Treatment for Torn Urethral Meatus
Establish urinary drainage immediately—either by gentle single-attempt urethral catheterization if the injury appears partial, or by suprapubic catheter if catheterization fails or the injury is complete—then pursue conservative management with delayed definitive repair rather than immediate surgical closure. 1, 2
Immediate Diagnostic Evaluation
Before attempting any intervention, you must determine the extent of injury:
Perform retrograde urethrography first if there is any suspicion of urethral injury beyond a simple meatal tear (diagnostic accuracy 95.9%). 2, 3 This is critical because blood at the meatus may indicate deeper urethral disruption in 37-93% of cases. 2
Never blindly pass a catheter through an injured meatus without imaging, as this can convert a partial injury into complete urethral disruption. 1, 2 This is the single most important pitfall to avoid.
The retrograde urethrogram technique involves injecting 20mL of undiluted water-soluble contrast through a catheter held in the fossa navicularis while obtaining oblique imaging. 2
Establishing Urinary Drainage (First Priority)
The immediate goal is securing bladder drainage, not definitive repair:
For isolated meatal tears or partial injuries: Attempt one gentle, well-lubricated urethral catheter placement by an experienced provider. 2, 3 If successful, this provides adequate drainage while the injury heals.
For complete disruption or failed catheterization: Place a suprapubic catheter immediately (either percutaneously or via open technique depending on clinical setting). 4, 1 Small caliber percutaneous catheters will require upsizing if there is hematuria or prolonged use anticipated. 4
Avoid repeated catheterization attempts, as this increases injury severity and delays drainage. 4
Definitive Management Algorithm
The approach depends on injury mechanism and location:
For Blunt Trauma (Straddle Injuries)
Initial conservative management with urinary drainage is the treatment of choice. 1, 3 This means suprapubic or urethral catheter drainage, not immediate surgical repair.
These injuries carry high risk for delayed stricture formation (14-100% after posterior injuries). 1 Plan for follow-up urethrography every 2 weeks until complete healing is documented. 1, 3
Delayed urethroplasty at least 3 months after injury is the optimal management for resulting strictures once inflammation and fibrosis have stabilized. 5
For Penetrating Injuries
Immediate direct surgical repair is recommended only for uncomplicated penetrating anterior urethral injuries in hemodynamically stable patients. 1, 3 This requires an experienced surgeon and stable patient without life-threatening associated trauma. 1
Even with penetrating injuries, if the patient is unstable or the injury is posterior, revert to suprapubic drainage with delayed repair. 4, 3
For Posterior Urethral Injuries (Pelvic Fracture-Associated)
Suprapubic tube placement with delayed urethroplasty remains the accepted standard. 4 Immediate sutured repair of posterior injuries is associated with unacceptably high rates of erectile dysfunction and urinary incontinence. 4, 2
Primary realignment may be considered in hemodynamically stable patients within the first few days, but only by experienced urologists in a proper operating room setting—never in the emergency department. 4 However, this remains controversial and does not eliminate the need for long-term monitoring for stricture. 4, 1
Follow-Up Protocol
Monitor all patients for complications (stricture, erectile dysfunction, incontinence) for at least one year following urethral injury. 4
Use urethrography or urethroscopy for follow-up imaging every 2 weeks until complete healing for blunt anterior injuries. 1, 3
Stricture rates vary based on injury severity and management approach, with most patients eventually requiring repeated instrumentation or formal urethroplasty. 1
Critical Clinical Pitfalls
Do not attempt immediate urethroplasty for posterior urethral injuries—this dramatically increases erectile dysfunction and incontinence rates. 2, 3
Do not perform prolonged or heroic attempts at endoscopic realignment—this increases injury severity without improving long-term outcomes. 4
Do not delay establishing urinary drainage—trauma resuscitations involve aggressive hydration requiring close volume monitoring. 4