MSD MANUAL

Professional Version
The trusted provider of medical information since 1899

Urethral Trauma
By Noel A. Armenakas , MD, Weill Cornell Medical School

Last full review/revision August 2019 by Noel A. Armenakas, MD

Urethral injuries usually occur in men. Most major urethral injuries are due to blunt trauma. Penetrating
urethral trauma is less common, occurring mainly as a result of gunshot wounds, or, alternatively, due to
inserting objects into the urethra during sexual activity or because of psychiatric illness.
Urethral injuries are classified as contusions, partial disruptions, or complete disruptions, and they may
involve the posterior or anterior urethral segments. Posterior urethral injuries occur almost exclusively with
pelvic fractures. Anterior urethral injuries are often consequences of a perineal straddle injury due to a fall,
perineal blow, or motor vehicle crash. Iatrogenic injuries occur during transurethral instrumentation (eg,
catheter placement or removal, cystoscopy).
Complications include infection, incontinence, erectile dysfunction, and stricture or stenosis ("stenosis" is
narrowing of the posterior urethra whereas "stricture" refers exclusively to the anterior urethra).

Symptoms and Signs

Symptoms include pain with voiding or inability to void. Blood at the urethral meatus is the most important
sign of a urethral injury. Additional signs include perineal, scrotal, penile, and labial ecchymosis, edema, or
both. Abnormal location of the prostate on rectal examination (so-called high-riding prostate) is an
inaccurate indicator of a urethral injury. Blood on digital, rectal, or vaginal examination requires thorough
evaluation.

Diagnosis
Retrograde urethrography

Any male patient with symptoms or signs suggestive of a urethral injury should undergo retrograde
urethrography. This procedure should always precede catheterization. Urethral catheterization in a male
with an undetected significant urethral injury may potentiate urethral disruption (eg, convert a partial
disruption to a complete disruption). Female patients require prompt cystoscopy and a thorough vaginal
examination.

Pearls & Pitfalls

If male urethral injury is suspected, do not

insert a urethral catheter until after

urethrography.

Treatment
 Usually urethral catheterization (for contusions) or suprapubic cystostomy

Sometimes endoscopic realignment or surgical repair (for select injuries)

Delayed definitive surgery

Contusions can be safely treated with an indwelling transurethral catheter for about 7 days. Partial
disruptions are best treated with bladder drainage via a suprapubic cystostomy. In select cases of posterior
partial disruptions, primary urethral realignment (endoscopic or open) may be attempted; if successful, this
approach may limit subsequent urethral stenosis.
The simplest and safest option for most patients with complete disruption is bladder drainage via a
suprapubic cystostomy. Definitive surgery is deferred for about 8 to 12 weeks until the urethral scar tissue
has stabilized and the patient has recovered from any accompanying injuries.
Open repair of urethral injuries is limited to those associated with penile fractures, penetrating injuries, and
all injuries in females.

Key Points

Most posterior urethral injuries are associated with pelvic fractures. Anterior injuries are
usually from a blunt mechanism; urethral injuries with penile fractures or from penetrating
trauma occur less frequently.

Consider urethral injuries particularly in patients who have pelvic fractures or straddle
injuries and who have blood at the urethral meatus or difficulty voiding.

In males, do retrograde urethrography before urethral catheterization.

In females, do cystoscopy and a thorough vaginal examination.

Treat contusions with urethral catheterization and most urethral disruptions initially with a
suprapubic cystostomy; consider primary realignment in select cases.

Delay surgical reconstruction except in select injuries (ie, penile fractures, penetrating
injuries, and female urethral injuries).

© 2019 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA)