Clinical presentation (Straddle injury (bicycle bar, fall astride object) — anterior urethral injury most common in children; blood at meatus, perineal hematoma/ecchymosis, inability to void, suprapubic tenderness/fullness; do NOT catheterize blindly (AAP urology, EAU pediatric trauma, ATLS))
First-line therapy
Do NOT catheterize blindly + retrograde urethrogram + urology • procedure
Duration: Immediate · Suspect urethral injury if blood at meatus, perineal hematoma, or inability to void after pelvic/straddle trauma; attempt spontaneous void if able; retrograde urethrogram (RUG) before any urethral instrumentation; suprapubic catheter if retention and RUG confirms injury (AAP, EAU pediatric, ATLS)
• **Do NOT catheterize blindly:** blood at meatus, perineal ecchymosis, high-riding prostate (adolescent), or inability to void — blind catheterization may convert partial to complete disruption (AAP urology, EAU).
• **Retrograde urethrogram (RUG):** gold standard before urethral instrumentation — contrast via meatus under fluoroscopy; defines site and severity of injury (EAU, AAP).
• **Suprapubic catheter:** if urinary retention and RUG confirms injury — place suprapubic drainage by experienced clinician; avoid urethral catheter until urology directs (EAU, AAP).
• **Attempt void:** if child can void spontaneously without difficulty and no blood at meatus — observe; document urine output; still consult urology if mechanism high-risk (EAU).
• **Analgesia and NPO:** prepare for possible operative repair; IV access; tetanus if contaminated perineal wound (ATLS, AAP).
Urology consult + operative repair if complete disruption • procedure
Duration: ED / inpatient · Pediatric urology for all suspected urethral injuries; operative repair for complete disruption, large perineal hematoma with urinary extravasation, or failed conservative management (EAU, AAP urology)
• **Urology consult (urgent):** all children with blood at meatus, inability to void, or perineal hematoma after straddle/pelvic trauma — do not delay for non-essential studies (EAU, AAP).
• **Operative repair indications:** complete urethral disruption, expanding perineal hematoma, urinary extravasation on RUG/CT, or associated pelvic fracture with posterior urethral injury (EAU, pediatric urology).
• **Pelvic fracture association:** posterior urethral injury more common with pelvic ring fractures — maintain skeletal stabilization; coordinate orthopedics and urology (ATLS, EAU).
• **Antibiotics:** NOT routine for isolated closed urethral injury without open wound — give if contaminated perineal laceration or open injury; see open urethral variant (AAP).
• **Follow-up:** stricture is late complication — urology follow-up with uroflow/cystoscopy as indicated (EAU, AAP).
Clinical notes
• Classic triad: blood at meatus, perineal ecchymosis, inability to void — do NOT pass Foley catheter blindly (AAP urology, EAU).
• Retrograde urethrogram before any urethral instrumentation — defines injury and guides management (EAU, AAP).
• Straddle injury in children: anterior urethral bulbar injury most common — often partial, may be managed conservatively with urology follow-up (EAU pediatric).
