What is the diagnosis and treatment for bleeding from the penile urethra?

Diagnosis and Management of Urethral Bleeding

Immediate Diagnostic Approach

Blood at the urethral meatus is a critical indicator of potential urethral injury and mandates immediate evaluation with retrograde urethrography before any attempt at urethral catheterization. 1, 2

Key Clinical Presentations to Identify

• Penile fracture with urethral injury: Look for history of cracking/snapping sound during sexual activity, rapid detumescence, acute pain, penile swelling, ecchymosis, "eggplant deformity," blood at meatus, gross hematuria, or inability to void 1, 3

• Pelvic trauma: Assess for associated pelvic fractures, perineal laceration, scrotal hematoma, urinary retention, difficulty with catheter insertion, or superiorly displaced prostate on rectal examination 1

• Penetrating trauma: Any penetrating injury to the penis, perineum, or pelvis warrants evaluation for urethral injury 1

Diagnostic Algorithm

Step 1: Clinical Assessment

• Inspect the external urethral meatus for blood, swelling, ecchymosis, or discharge 2
• In males, retract the prepuce to avoid contamination 2
• Perform rectal examination to assess for prostate displacement or associated rectal injury 1

Step 2: Imaging Selection Based on Clinical Context

For suspected penile fracture with equivocal findings:

• Ultrasound is the first-line imaging modality due to wide availability, low cost, and rapid examination times 1, 4
• MRI can be considered if ultrasound is equivocal 1
• If imaging remains equivocal or diagnosis is in doubt, proceed directly to surgical exploration 1

For confirmed or suspected urethral trauma:

• Retrograde urethrography is the gold standard diagnostic procedure and must be performed before any catheterization attempt 1, 5
• Urethroscopy is an alternative diagnostic modality, neither method is superior 1
• In penile lesions specifically, urethroscopy is preferred over retrograde urethrography 1, 2

For hemodynamically unstable patients:

• Postpone all urethral investigations and place suprapubic catheter for urinary drainage 1
• Proceed to emergency surgery if indicated by other injuries 1

Management Based on Diagnosis

For penile fracture with urethral injury:

• Perform prompt surgical exploration and repair immediately 1, 2
• Expose injured corpus cavernosum through ventral midline or circumcision incision 1
• Repair tunica albuginea with absorbable suture 1
• Perform urethral reconstruction with interrupted sutures over Foley catheter 3, 6
• Maintain urethral catheter for 6 days and consider suprapubic catheter for 3 months to protect urethral healing 6

For isolated urethral injury without fracture:

• Urethroscopy under semi-tumescent penis can identify bleeding site 7
• Transurethral fulguration may be sufficient for isolated posterior urethral injuries 7

For vascular causes (pseudoaneurysm/AVM):

• Angiography with selective embolization is indicated for intractable bleeding when other evaluations are non-diagnostic 1, 8
• Surgical repair is an alternative for symptomatic arteriovenous malformations 9

Critical Pitfalls to Avoid

• Never attempt blind catheterization before imaging in trauma cases—this may worsen urethral injuries 1, 2, 5
• Never perform repeated catheter placement attempts, as this increases injury extent 2
• Do not delay surgical exploration in penile fracture cases—immediate repair within hours provides best functional outcomes 1, 4
• In pelvic fractures with blood at meatus, always evaluate for urethral injury before bladder catheterization 2, 5