Urethral injury is frequently due to motorcycle trauma, more frequent in males, where it can manifest with urethrorrhagia, penis and scrotal hematoma, penile or pubic branch fracture, and difficult urination [11, 12]. It can be defined by Goldman classification of urethral injury, which considers the type of trauma and the anatomical site involved, identified by imaging, in this way guiding the following therapeutic management .
Patients with suspected urethral injury should undergo, if possible, a retrograde urethrography , remembering that traumatic urethrorrhagia is not always due to a urethral injury .
The bulbar urethra, which is less mobile compared with its other tracts, can be compressed in high-energy trauma between the inferior pubic branch and external bodies  and, therefore, we thought that the reported vascular injury could be due to the energy and violence of the motorcycle crash.
Urethrorrhagia due to a traumatic pseudoaneurysm is an extremely rare event and it represents a potentially fatal event; when it involves one of the distal branches of the internal pudendal artery, it can manifest with penis hematoma and perineal swelling [5, 14, 15].
In literature, 10 cases of urethrorrhagia successfully treated with endovascular embolization are reported, due to urinary catheterization, endoscopic or surgical procedures, neoplasms, different kind of trauma (motorcycle, extreme sport, horse riding); half of them was due to bilateral supply of arterial lesion and main angiographic sign described are pseudoaneurysms, fistula, and arterial blushes.
Conservative management, initial preferred approach in these patients, consisted in the administration of hemostatic drug and antibiotics, suspension of eventual anticoagulant and/or antiplatelet therapies, external perineal or mechanical internal compression with urinary catheter; only after the failure of this first-line treatment, TAE could be considered and in the majority of cases, it revealed clinically effective, without significant short- and long-term complications .
In cases where urethral injury can be excluded by retrograde urethrography, an effective first-line strategy can be represented by urinary catheters, also of elevated caliber, as hemostatic therapy . Particular attention has to be paid to Foley urinary catheters when there is a concomitant anticoagulant and antiplatelet therapy, as these patients have a higher risk of developing vascular lesions .
Another possible cause of urethrorrhagia, although less frequent, is the sexual activity named “urethral sounding”, as described by Kwong where conservative management proved to be effective, discouraging the patient to keep on practicing it anymore .
Two singular and unique cases, both successfully treated by TAE employing autologous clots, are represented by a first patient with priapism due to surgical urethrotomy who manifested intermittent urethrorrhagia after every attempt to remove the urinary catheter  and a second patient with urethrorrhagia that was clinically evident only in case of penile erection. In the latter, it was necessary to perform a MRI of the penis, to precisely anatomically identify the tunica albuginea, urethra, and its corpus spongiosum, and allow a better definition and visualization of the injury to correctly plan the correct management .
Angiography proved that DSA allows in more than 50% of cases to better identify the target vessel and the precise localization of active bleeding and extravasation of contrast agent, rather than conventional fluoroscopy, due to a better contrast resolution and proved, in addition, that sometimes the diagnosis can be missed owing for the lacked selectivity of the angiographic study performed .
The internal pudendal artery is fundamental for erectile function and so in order to preserve the patency of its arterial terminal branches is fundamentally performing a TAE with the tip of microcatheter as closer as possible to the vascular injury; this principle is important to avoid non-target embolization and to reduce at the minimum the risk of subsequent iatrogenic erectile dysfunction .
Since the complexity of perineal arterial district, the use of embolic agents, temporary or permanent ones, requires adequate experience and training by the operators [1, 19, 20].
Sometimes, endovascular embolization of the bulbo-urethral artery can be indicated in recurrent hematuria as an alternative to manual compression and to electro-fulguration .
The reported complications in the literature of endovascular embolization of internal pudendal artery for urethrorrhagia are rare: erectile dysfunction, urethral ischemia with associated stenosis ; after the reported experience of ischemia and necrosis of glans, Kim suggests to carefully control eventual change in color of glans itself .
Since there are too few cases reported in the literature, it is not possible to define with certainty if the simultaneous bilateral endovascular embolization of distal branches of both internal pudendal arteries can effectively influence erectile function .
Some authors state that it is not clear if endovascular embolization is really associated with erectile dysfunction, as the latter can be the clinical expression of a systemic vascular disease too, such as endothelial disfunction .
In our patient, we decided to perform TAE with detachable micro-coils because we thought that particles (either temporary or permanent) would not have been enough considering the entity of vascular injury, while a liquid one (such as n-butyl-cyanoacrylate) would not have guaranteed an adequate control during its injection; we excluded from our choices autologous clots because we think they are not effective, according to our experience, and outdated compared with other embolic agents available.
Owing to the considerable complexity of vascular and nervous structures in the perineal area and at the penis root, it is universally recognized that TAE represents a more effective solution to refractory urethrorrhagia rather than open surgery [6, 7, 11, 22]. However, it is reported a case of massive urethrorrhagia due to an arterio-venous malformation successfully treated with surgical ligation with no complicancies .