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Emergency and Acute Medicine: Urethral Trauma
Urethral trauma is a significant genitourinary injury most commonly associated with pelvic fractures and high-energy trauma. Classic clinical findings include blood at the urethral meatus, inability to void, a palpable distended bladder, and/or gross hematuria. It occurs in approximately 14% of pelvic fractures and is strongly associated with bilateral pubic rami (straddle) fractures.
In females, urethral injuries are rare due to the short, mobile, and relatively protected urethra, though risk is higher in younger patients with more flexible pelvic anatomy. When injuries do occur, the bladder neck is most commonly affected. In males, urethral trauma is more common and anatomically divided into anterior and posterior injuries. Posterior urethral injuries—affecting the prostatic and membranous urethra—account for about 90% of cases and are typically associated with pelvic fractures. These injuries are classified as stretching (type 1), partial or complete disruption with intact urogenital diaphragm (type 2), or complete disruption both proximal and distal to the diaphragm (type 3). Anterior urethral injuries (bulbar or penile) are less common and are typically associated with straddle injuries or penetrating trauma.
Etiologies differ by sex and mechanism. In males, pelvic fractures, straddle injuries, penetrating trauma, and instrumentation are common causes. In females, causes include pelvic trauma, childbirth, surgical injury, or sexual trauma. A history of pelvic or perineal trauma is often present.
Clinically, males may present with blood at the urethral meatus (seen in about 50% of cases), gross hematuria, and urinary retention. In females, blood may be seen in the vaginal vault. Physical examination during trauma assessment may reveal pelvic tenderness and bladder distention. The classic triad—blood at the meatus, inability to void, and a palpable bladder—is highly suggestive. A “high-riding prostate” on digital rectal exam has low sensitivity and should not be relied upon. Bedside ultrasound (FAST) may demonstrate fluid around the bladder.
Diagnosis requires a high index of suspicion. The essential rule in suspected urethral injury is to avoid blind Foley catheter placement until urethral integrity is confirmed. The gold standard diagnostic test is retrograde urethrography (RUG), in which contrast is injected into the urethra to assess for extravasation. Complete tears show no contrast entering the bladder, while partial tears allow some contrast passage with leakage. Because up to 40% of urethral injuries are associated with bladder injuries, cystography is also recommended.
Management prioritizes overall trauma stabilization (ABCs) before addressing the urethral injury. Early urologic consultation is essential. Bladder decompression is a key step; if urethral catheterization is unsafe or unsuccessful, suprapubic catheter placement or cystostomy is performed. Definitive management depends on the severity of injury: partial tears are typically managed with catheter drainage, while complete disruptions often require surgical repair or delayed reconstruction.
Patients with associated injuries, hemodynamic instability, or severe urethral damage require admission, often to a surgical or ICU setting. Isolated injuries may be managed on an outpatient basis after appropriate urinary diversion and with close urologic follow-up.
Important clinical pearls include recognizing blood at the urethral meatus as a red flag for urethral injury and avoiding catheter insertion until imaging is performed. Failure to diagnose urethral trauma can result in long-term complications such as urinary incontinence, urethral stricture, and sexual dysfunction.
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