Urethral injury is rarely an isolated event; it is often associated with multiple trauma. Anterior urethral injuries are most often the result of a straddle injury and may present late (many patients are still able to void) with a local infection or sepsis from extravasated urine. Posterior urethral injuries occur in motor vehicle and motorcycle accidents and are usually the result of pelvic fractures. Patients have blood at the urethral meatus, cannot void, and have perineal bruising. In men, the prostate is often boggy or free-floating or may not be palpable at all if there is a retroperitoneal hematoma between the prostate and the rectum.
Management and Disposition
Do not allow urethral instrumentation such as Foley catheterization prior to a retrograde urethrogram with highly concentrated water-soluble contrast. If there is only a partial anterior tear, gently attempt catheterization but abandon it at the 1st sign of resistance. If catheterization is unsuccessful and whenever there is a posterior tear, place a suprapubic catheter if relief of bladder distention is required prior to operative repair.
Foley catheter insertion is contraindicated in patients with a suspected urethral injury prior to a retrograde urethrogram.
Urethral injury should be suspected in the multiple-trauma patient who is unable to void or has blood at the meatus, a high-riding prostate, or perineal trauma.
Vaginal lacerations due to trauma in women should prompt consideration of a urethral tear.
Occasionally, urine from an anterior urethral tear will extravasate into the scrotum, causing marked swelling.
Posterior injuries are frequently associated with other intra-abdominal injury.
Urethral Rupture. (A) Blood at the urethral meatus in a patient with an anterior urethral rupture secondary to a straddle injury. (B) A retrograde urethrogram shows extravasation of dye indicating rupture. (Photo contributor: David Effron, MD.)
Urethral Injury. A retrograde urethrogram demonstrates contrast extravasation, signifying a urethral injury. (Photo contributor: Dirk Liebchen, MD.)