuries

Blunt Trauma (Straddle Injuries):

• Initial conservative management is the treatment of choice with urinary drainage via either urethral or suprapubic catheter 1
• Attempt endoscopic realignment before considering surgery 1
• Delayed surgical repair (urethroplasty) should be performed only if conservative treatment and endoscopic approaches fail 1
• Perform urethrography every two weeks until complete healing is documented 1

Penetrating Trauma:

• Immediate direct surgical repair is recommended if the patient is hemodynamically stable and an experienced surgeon is available 1
• Selected cases of incomplete penetrating injuries may be managed with trans-urethral catheter placement 1
• For large anatomic defects (>2-3 cm in bulbar urethra, >1.5 cm in penile urethra), perform urethral marsupialization with suprapubic catheter and delayed reconstruction at >3 months 1
• Conservative treatment of penetrating urethral injuries is generally not recommended 1

Posterior Urethral Injuries

Blunt Trauma (Pelvic Fracture-Associated):

• Initial conservative treatment with planned delayed surgical management is recommended to allow multidisciplinary care 1
• In hemodynamically stable patients with complete lesions and no life-threatening injuries, immediate endoscopic realignment is preferred over immediate urethroplasty 1
• Endoscopic realignment is associated with improved outcomes compared to immediate surgical repair 1
• If endoscopic realignment is unsuccessful, place suprapubic catheter and perform delayed urethroplasty, preferably within 14 days from injury 1
• When associated with pelvic fractures, definitive surgery must be postponed until after healing of pelvic ring injuries 1
• Immediate urethroplasty is not routinely recommended due to unacceptably high rates of erectile dysfunction and urinary incontinence 1

Penetrating Trauma:

• In hemodynamically stable patients without severe associated injuries, immediate retropubic exploration and primary repair is recommended 1
• In life-threatening associated injuries requiring damage control, perform urinary diversion with delayed urethroplasty 1

Partial Injuries:

• May be initially managed conservatively with urinary drainage via urethral or suprapubic catheter and endoscopic realignment 1
• Definitive surgical management should be delayed for 14 days if no other indications for laparotomy exist 1

Urinary Drainage Strategy

• Establish urinary drainage as soon as possible in any traumatic urethral injury 1
• For hemodynamically unstable patients, immediate urinary drainage with delayed treatment is mandatory 1
• Either urethral or suprapubic catheter placement is acceptable for initial drainage 1

Follow-Up Protocol

• Ureteroscopy or urethrogram are the methods of choice for follow-up of urethral injuries 1
• Follow-up imaging should be performed every two weeks until complete healing in blunt anterior injuries 1
• Return to sport activities should be allowed only after microscopic hematuria resolves 1

Critical Pitfalls to Avoid

• Never attempt immediate urethroplasty for posterior urethral injuries due to high complication rates (erectile dysfunction, incontinence) 1
• Do not perform definitive repair of posterior urethral injuries associated with pelvic fractures until the pelvic ring has healed 1
• Avoid conservative management of penetrating urethral injuries when surgical repair is feasible 1
• Do not delay urinary drainage establishment in any urethral injury 1
• Recognize that primary realignment success rates are variable (14-100% stenosis rates reported), and most patients eventually require repeated instrumentation or formal urethroplasty 1