Penis Injury and Hematuria in a Man Who Fell on a Log

D. Brady Pregerson, MD


March 19, 2021

Symptoms of urethral injury may include pain, hematuria or meatal bleeding, dysuria, and urinary retention. Signs may include blood at the meatus, a high-riding prostate (seen on radiograph), or evidence of concomitant trauma (such as contusions, lacerations, or pelvic fractures). Approximately half of patients, however, do not have blood present at the urethral meatus.

In the setting of a multisystem blunt trauma in the ED, the diagnosis of urethral injury may often not be initially suspected or confirmed, with the initial consideration only occurring with resistance being encountered at the time of placement of the urethral catheter (ie, Foley catheter). Other potential physical examination findings include the presence of a perineal hematoma, sleeve-like ecchymosis around the penis, or soft-tissue swelling resulting from the extravasation of urine and/or blood. A "butterfly" hematoma is considered pathognomonic for a urethral injury; therefore, a perineal examination is important. In the setting of multisystem blunt trauma, other potential or confirmed life-threatening injuries demand attention before the evaluation of urethral injuries. After the patient has been adequately stabilized, however, an assessment for possible urethral injury should be carried out.

The initial diagnostic study of choice for suspected urethral injury is the RUG. In this study, through a catheter placed just inside the meatus, 20-30 mL of water-soluble contrast medium is gently injected under fluoroscopy or with multiple plain film views. Depending on the patient, the contrast material may or may not overcome reflex constriction of the urinary sphincter mechanism, which can mimic a stricture but is in fact the normal urethra traveling through the sphincter. In addition to the anterior-posterior views of the urethrogram, oblique views are important as well; extravasation of the contrast material, if directly posterior or anterior, will be missed without the oblique views. Urethral injury will be noted as the presence of contrast medium outside the normal columnar space of the urethra. A partial tear is diagnosed when extravasation is seen and the contrast material still reaches the bladder; a complete tear is diagnosed when extravasation is present and no contrast material is present in the bladder or proximal to the urethral disruption. The relative frequency of partial tears vs complete tears is highly variable in the literature.

A classification of RUG findings that is sometimes used to define urethral injury, based on the anatomic findings of injury for urethral injuries (both anterior and posterior), is the Goldman classification.[3] The classification defines five major types of urethral injuries:

  • Type I urethral injury: The urethra remains intact, but it is severely stretched, resulting in rupture of the puboprostatic ligament and thus allowing the prostate to move superiorly. No extravasation of contrast material is seen with radiography, and continuity is maintained with the bladder.

  • Type II urethral injury: The trauma results in a posterior urethral injury with tearing of the urethra superior to the urogenital diaphragm. Contrast-agent extravasation is seen within the extraperitoneal pelvis, but contrast material is not present within the perineum. The urogenital diaphragm is intact, preventing the spread of the contrast material inferiorly.

  • Type III urethral injury: Disruption above the urogenital diaphragm is noted, with the injury extending through the urogenital diaphragm to include the proximal bulbous urethra. In this injury, extravasation of the contrast material can be found within the extraperitoneal pelvis and within the perineum.

  • Type IV urethral injury: The tear involves the bladder neck and extends into the proximal urethra. Contrast-agent extravasation is seen in the extraperitoneal pelvis around the proximal urethra. Such injuries can damage the internal urethral sphincter, resulting in incontinence; therefore, proper diagnosis of the tear is essential.

  • Type V urethral injury: All cases of this type of injury are isolated to the anterior urethra and occur distal to the urogenital diaphragm. They are usually associated with perineal crush or straddle injuries. A partial tear of the bulbous urethra may be present. Contrast-agent extravasation occurs inferior to the urogenital diaphragm. If the Buck fascia is intact, the extravasation is limited to the penile shaft; if the Buck fascia is disrupted, the contrast material is contained within the limits of the Colles fascia and may be found in the lower abdomen, thighs, and scrotum.

Under certain circumstances, all of the clinical signs of urethral disruption may be present, but contrast extravasation may be completely absent. In such a case, a diagnosis of urethral contusion is often made. If the urethrogram findings are normal, further evaluation with a cystogram may be indicated.


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