What is the appropriate treatment for urethral bleeding?

Management of Urethral Bleeding

The immediate priority is to establish urinary drainage as soon as possible, followed by diagnostic imaging with retrograde urethrography to determine injury severity and guide definitive management. 1

Immediate Stabilization

Secure urinary drainage immediately—this is the cornerstone of initial management regardless of injury type. 1

• Attempt gentle urethral catheter placement first if the injury appears partial and there are no contraindications 2
• Place a suprapubic catheter if urethral catheterization fails or if complete urethral disruption is suspected 1
• In cases of massive uncontrolled hemorrhage unresponsive to standard measures, gradual inflation of a catheter balloon (up to 4 mL) can provide tamponade effect 3, 4

Diagnostic Evaluation

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 examination. 1, 5

• This imaging has 95.9% diagnostic accuracy and determines whether the injury is anterior (penile/bulbar) or posterior (membranous/prostatic) 5
• The location and completeness of injury dictates the treatment algorithm 1

Definitive Management Algorithm

For Blunt Anterior Urethral Injuries (Straddle Injuries)

Initial conservative management with urinary drainage is the treatment of choice. 1

• Maintain drainage via urethral or suprapubic catheter 1
• Attempt endoscopic realignment before considering surgery 1, 5
• Delayed surgical repair (urethroplasty) should be performed only if conservative treatment and endoscopic approaches fail 1
• These injuries carry high risk for delayed stricture formation 1

For Blunt Posterior Urethral Injuries

Partial injuries may be managed conservatively with urinary drainage and endoscopic realignment; definitive surgery should be delayed for 14 days if no other indications for laparotomy exist. 1

• In hemodynamically unstable patients, establish immediate urinary drainage and delay definitive treatment 1
• Primary realignment (advancing a catheter across the rupture) has become more common with improved endoscopic techniques, though stricture rates remain variable (14-100%) 1
• Avoid immediate sutured repair of posterior urethral injuries—this approach is associated with unacceptably high rates of erectile dysfunction and urinary incontinence 1, 5
• When associated with complex pelvic fractures, postpone definitive urethroplasty until after pelvic ring healing 1

For Penetrating Urethral Injuries

Conservative treatment is generally not recommended for penetrating injuries. 1

• Anterior penetrating injuries should receive immediate direct surgical repair if the patient is hemodynamically stable and an experienced surgeon is available 1, 5
• Selected incomplete penetrating injuries may be managed with trans-urethral catheter placement 1
• If damage control procedures are needed or the patient is unstable, establish urinary drainage and plan delayed treatment 1
• Posterior penetrating injuries should receive primary repair only if clinical conditions allow; otherwise, urinary drainage and delayed urethroplasty is recommended 1

Follow-Up Protocol

Perform urethrography or ureteroscopy for follow-up imaging. 1, 5

• Repeat urethrography every two weeks until complete healing is documented for blunt anterior injuries 1, 2
• Most patients with posterior injuries eventually require repeated instrumentation or formal urethroplasty to maintain patency 1

Critical Pitfalls to Avoid

• Never delay establishing urinary drainage—this is the immediate goal regardless of injury type 1
• Never attempt immediate urethroplasty for posterior urethral injuries due to high complication rates 1, 5
• Do not blindly catheterize when complete urethral disruption is suspected; obtain imaging first or place suprapubic catheter 1
• In females with pelvic fractures, suspect urethral injury if labial edema or blood in vaginal vault is present during pelvic exam 1