Posterior urethral hemangioma is a rare and frequently misdiagnosed vascular lesion of the membranous urethra. It typically presents as painless, intermittent gross hematuria, often triggered by erection or ejaculation. Due to its rarity and nonspecific symptoms, diagnosis is often delayed or overlooked, even with cystoscopic evaluation. Advanced imaging techniques may improve detection in cases where conventional diagnostics fail.

We report the case of a 63-year-old male who presented with intermittent painless gross hematuria for two weeks, particularly following erection. Initial assessments included urinalysis, ultrasound of the kidneys and bladder, and cystoscopy, which did not reveal any abnormalities. Given the clinical suspicion of a vascular lesion, computed tomography angiography (CTA) of the pelvis and penis was performed, followed by selective angiography of the internal pudendal arteries.

CTA demonstrated contrast pooling at the left root of the penis, suggestive of vascular malformation. Subsequent selective angiography confirmed a hemangioma originating from the left internal pudendal artery. After discussing treatment options, including embolization and direct lesion fulguration, the patient opted for conservative management with oral estrogen therapy to reduce penile rigidity and vascular congestion. Symptom improvement was observed, and the patient continues to be monitored in the outpatient setting without recurrence of hematuria.

Posterior urethral hemangioma should be considered in patients presenting with hematuria associated with erection or ejaculation. While cystoscopy remains the primary diagnostic tool, adjunctive imaging modalities such as CTA and angiography are valuable in detecting lesions when cystoscopic findings are inconclusive. Conservative treatment may be an effective option in selected cases, minimizing the risk of complications associated with invasive interventions.