Immediate Management of Post-Coital Genital Trauma in FTM Patient
This patient requires prompt clinical evaluation with urinalysis and culture, followed by short-term urinary catheter drainage (7-14 days) if urethral/vaginal mucosal injury is confirmed, along with analgesics, pelvic rest, and close monitoring for infection or worsening symptoms. 1
Clinical Assessment Priority
The constellation of swelling at the vaginal opening, visible tear, dysuria with urinary hesitancy, and mild constipation two days after rough penetrative trauma strongly suggests anterior urethral/vaginal mucosal injury rather than simple infection, given the mechanism and timing. 1 The management principles for FTM patients who have not undergone genital reconstruction are identical to those for female patients, as the same anatomical structures are at risk for the same injury patterns. 1
Key Physical Examination Findings to Document
- Blood at the urethral meatus or vaginal vault (present in 37-93% of urethral injuries) 1
- Perineal/genital ecchymosis and labial edema (cardinal signs indicating tissue trauma severity) 1
- Ability to void completely (complete inability suggests severe injury requiring immediate intervention) 1
- Location and extent of visible tears 2
Diagnostic Testing Required
Immediate Laboratory Work
- Urinalysis with culture to rule out concurrent UTI and assess for hematuria (present in 77-100% of bladder/urethral injuries) 1
- STI screening via nucleic acid amplification test for N. gonorrhoeae and C. trachomatis, given unprotected sexual exposure 1
Consider Retrograde Urethrography If:
- Blood at meatus persists 1
- Severe dysuria continues 1
- Complete inability to void develops 1
- Symptoms worsen despite initial management 2
Important caveat: Retrograde urethrography should be performed before attempting urethral catheterization if urethral injury is strongly suspected. 2
Treatment Protocol
Primary Management for Uncomplicated Mucosal Injury
- Urinary catheter drainage for 7-14 days to allow healing and prevent urinary extravasation 1, 2
- Analgesics for pain control 1
- Strict pelvic rest (no penetrative activity) 1
- Sitz baths for comfort and hygiene 1
If STI Testing Returns Positive
- Ceftriaxone plus doxycycline per CDC guidelines 1
- Partner treatment within 60 days of symptom onset 1
Addressing Constipation
The mild constipation is likely secondary to pelvic trauma and pain-related guarding. Recommend stool softeners and adequate hydration to avoid straining, which could worsen perineal trauma. 1
Follow-Up Schedule
Mandatory Reassessment Points
- 3-day follow-up to assess for improvement; failure to improve requires reassessment for missed injury or infection 1
- Post-catheter removal evaluation to ensure adequate voiding 1
- Long-term monitoring for delayed stricture formation using uroflowmetry, retrograde urethrogram, and/or cystoscopy within the first year 2, 1
Red Flags Requiring Urgent Re-evaluation
- Fever or systemic symptoms suggesting infection 2
- Worsening pain or swelling 1
- Complete urinary retention 1
- Increasing hematuria 1
- Signs of abscess formation (purulent drainage, erythema, tenderness) 2
Common Pitfalls to Avoid
Do not empirically treat with antibiotics alone without establishing urinary drainage if there is significant mucosal injury, as this will not address the mechanical problem and risks urinary extravasation. 1, 2
Do not attempt immediate surgical repair in the acute setting of crush/blunt trauma, as the injury border is indistinct; delayed reconstruction after catheter drainage is preferred. 2
Do not overlook STI screening despite both partners reporting being "clean"—formal testing is still required given the exposure. 1
Do not dismiss the constipation as unrelated—it may worsen with straining and should be proactively managed. 1