Urethral injuries from an external force usually occur in men; female urethral injuries are rare. 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, penile fractures, or because of a mental health condition. Iatrogenic causes of urethral injuries are more common and can occur after any transurethral procedure (including Foley catheter placement or prostatic surgery) or radiation therapy for prostate cancer.
Urethral injuries are classified as contusions, partial disruptions, or complete disruptions, and they may involve the posterior urethra (membranous and prostatic) or anterior urethra (bulbous and penile segments). Posterior urethral injuries occur almost exclusively with pelvic fractures. Anterior urethral injuries are often consequences of a perineal blow, motor vehicle crash, or perineal straddle injury due to a fall.
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 of Urethral Trauma
Symptoms of urethral injuries 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 further evaluation for potential associated injury to those organs.
Diagnosis of Urethral Trauma
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. CT alone is inadequate to diagnose and evaluate urethral trauma.
Pearls & Pitfalls
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Treatment of Urethral Trauma
Usually urethral catheterization (for contusions) or suprapubic cystostomy (for disruptions)
Sometimes endoscopic realignment or surgical repair (for selected injuries)
Delayed definitive surgery
Urethral contusions can be safely treated with an indwelling transurethral catheter for approximately 5 to 7 days. Partial disruptions are best treated with bladder drainage via a suprapubic cystostomy. In selected cases, primary urethral realignment (endoscopic or open) may be attempted; if successful, this approach may limit subsequent urethral stenosis.
The preferred initial management for most urethral injuries associated with pelvic fracture is open or percutaneous suprapubic tube placement (1, 2). Definitive surgery is deferred for approximately 8 to 12 weeks until the urethral scar tissue has stabilized and the patient has recovered from any accompanying injuries.
Immediate open repair of urethral injuries is limited to those associated with penile fractures, penetrating injuries, and all injuries in females.
Treatment references
1. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30-35. doi:10.1097/JU.0000000000001408
2. Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335. doi:10.1016/j.juro.2014.05.004
Key Points
Anterior urethral injuries are usually from blunt trauma; urethral injuries with penile fractures or from penetrating trauma occur less frequently.
Most posterior urethral injuries are associated with pelvic fractures.
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 suprapubic tube placement; consider primary realignment in selected cases.
Delay surgical reconstruction except in select injuries (ie, penile fractures, penetrating injuries, and female urethral injuries) that require immediate open repair.
