What is the approach for a patient with a urethral meatus split at the tip of the penis, drainage from the split, and a catheter (catheterization) in situ?

Management of Urethral Meatal Split with Catheter in Situ

Remove the catheter immediately and establish alternative urinary drainage via suprapubic catheter, then pursue conservative management with delayed definitive repair. 1

Immediate Actions

Secure Urinary Drainage

• Do not attempt to replace or manipulate the existing urethral catheter through the split meatus, as this will worsen the injury and increase risk of complete urethral disruption 1
• Place a suprapubic catheter as the primary drainage method since urethral catheterization has already failed (evidenced by the meatal split) 1
• The American College of Surgeons recommends establishing urinary drainage immediately, with suprapubic catheter preferred when there is evidence of urethral injury 1

Diagnostic Evaluation

• Perform retrograde urethrography to define the extent and location of injury, which has 95.9% diagnostic accuracy 1, 2
• Blood at the urethral meatus (which you have as "drainage from split") mandates retrograde urethrography after pelvic or genital trauma 3
• The retrograde urethrogram will demonstrate whether this is a partial or complete urethral disruption, guiding definitive management 3

Definitive Management Algorithm

Conservative Approach (Preferred)

• Initial conservative management with urinary drainage via suprapubic catheter is the treatment of choice for anterior urethral injuries 1, 2
• Plan for delayed surgical reconstruction rather than immediate repair 1
• Repeat urethrography every two weeks until complete healing is documented 1, 2

When to Consider Immediate Repair

• Immediate surgical repair is reserved exclusively for penetrating injuries in hemodynamically stable patients with experienced surgeons available 2
• This catheter-induced injury is iatrogenic trauma, not penetrating trauma, so conservative management applies 1

Critical Pitfalls to Avoid

• Never blindly pass another urethral catheter through the injured meatus, as this can convert a partial injury to complete urethral disruption 3
• Immediate sutured repair of urethral injuries is associated with high rates of erectile dysfunction and urinary incontinence 2
• Delaying establishment of urinary drainage (via suprapubic route in this case) increases risk of complications 2
• Unsecured catheters cause urethral erosion and meatal trauma—the likely cause of this patient's split meatus 4

Expected Complications and Follow-Up

• Stricture rates after urethral injury range from 14-100%, with most patients eventually requiring repeated instrumentation or formal urethroplasty 1, 2
• Use urethrography or ureteroscopy for follow-up imaging every two weeks until healing is complete 1, 2
• Early establishment of suprapubic drainage and delayed reconstruction minimizes long-term complications compared to immediate repair 1

Root Cause Analysis

This meatal split likely resulted from:

• Catheter traction on the urethral meatus causing tissue breakdown 5
• Improper catheter securement leading to urethral erosion 4
• Excessive catheter size (large Charrière) causing pressure necrosis 5