What are the treatment options for a 27-year-old female-to-male (FTM) patient experiencing swollen vaginal opening, dysuria (painful urination), spotting (light bleeding), and urinary hesitancy two days after rough sexual intercourse?

Management of Post-Coital Genital Trauma in FTM Patient

This patient most likely has traumatic injury to the vaginal/urethral tissues from rough intercourse and should be managed conservatively with urinary catheter drainage, analgesia, pelvic rest, and close monitoring for signs of infection or urethral injury requiring surgical intervention.

Immediate Clinical Assessment

The constellation of swelling, dysuria, light bleeding, and urinary hesitancy two days post-trauma suggests either:

• Anterior urethral/vaginal mucosal injury (most likely given the mechanism and timing) 1
• Urinary tract infection (less likely without fever or purulent discharge) 2, 3

Key Physical Examination Findings to Document

• Blood at the urethral meatus or vaginal vault - present in 37-93% of urethral injuries and should be specifically assessed 1
• Perineal/genital ecchymosis - indicates tissue trauma severity 1
• Labial edema - in females with urethral injuries, this is a cardinal sign 1
• Ability to void - complete inability suggests more severe injury requiring immediate intervention 1

Diagnostic Workup

Essential Testing

• Urinalysis with culture - to rule out concurrent UTI and assess for hematuria (present in 77-100% of bladder/urethral injuries) 1, 2, 3
• Retrograde urethrography - if urethral injury is suspected based on blood at meatus, inability to void, or severe dysuria 1
• STI screening - given sexual exposure, test for N. gonorrhoeae and C. trachomatis via nucleic acid amplification test 1

When Imaging is NOT Needed

If the patient can void (even with difficulty), has no blood at the meatus, and symptoms are mild, conservative management without urethrography is appropriate 1

Treatment Algorithm

For Traumatic Injury Without Urethral Disruption (Most Likely Scenario)

Primary Management:

• Urinary catheter drainage (urethral or suprapubic) for 7-14 days to allow tissue healing and divert urine from injured areas 1
• Analgesics - NSAIDs or acetaminophen for pain control 1
• Pelvic rest - strict avoidance of sexual activity, tampon use, or anything inserted vaginally until complete healing 1
• Sitz baths - warm water immersion 2-3 times daily to reduce swelling and promote comfort 1

Monitoring:

• Re-evaluate in 3 days; failure to improve requires reassessment for missed injury or infection 1
• High risk for delayed stricture formation with anterior urethral injuries, requiring long-term follow-up 1

If STI Testing is Positive

For C. trachomatis or N. gonorrhoeae:

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg PO twice daily for 10 days 1
• Treat sex partners within 60 days of symptom onset 1
• Abstain from sexual activity until both patient and partner complete therapy 1

If UTI is Confirmed

For uncomplicated cystitis:

• Use single effective antibacterial agent (nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin) rather than combination therapy for simple UTI 4, 3
• Duration: 3-7 days for uncomplicated infection 3

Critical Pitfalls to Avoid

Do NOT Attempt Immediate Surgical Repair

• Immediate sutured repair of urethral injuries (if present) is associated with unacceptably high rates of erectile dysfunction and urinary incontinence 1
• Straddle-type injuries (similar mechanism to rough intercourse trauma) are initially treated with catheter drainage, NOT surgery 1

Do NOT Empirically Treat as Simple UTI Without Examination

• Vaginal discharge or visible trauma decreases likelihood of simple UTI and requires investigation of other causes 2
• Virtual encounters without physical examination increase recurrent symptoms and unnecessary antibiotic courses 2

Do NOT Miss Concurrent Injuries

• 15% of urethral injuries have concomitant bladder injuries 1
• If gross hematuria is present, retrograde cystography is critical to rule out bladder rupture 1

Follow-Up Requirements

• 3-day reassessment - if no improvement, consider missed diagnosis (abscess, complete urethral disruption, or intraperitoneal injury) 1
• Post-catheter removal evaluation - assess for stricture formation or persistent symptoms 1
• Long-term monitoring - anterior urethral injuries carry high risk of delayed stricture requiring repeated instrumentation or formal urethroplasty 1

Special Considerations for FTM Patients

While the provided guidelines address female anatomy, the management principles remain identical for FTM patients who have not undergone genital reconstruction surgery. The same anatomical structures are at risk for the same injury patterns from the same mechanisms 1.