What should I do for urethral bleeding?

Management of Urethral Bleeding

If urethral bleeding is present, you must immediately investigate for urethral injury before attempting any urethral catheterization, using retrograde urethrography or urethroscopy as your diagnostic modality of choice. 1

Initial Assessment and Diagnostic Approach

Clinical Evaluation

• Blood at the urethral meatus is the hallmark sign requiring immediate investigation for urethral injury, present in 37-93% of cases 1
• Examine for associated findings: perineal/scrotal hematoma, inability to void, high-riding or non-palpable prostate on rectal exam, and pelvic instability 1
• In trauma settings, urethral injuries occur in 1.5-10% of pelvic fractures, with 15% having concomitant bladder injuries 1

Critical Diagnostic Rule

Never attempt blind urethral catheterization when urethral injury is suspected—this can convert a partial injury into complete urethral disruption. 2 The World Society of Emergency Surgery explicitly warns against this practice 1.

Diagnostic Workup Algorithm

Primary Diagnostic Modalities

• Retrograde urethrography is the procedure of choice and must be performed before any urethral manipulation 1
• Urethroscopy should be preferred over retrograde urethrography in cases with penile lesions 1
• Both modalities are equally valid for investigating traumatic urethral injuries 1

Imaging Sequence Considerations

• If hemodynamic status permits and urethral injury is suspected, perform late-phase contrast CT with urologic study 1
• Performing retrograde urethrography before CT may increase false-negative CT results 1
• In hemodynamically unstable patients, postpone all urethral investigations and establish immediate urinary drainage via suprapubic catheter 1

Management Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Establish suprapubic catheter drainage immediately without attempting urethral investigation 1, 3
• All diagnostic procedures should be deferred until stabilization 1
• Posterior urethral injuries with hemodynamic instability require immediate urinary drainage and delayed definitive treatment 1

Hemodynamically Stable Patients

For Traumatic Urethral Injuries

• Posterior urethral injuries: Suprapubic catheter placement with delayed urethroplasty is the traditional standard 1, 3
• Primary realignment may be considered but has variable success rates (14-100% stenosis rates) and most patients eventually require formal urethroplasty 1
• Penetrating anterior urethral injuries: Immediate direct surgical repair if clinical conditions allow and experienced surgeon available; otherwise, urinary drainage with delayed treatment 1
• Penetrating posterior urethral injuries: Primary repair only if clinical conditions permit; otherwise, urinary drainage and delayed urethroplasty 1

For Penile Fracture with Urethral Bleeding

• Urethral injury occurs in 10-38% of penile fractures 2
• If blood at meatus, gross hematuria, or inability to void: perform urethroscopy or retrograde urethrogram before catheterization 2
• If no signs of urethral injury: proceed directly to surgical exploration without preoperative imaging 2

Hemorrhage Control Techniques

For Massive Uncontrolled Bleeding

• Standard methods include intermittent penile compression and continuous perineal pressure 4
• Novel technique for refractory bleeding: Gradually inflate catheter balloon (up to 4 mL) to achieve tamponade effect 4, 5
• Angiography with embolization for persistent bleeding unresponsive to conservative measures, targeting pseudoaneurysms or active arterial extravasation 5

Important Caveat

• Consider coagulopathy evaluation (including von Willebrand disease) in patients with persistent urethral bleeding despite appropriate local management 6

Timing of Definitive Treatment

• Urethral injury treatment is not an immediate emergency once suprapubic drainage is established 3
• For massive urethral dislocations, delaying definitive repair by one week may be advantageous as patients are fitter and hemorrhage risk is reduced 3
• When posterior urethral injury is associated with complex pelvic fracture, perform definitive urethroplasty after pelvic ring healing 1

Follow-up Protocol

• Urethroscopy or urethrogram are the methods of choice for follow-up of urethral injuries 1
• Long-term complications include stricture formation, erectile dysfunction, and urinary incontinence, particularly with immediate surgical repair of posterior injuries 1