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

D. Brady Pregerson, MD


March 19, 2021

As a result of the relative infrequency of anterior urethral injury, the best method of treatment is not certain. Some sources recommend that simple urethral injuries can be treated with 7-10 days of splinting by Foley catheter (silicone is preferred) along with analgesia and antibiotic prophylaxis; however, a catheter should only be passed with extreme caution under the advisement of a urologist after the urethrogram has been performed and it has been deemed safe to proceed. Partial tears can be converted into complete disruptions with catheterization; therefore, most experts advocate the initial placement of a temporary transcutaneous suprapubic catheter.

Delayed surgical repair (often weeks later) may be required as a definitive treatment.[4] Severe injuries, complete transections, or injuries in which passing a urethral catheter is impossible likely require surgical repair.[5] In fact, penetrating anterior urethral injuries should generally be explored with examination of the area of injury and debridement of any devitalized tissue to minimize tissue loss. Primary repair via a direct anastomosis over a catheter is acceptable for defects up to 1.5 cm in the penile urethra, whereas longer defects should be reconstructed at a later point in time to allow for resolution of other injuries and for planning of any required tissue transfers.

A urinary diversion via placement of a suprapubic catheter may be performed. All cases should be discussed with a urologist while the patient is still in the ED. Long-term complications are more common in posterior injuries, and they may include impotence, strictures, and urinary incontinence. It is crucial that the physician discuss with the patient at presentation the possibility of erectile dysfunction due to the injury.

The patient in this case had a type V urethral tear as well as an incidental stricture. After discussion, the on-call urologist recommended treatment with a Foley catheter by the ED staff. Because the presence of a stricture raised concern that passing a Foley catheter was likely to be difficult, as well as possible confusion over whether any resistance was being caused by the tear or the stricture, this recommendation was declined, and the urologist was requested to come to the hospital.

Adequate drainage was established by the urologist with a Coude catheter, and the patient was discharged to home on a 7-day course of ciprofloxacin. On the eighth day, the catheter was removed, and the patient was soon able to urinate with only mild discomfort and microscopic hematuria. The stricture remained asymptomatic and was managed expectantly. These injuries, however, should be followed as many will progress or recur over time. Flow rates or, at minimum, American Urological Association symptom scores can be followed yearly to monitor urine flow.


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