Guideline sources The following summarized guidelines for the evaluation and management of urethral injury are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023; 2022), the World Society of Emergency Surgery (WSES/AAST 2019), and the American Urological Association (AUA 2014). 1 2 3 4 Guidelines 1. Screening and diagnosis Diagnosis: evaluate patients with post-traumatic urethral hemorrhage for urethral injuries. B 2. Diagnostic investigations Urethrography and uretheroscopy: As per EAU 2023 guidelines: Obtain retrograde urethrography with voiding cystourethrography to evaluate pelvic fracture urethral injuries. A https://web.pathway.md/diseases/reckPp8j7I5cxGnEa 1/4 6/29/23, 3:48 AM Urethral injury Pathway Obtain retrograde urethroscopy and antegrade cystoscopy as an adjunct to imaging to evaluate pelvic fracture urethral injuries, if further information is required. B As per EAU 2022 guidelines: Obtain flexible cystourethroscopy and/or retrograde urethrography for the evaluation of male patients with urethral injuries. A Obtain cystourethroscopy and vaginoscopy for the evaluation of female patients with urethral injuries. A As per WSES 2019 guidelines, obtain retrograde urethrography or selective urethroscopy for the evaluation of traumatic urethral injuries. B Prefer urethroscopy over retrograde urethrography in patients with penile lesions. B As per AUA 2014 guidelines, obtain retrograde urethrography in patients with blood at the urethral meatus after pelvic trauma. B 3. Medical management Non-operative management: As per EAU 2022 guidelines: Perform suprapubic or urethral catheterization for the management of patients with partial blunt anterior urethral injuries, and for the initial management of partial posterior urethral injuries. A Perform transurethral or suprapubic catheterization for the initial management of hemodynamically unstable patients with pelvic fracture urethral injuries. A As per WSES 2019 guidelines, perform urinary drainage as soon as possible in patients with traumatic urethral injury. B Show 4 more As per AUA 2014 guidelines, perform prompt urinary drainage in patients with pelvic fracture- associated urethral injury or straddle injury to the anterior urethra. B 4. Therapeutic procedures Endoscopic urethral realignment: Perform early endoscopic realignment when feasible in male patients with pelvic fracture urethral injuries. B Do not repeat endoscopic treatments after failed realignment in male patients with pelvic fracture urethral injuries. D 5. Surgical interventions Indications for surgery: As per EAU 2022 guidelines, perform transurethral or suprapubic urinary diversion in patients with iatrogenic anterior urethral injuries. A Show 5 more https://web.pathway.md/diseases/reckPp8j7I5cxGnEa 2/4 6/29/23, 3:48 AM Urethral injury Pathway As per WSES 2019 guidelines, perform direct inspection of the urethra, whenever feasible, during emergency laparotomy in patients with suspected urethral injury. B Show 3 more As per AUA 2014 guidelines, consider placing suprapubic tubes in patients undergoing open reduction internal fixation for pelvic fracture. E Show 2 more 6. Specific circumstances Patients with penile trauma: As per EAU 2022 guidelines: Evaluate for urethral injury in patients with penile fracture. A Perform surgery with the closure of tunica albuginea for the treatment of patients with penile fractures. A As per AUA 2014 guidelines, suspect penile fracture in patients presenting with penile ecchymosis, swelling, pain cracking or snapping sound during intercourse or manipulation, and immediate detumescence. B Show 6 more 7. Preventative measures Prevention of iatrogenic injury: ensure appropriate training to reduce the risk of traumatic catheterization. A 8. Follow-up and surveillance Follow-up: As per WSES 2019 guidelines, obtain ureteroscopy or urethrography as the method of choice for the follow-up of urethral injuries. (GoR 2A. As per AUA 2014 guidelines, monitor patients for complications (such as stricture formation, erectile dysfunction, and incontinence) for at least one year after urethral injury. B Clinical findings Symptoms Past medical history Difficulty urinating Bladder injury Dysuria Pelvic fracture Hematuria Pelvic trauma Suprapubic pain Abdominal exam Urinary retention Suprapubic tenderness Past events https://web.pathway.md/diseases/reckPp8j7I5cxGnEa 3/4 6/29/23, 3:48 AM Urethral injury Pathway Penile trauma Gynecologic exam Saddle injury Vulvar swelling Genitourinary exam Blood at urethral meatus Perineal bruising Testicular swelling References 1. Federico Coccolini, Ernest E Moore, Yoram Kluger et al. Kidney and uro-trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 2;14 54. Open 2. N.D. Kitrey Chair), F. Campos-Juanatey, P. Hallscheidt et al. EAU Guidelines on Urological Trauma. EAU. 2022. Open 3. Morey AF, Brandes S, Dugi DD rd et al. Urotrauma: AUA guideline. J Urol. 2014 Aug;192 2 327 35. Open 4. N. Lumen Chair), F. Campos-Juanatey, K. Dimitropoulos et al. EAU Guidelines on Urethral Strictures. EAU. 2023. Open https://web.pathway.md/diseases/reckPp8j7I5cxGnEa 4/4