What is the best course of treatment for a patient with drainage from the tip of the penis, likely due to a urethral meatus split?

Management of Drainage from the Tip of the Penis (Urethral Meatal Split)

If you suspect a urethral meatal split with drainage, immediately perform retrograde urethrography to define the injury extent before any further catheter manipulation, then establish urinary drainage via either urethral or suprapubic catheter depending on injury severity. 1, 2

Immediate Diagnostic Evaluation

Do not blindly pass another urethral catheter through the injured meatus, as this can convert a partial injury into complete urethral disruption. 2 The presence of blood at the urethral meatus mandates retrograde urethrography after any genital trauma. 1, 3

How to Perform Retrograde Urethrography:

• Position the patient obliquely with the bottom leg flexed and top leg straight (or supine if severe injuries present) 1
• Insert a 12Fr Foley catheter or catheter-tipped syringe into the fossa navicularis 1
• Place the penis on gentle traction and inject 20 mL undiluted water-soluble contrast while acquiring the image 1
• This study has 95.9% diagnostic accuracy and will demonstrate whether the injury is partial or complete 2, 3

Establishing Urinary Drainage

Urinary drainage must be obtained as soon as possible. 1, 3 The approach depends on injury severity:

For Partial Injuries:

• Attempt gentle urethral catheter placement first with a well-lubricated catheter by an experienced team member (single attempt only) 1
• If successful, this provides adequate drainage without need for suprapubic catheter 1

For Complete Disruption or Failed Urethral Catheterization:

• Place a suprapubic catheter immediately 1, 2, 3
• This can be done percutaneously or via open technique depending on clinical setting 1
• Small caliber percutaneous catheters will require upsizing if hematuria is present or prolonged use is anticipated 1

Definitive Management Strategy

Initial conservative management with urinary drainage is the treatment of choice for blunt anterior urethral injuries (including meatal splits). 1, 2, 3

Conservative Management Protocol:

• Maintain urinary drainage via urethral or suprapubic catheter 1, 3
• Perform urethrography every two weeks until complete healing is documented 1, 2
• Attempt endoscopic realignment before considering surgery 1, 3
• Reserve delayed surgical repair (urethroplasty) for cases where conservative treatment fails after endoscopic approach 1

When to Consider Immediate Surgical Repair:

Only for uncomplicated penetrating injuries in hemodynamically stable patients without life-threatening associated trauma. 2, 3 This does not typically apply to simple meatal splits from catheterization.

Critical Pitfalls to Avoid

• Never make repeated attempts at urethral catheter placement, as this increases injury extent and delays drainage 1
• Never perform blind catheter passage prior to retrograde urethrogram unless exceptional circumstances require emergent drainage for monitoring 1
• Do not delay imaging studies to assess urethral trauma and catheter positioning, as delayed diagnosis worsens outcomes 4

Expected Outcomes and Follow-Up

The rate of stricture after urethral injury ranges from 14-100%, with most patients eventually requiring repeated instrumentation or formal urethroplasty. 2 Follow-up imaging with urethrography should be performed every two weeks until complete healing is documented. 1, 2, 3

For simple meatal web formation causing stenosis (a potential late complication), wedge urethral meatotomy has shown 97% success rates with only 3% developing mild stricture not requiring further intervention. 5