What is the management approach for a male patient with blood at the meatus?

Blood at the Meatus in Males: Immediate Management

Perform retrograde urethrography immediately before any attempt at urethral catheterization when blood is present at the urethral meatus—do not blindly pass a catheter as this may convert a partial urethral injury into complete disruption. 1, 2

Initial Clinical Assessment

Blood at the urethral meatus is the most common finding in urethral injury, present in 37-93% of cases, and warrants immediate investigation for urethral disruption. 3, 1 Key clinical findings to assess include:

• Inability to void 3, 4
• Perineal or genital ecchymosis (butterfly hematoma) 3, 5
• High-riding prostate on digital rectal exam 3, 5
• Associated pelvic fracture (present in 1.5-10% of pelvic fractures with posterior urethral injury) 3, 4
• Mechanism of injury: straddle injuries, pelvic trauma, or penile trauma during sexual activity 3, 6, 7

Diagnostic Algorithm

Step 1: Retrograde Urethrography (RUG)

This is the mandatory first diagnostic step before any catheterization attempt. 3, 1, 8

The technique involves: 1

• Position patient obliquely
• Introduce 12Fr Foley catheter or catheter-tipped syringe into fossa navicularis
• Inject 20 mL undiluted water-soluble contrast under fluoroscopy
• Acquire images during injection

Interpretation of findings: 8

• Partial injury: Contrast extravasation WITH bladder filling (some urethral continuity remains)
• Complete disruption: Contrast extravasation WITHOUT bladder filling (total urethral disruption)

Step 2: Additional Imaging if Indicated

• CT cystography if concomitant bladder injury suspected, particularly with pelvic fractures 1
• MRI may reveal associated injuries (e.g., corporal cavernosum injury in penile trauma) if physical examination worsens 5

Management Based on RUG Findings

For Partial Urethral Injuries

A single attempt with a well-lubricated catheter may be attempted by an experienced provider only. 1, 2 If this fails, proceed to suprapubic tube placement. 2

For Complete Urethral Disruption

Immediate suprapubic tube (SPT) placement is required for urinary drainage. 1, 2, 4 This can be placed percutaneously or via open technique depending on clinical setting. 2

For Anterior Urethral Injuries (Straddle/Penetrating)

• Penetrating injuries: Immediate surgical closure is recommended 3, 1
• Straddle injuries: Initial treatment with suprapubic or urethral drainage; high risk for delayed stricture formation 3, 1

For Posterior Urethral Injuries (Pelvic Fracture)

Avoid immediate sutured repair—this is associated with unacceptably high rates of erectile dysfunction (38%) and urinary incontinence (10%). 3, 1, 9

Two management options exist: 3, 1

• Traditional approach: SPT placement with delayed urethroplasty (at least 3 months post-trauma) 3, 4
• Primary realignment: Advancing urethral catheter across rupture using endoscopic techniques (more common with improved technology, but should not involve prolonged attempts) 3, 2

Critical Pitfalls to Avoid

• Never attempt blind catheterization before RUG—this can worsen injury extent and convert partial to complete disruption 1, 2, 8
• Avoid repeated catheterization attempts—these increase morbidity and delay definitive management 2, 8
• Do not perform immediate surgical repair of posterior urethral injuries—stricture rate is 62% and complications include high rates of impotence and incontinence 3, 9
• In hemodynamically unstable patients, postpone all urethral investigations and place SPT immediately 3, 8

Special Considerations

Penile Fracture with Blood at Meatus

This combination suggests concomitant urethral injury requiring immediate surgical exploration after RUG confirmation. 6, 7 Complete urethral transection can occur with severe penile trauma and requires both tunica albuginea repair and urethral reconstruction. 6, 7

Female Patients

Urethral injuries in females are rare, occurring almost exclusively with pelvic fractures, and should be suspected with labial edema and/or blood in vaginal vault. 3 Endoscopic retrograde urethrocystography is recommended given short urethral length that precludes standard retrograde visualization. 3