Urethral Trauma Management (AUA Urotrauma 2020)

Algorithm Steps

1. ▶

   Start

   Suspected Urethral Trauma

   Blood at meatus, inability to void, pelvic fracture

   1. ●

      Action

      Clinical Indicators

      Classic signs of urethral injury

      • Blood at urethral meatus (most reliable)
      • Inability to void
      • Perineal/scrotal ecchymosis (butterfly)
      • High-riding or non-palpable prostate
      • Pelvic fracture present
      • Straddle mechanism injury
      1. ⚠

         Warning

         ⚠️ DO NOT BLINDLY CATHETERIZE

         Critical: May convert partial to complete disruption

         • NEVER attempt urethral catheter if injury suspected
         • One gentle attempt may be acceptable if trained
         • If resistance: STOP immediately
         • Proceed to imaging before any urethral instrumentation
         1. ●

            Action

            Retrograde Urethrogram (RUG)

            Gold standard for diagnosis (AUA Strong Rec)

            • Insert small catheter tip into fossa navicularis
            • Inject 20-30mL dilute contrast
            • Obtain oblique fluoroscopy images
            • Look for: contrast extravasation, complete disruption
            • Partial injury: some contrast reaches bladder
            • Complete: no contrast above injury
            1. ◆

               Decision

               Anterior or Posterior Injury?

               Location determines mechanism and management

               1. ●

                  Action

                  Anterior Urethral Injury

                  Penile or bulbar urethra

                  • Mechanism: straddle injury, instrumentation, blunt
                  • Bulbar urethra most common site
                  • Penile urethra: direct trauma, fracture-related
                  • Usually no pelvic fracture association
                  • Perineal/scrotal butterfly ecchymosis classic
                  1. ◆

                     Decision

                     Partial or Complete Disruption?

                     Determines initial management approach

                     1. ●

                        Action

                        Partial Urethral Injury

                        Some urethral continuity preserved

                        • Contrast reaches bladder on RUG
                        • Gentle catheter attempt may succeed
                        • Use small caliber (14-16 Fr) catheter
                        • If passes easily: leave in place 2-3 weeks
                        • If resistance: SPC
                        • Many heal without stricture
                        1. ●

                           Action

                           Long-Term Follow-Up

                           Monitor for complications

                           • Voiding symptoms: flow rate, hesitancy
                           • Stricture recurrence: may need repeat surgery
                           • Erectile dysfunction: 20-60% with PFUI
                           • Incontinence: 2-20% depending on injury
                           • Urethroscopy if symptoms develop
                           1. ✓

                              Outcome

                              Expected Outcomes

                              Variable by injury severity

                              • Anterior partial: excellent prognosis
                              • PFUI: 50-100% stricture rate
                              • Urethroplasty success: >90%
                              • ED and incontinence dependent on injury severity
                        2. ●

                           Action

                           Suprapubic Catheter Placement

                           Urinary diversion

                           • Open or percutaneous approach
                           • Ultrasound guidance if bladder not distended
                           • Confirm bladder distension before percutaneous
                           • 12-14 Fr catheter typically
                           • Allows definitive management planning
                           1. ●

                              Action

                              Early Endoscopic Realignment

                              Within 7-14 days of injury

                              • Combined antegrade/retrograde approach
                              • Pass guidewire across disruption
                              • Place catheter over wire
                              • May reduce stricture severity
                              • Does not eliminate stricture risk
                              • Consider if patient stable for OR
                           2. ●

                              Action

                              Delayed Urethroplasty

                              Definitive repair at 3+ months

                              • Allow inflammation to resolve
                              • RUG + VCUG to delineate stricture
                              • Anastomotic urethroplasty for short strictures
                              • Substitution urethroplasty if long gap
                              • Success rate >90% at experienced centers
                     2. ●

                        Action

                        Complete Urethral Disruption

                        No urethral continuity

                        • No contrast above level of injury
                        • Requires suprapubic catheter (SPC)
                        • Options: Immediate realignment OR delayed repair
                        • Early realignment: lower stricture rate
                        • Delayed repair: 3+ months, definitive urethroplasty
                        • Both approaches acceptable (AUA)
               2. ●

                  Action

                  Posterior Urethral Injury

                  Membranous or prostatic urethra (PFUI)

                  • Mechanism: pelvic fracture (shearing force)
                  • Membranous urethra at urogenital diaphragm
                  • 1.6-25% of pelvic fractures have PFUI
                  • Associated with bladder injury in 10-20%
                  • Higher risk of incontinence/ED