Chapter 41 · Urological trauma
Urethral injury
Definition
Urethral injury most often occurs with pelvic fractures (posterior urethra) or direct perineal trauma (anterior urethra).
Clinical presentation
- Pelvic fractures: urethral bleeding, inability to void, perineal hematoma.
- Direct trauma: urethral bleeding, pain, hematoma.
Diagnosis
- Retrograde urethrography is the gold standard.
- CT for associated injuries.
Emergency management
- Suspect urethral injury in the presence of blood at the urethral meatus, inability to void, a perineal hematoma, or a relevant injury mechanism. Do not make repeated blind catheterization attempts.
- Retrograde urethrography is the standard initial investigation. In selected circumstances, one gentle catheterization attempt by an experienced specialist or endoscopically guided access is acceptable.
- If safe transurethral access is impossible, provide suprapubic drainage; subsequent reconstruction depends on the site and nature of the injury.
Algorithm
| Step | Action |
|---|---|
| 1 | Assess signs of urethral injury: blood at the meatus, urinary retention, perineal hematoma, mechanism |
| 2 | If suspected: retrograde urethrography; no repeated blind attempts |
| 3 | One gentle expert attempt or endoscopic access may be appropriate to the clinical context |
| 4 | If safe access is impossible: suprapubic cystostomy |
| 5 | Plan reconstruction according to the site and nature of injury |