What is the appropriate management for blood at the meatus?

Management of Blood at the Urethral Meatus

Perform retrograde urethrography immediately before any attempt at urethral catheterization when blood is present at the urethral meatus after pelvic or genital trauma. 1

Initial Assessment and Critical Actions

Do NOT Blindly Catheterize

• Avoid blind catheter passage prior to retrograde urethrogram as this may convert a partial urethral injury into a complete disruption or worsen existing trauma 1, 2
• The only exception is in exceptional circumstances requiring emergent catheter drainage for monitoring, where a single attempt with a well-lubricated catheter may be attempted by an experienced team member in the setting of partial urethral disruption 1

Clinical Context Matters

• Blood at the urethral meatus is the most common finding in urethral injury, present in 37-93% of cases 1
• This finding is particularly significant when associated with pelvic fractures (50% incidence of genitourinary injury) or straddle injuries 1
• Other clinical findings suggesting urethral injury include inability to urinate, perineal/genital ecchymosis, and high-riding prostate on physical exam 1

Diagnostic Algorithm

Step 1: Retrograde Urethrography (RUG)

Technique for performing RUG: 1

• Position patient obliquely with bottom leg flexed at knee and top leg straight
• If severe pelvic or spine fractures present, keep patient supine and place penis on stretch
• Introduce 12Fr Foley catheter or catheter-tipped syringe into fossa navicularis
• Place penis on gentle traction and inject 20 mL undiluted water-soluble contrast material while acquiring image
• The RUG will demonstrate partial or complete urethral disruption, guiding acute bladder drainage management 1

Step 2: If Catheter Already Placed

• If a Foley catheter was placed before urethral evaluation and blood is present at meatus, perform pericatheter retrograde urethrogram 1
• Inject contrast material through a 3Fr catheter or angiocatheter held in fossa navicularis to distend urethra and prevent contrast leak per meatus 1

Step 3: Additional Imaging

• In males with gross blood at meatus, retrograde urethrography is warranted to evaluate urethral integrity 1
• Consider CT cystography if concomitant bladder injury is suspected, particularly with pelvic fractures 1

Management Based on Findings

Establish Prompt Urinary Drainage

The immediate goal is securing catheter drainage of the bladder regardless of injury type 1, 2

For Partial Urethral Injuries

• A single attempt with well-lubricated catheter may be attempted by experienced team member 1
• If successful, urethral catheter drainage is appropriate 1

For Complete Urethral Disruption

• Suprapubic tube (SPT) placement is traditional management for pelvic fracture urethral injury with delayed urethroplasty 1
• Primary realignment (advancing urinary catheter across ruptured urethra) has become more common with improved endoscopic techniques, though urethral stenosis rates vary from 14-100% 1

For Anterior Urethral Injuries (Penetrating)

• Immediate surgical closure is recommended primarily for penetrating injuries of anterior urethra 1
• Straddle injuries are initially treated with suprapubic or urethral drainage and carry high risk for delayed stricture formation 1

For Posterior Urethral Injuries

• Avoid immediate sutured repair as this is associated with unacceptably high rates of erectile dysfunction and urinary incontinence 1

Critical Pitfalls to Avoid

• Never perform blind basketing or blind catheterization in trauma cases as this risks worsening urethral injury 2
• Do not rely on single clinical finding alone; blood at meatus has variable sensitivity (37-93%) 1
• In females, urethral injuries occur almost exclusively with pelvic fractures; suspect injury with labial edema and/or blood in vaginal vault 1
• Always evaluate for concomitant bladder injury (present in 15% of posterior urethral injuries) 1