A posterior urethral injury affects the urethra near the prostate and urinary sphincter, most commonly after major pelvic trauma. It may be partial or complete. Blood at the urethral opening, inability to pass urine and a pelvic fracture are important warning signs. Initial management focuses on the patient’s overall trauma and safe urinary drainage; repeated forceful catheter attempts should be avoided. Partial injuries may heal with drainage, while complete pelvic fracture urethral injuries often form an obliterative scar and later require reconstructive urethroplasty.

What is the posterior urethra?

The posterior urethra includes the prostatic and membranous regions, close to the bladder neck and urinary sphincter. Injury here is different from an anterior straddle injury because it is usually associated with major pelvic forces and can coexist with bladder, rectal, vascular or neurological injury.

How does posterior urethral injury happen?

• Pelvic fracture with disruption around the bulbomembranous urethra.
• Penetrating pelvic injury.
• Rare severe iatrogenic injury around the prostate/bladder neck.
• Associated bladder-neck or prostatic urethral laceration in major trauma.

Signs that suggest urethral injury after trauma

• Blood at the urethral opening.
• Inability to pass urine despite a full bladder.
• Pelvic fracture with perineal or scrotal bruising.
• A catheter that will not pass easily after major trauma.
• Urine extravasation seen on imaging.

How is the injury diagnosed?

In a stable patient, retrograde urethrography (RGU/RUG) is a standard way to assess male urethral injury. Flexible cystoscopy can also be used. In established pelvic fracture urethral injury, combined retrograde and voiding imaging, and sometimes combined antegrade and retrograde endoscopy, help define the gap, bladder-neck competence, false passages, stones and fistulae before reconstruction.

Partial injury versus complete disruption

When is urethroplasty performed?

For established complete pelvic fracture urethral injury, deferred urethroplasty after the patient has recovered remains the standard reconstructive strategy. By then the pelvic haematoma has resolved, the prostate has descended and the scar has stabilised. Selected stable patients may undergo earlier urethroplasty in specialised settings, but immediate urethroplasty within the first 48 hours is generally avoided in male PFUI because of bleeding and complication risk.

What operation is usually used?

A perineal anastomotic urethroplasty is the usual definitive repair: scar is removed and healthy urethral ends are reconnected without tension. More extensive manoeuvres or an abdominoperineal approach are reserved for difficult gaps, bladder-neck injury, fistula or multiple previous failed repairs.

What about erections and continence?

Erectile dysfunction after pelvic fracture often results from the original vascular and nerve injury, not simply from later urethroplasty. Continence usually depends on the bladder neck and sphincter being intact. Both functions should be assessed and discussed before reconstruction.

What makes posterior urethral reconstruction different

Posterior urethral injury usually occurs at the bulbomembranous junction during major pelvic trauma. The apparent “gap” seen on imaging is not simply an empty distance that must be filled. Scar, displacement of the prostate, pelvic fracture callus and loss of urethral length all influence how easily the two healthy mucosal ends can be brought together.

Definitive delayed repair is commonly performed through the perineum after the patient has recovered from associated injuries. The surgeon progressively mobilises the bulbar urethra and uses only as many additional manoeuvres as are required to achieve a tension-free mucosa-to-mucosa anastomosis. These may include separation of the corporal bodies or an inferior pubectomy in difficult cases. The principle is to obtain alignment without excessive tension rather than to perform every manoeuvre routinely.

Continence and erections deserve separate pre-operative documentation. Continence usually depends mainly on an intact bladder neck/proximal sphincter in these injuries. Erectile dysfunction may result from the original pelvic trauma itself, vascular injury or nerve injury, so a postoperative erection problem should not automatically be attributed to the urethroplasty.

Tests before delayed posterior urethroplasty

RGU alone may show only the distal end of a complete posterior defect. MCU/VCUG through a suprapubic catheter shows the bladder neck and proximal urethra during filling or voiding, allowing the surgeon to estimate distraction length and alignment. The two studies are interpreted together.

Antegrade cystoscopy through a mature suprapubic tract can add information about the bladder neck, proximal urethra, stones and false passages. Pelvic CT is reviewed when bony deformity or previous fixation may affect the reconstructive route. Urine culture is checked before surgery because long-term suprapubic drainage can be associated with bacteriuria.

Baseline continence and erectile function should be documented. These are not extra quality-of-life questions; they help distinguish consequences of the original pelvic trauma from outcomes of the later urethral reconstruction.

Why delayed posterior urethroplasty is often planned rather than rushed

In major pelvic trauma, survival, bleeding control, orthopaedic injuries and bladder drainage take priority. A suprapubic catheter can safely divert urine while the pelvis heals and the true urethral distraction defect matures. This interval allows haematoma and inflammation to settle before definitive reconstruction.

The later operation is not simply “opening a scar.” The surgeon must find healthy urethra on both sides of the defect, remove intervening fibrosis and create a tension-free mucosa-to-mucosa anastomosis. Additional manoeuvres may be needed to gain length when the gap is large.

Erectile dysfunction after pelvic fracture may result from the original vascular or nerve injury and can exist before urethroplasty. Documenting erectile function before definitive repair is therefore useful for counselling and later treatment.

What to bring for reconstructive consultation

• Original trauma CT scans and discharge summary.
• RGU and MCU/VCUG images.
• Details of suprapubic catheter placement and changes.
• Previous realignment, urethrotomy or reconstruction records.
• Current urinary continence and erectile-function history.
• Any history of rectal injury, fistula or pelvic infection.

FAQs

Related reading

• Pelvic Fracture Urethral Injury
• RGU Test for Urethral Stricture
• MCU Test for Urethral Stricture
• Anastomotic Urethroplasty / End-to-End Urethroplasty
• Redo Urethroplasty After Failed Surgery
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Urological Trauma, 2026 https://uroweb.org/guidelines/urological-trauma
• European Association of Urology. EAU Guidelines on Urethral Strictures: Diagnostic Evaluation, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/diagnostic-evaluation
• European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males
• European Association of Urology. EAU Guidelines on Urethral Strictures: Follow-up, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/followup
• European Association of Urology. EAU Guidelines on Urethral Strictures, 2026 https://uroweb.org/guidelines/urethral-strictures
• American Urological Association. Urethral Stricture Guideline (2023 amendment) https://www.auanet.org/guidelines-and-quality/guidelines/urethral-stricture-guideline