Urethral injuries are identified by retrograde urethrography. However, some surgical teams may not have the contrast or X-ray capability to perform retrograde urethrography, such as far-forward austere resuscitative surgical teams or aircraft carrier surgical teams. If there is a concern for a urethral injury based on the injury mechanism, an attempt may be made to place a urinary catheter safely. The most experienced provider should perform this. A suprapubic catheter should be placed if any resistance or difficulty is encountered. Alternatively, a suprapubic catheter should be placed if there is blood at the meatus or concern for urethral injury based on mechanism. Complete transections of the urethra warrant suprapubic urinary drainage (See Algorithm for Urologic Trauma.)27

Blunt anterior urethral injuries should be diverted with a suprapubic cystostomy. This injury can be stented with a urethral catheter if an experienced surgeon is present. Posterior urethral injuries can be managed with suprapubic cystostomy alone.13 For complete urethral transections, suprapubic cystotomy is recommended (Figure 11).27 Penetrating anterior urethral injuries can be primarily repaired with a fine absorbable suture over a urethral catheter when the degree of soft tissue injury/contamination is limited. However, when complex blast injury results in anterior urethral injury associated with significant soft tissue loss of the perineum or genitalia, urinary diversion alone (transurethral or suprapubic) is sufficient to facilitate urinary drainage until the patient can be evaluated by a urologist who can assist with the wound care and complex urethrogenital reconstruction frequently needed in these cases. This is most appropriately performed at a Role 4 facility following multidisciplinary planning.