In a patient with a pelvic fracture and blood at the urethral meatus, urethral injury must be strongly suspected. Other signs may include perineal hematoma, high-riding prostate, or inability to void. The key principle is do not insert a Foley catheter until urethral integrity is confirmed, as blind catheterization may worsen a partial tear into a complete disruption. The appropriate next diagnostic step is retrograde urethrography (RUG), which evaluates the urethra for extravasation of contrast and identifies the site and extent of injury.

Voiding cystography evaluates bladder injury and is performed after urethral integrity is confirmed or via suprapubic access. Transrectal ultrasound and penile sonography are not appropriate in acute trauma assessment of suspected urethral disruption. Continuous bladder irrigation is contraindicated until urethral injury is excluded.

MCCQE objectives emphasize recognition of urethral injury in pelvic trauma and adherence to trauma principles: stabilize first, suspect urethral injury when blood is present at the meatus, and perform retrograde urethrography prior to catheterization.