Clinical Considerations Clinical Recognition Blood at the meatus has been reported in up to 90% of patients sustaining anterior urethral injuries Other findings include hematuria, inability or difficulty voiding, and periurethral or perineal edema, ballooning and ecchymosis Perineal ecchymosis in the shape of a butterfly is typical for these injuries Posterior urethral injury may be predicted by the location and displacement of associated pelvic fractures There is an association between pubic arch fractures and urethral injury, with higher risk as the number of broken rami increases The classically described “high-riding prostate” is rarely found clinically Because the female urethra is relatively mobile and short, trauma to the urethra is uncommon It was reported in less than 6% of cases with associated pelvic fractures in one series of women and girls When it does occur, it is found more commonly in girls than in women In one series, every female patient with a significant urethral injury had gross hematuria or blood at the introitus and a pelvic ring fracture Any female patient with this combination of findings should be evaluated for a urethral injury Most serious injuries involve the vesicourethral junction and extend to the vagina Initial Assessment/Diagnostic Testing Urethral injuries in males can be diagnosed by a retrograde urethrogram (RUG) The patient is positioned with a bump under one side with the lower leg slightly bent A tapered inserter (such as a pediatric Taylor adaptor or angiocatheter) or if necessary, a Foley catheter appropriate for the size of the patient is inserted into the urethra to the fossa navicularis If a Foley is used, the balloon should not be inflated within the urethra Contrast material is injected via the catheter to gently distend the urethra and images are obtained If a Foley catheter is already in place, the urethrogram can still be performed via a small feeding tube passed alongside the catheter Retrograde urethrography should be performed under fluoroscopy with minimal pressure Gross extravasation of the contrast agent at the site of the injury without visualization of the proximal urethra and bladder is diagnostic for complete rupture of the urethra Partial rupture is represented by localized extravasation at the site of the injury, with some contrast passing into the proximal urethra and bladder If no extravasation is noted, a urinary catheter can be gently advanced into the bladder CT is not adequate for diagnosing urethral injuries and is presumptive only if extravasation is detected at the bladder neck or urethra ( Fig 108.5 ) US or MRI may provide useful information in