A 10-year-old boy is brought to the emergency department due to penile pain. Two hours earlier, he was practicing martial arts with his older brother when he was accidentally kicked directly in the groin. The patient had severe pain at the time of impact and continues to have moderate pain but no nausea or vomiting. Temperature is 36.7 C (98.1 F), blood pressure is 118/62 mm Hg, and pulse is 88/min. The pelvis is stable and nontender to downward pressure. The medial thighs and perineum appear normal. The dorsal aspect of the penis has moderate bruising and swelling. There is a small contusion on the left hemiscrotum. Bilateral testes are nontender to palpation, have normal contours, and retract with stroking of the medial thighs. The patient gives a urine sample, which is pinkish red. Which of the following is the best next step in management of this patient?

Question

A 10-year-old boy is brought to the emergency department due to penile pain.  Two hours earlier, he was practicing martial arts with his older brother when he was accidentally kicked directly in the groin.  The patient had severe pain at the time of impact and continues to have moderate pain but no nausea or vomiting.  Temperature is 36.7 C (98.1 F), blood pressure is 118/62 mm Hg, and pulse is 88/min.  The pelvis is stable and nontender to downward pressure.  The medial thighs and perineum appear normal.  The dorsal aspect of the penis has moderate bruising and swelling.  There is a small contusion on the left hemiscrotum.  Bilateral testes are nontender to palpation, have normal contours, and retract with stroking of the medial thighs.  The patient gives a urine sample, which is pinkish red.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d1b7_726d_bc81_f3fcbb416ca8_MD0003_00 Male patients with external genital trauma should undergo a systematic examination of the skin and soft tissue of all genital structures (eg, penis, scrotum, testes), with a high level of suspicion for underlying injuries (eg, urethral injury, testicular rupture). This patient's examination shows evidence of trauma isolated primarily to the penis, with dorsal bruising and swelling likely caused by contusion of the dorsal superficial veins. Because concomitant anterior urethral injury can occur with penile trauma, any of the following should prompt evaluation for urethral injury: Blood at the urethral meatus Hematuria (eg, pinkish-red urine) Difficulty voiding (due to disruption of urethral continuity) Retrograde urethrography involves x-ray of the urethral tract following injection of radiopaque contrast through the urethral meatus. Extravasation of contrast from the urethra is diagnostic of urethral injury. Urethrography should precede any attempts at urethral (eg, Foley) catheterization because catheterization can worsen the injury, potentially converting a partial urethral tear into a complete urethral laceration (Choice C). (Choice A) In patients with blunt abdominal trauma, CT scan of the abdomen and pelvis may be necessary to evaluate for suspected intraabdominal injury or pelvic fracture. However, these injuries are unlikely in this patient given the mechanism of injury (direct kick to the groin rather than the abdomen) and lack of signs of pelvic fracture (eg, pelvic instability/pain on palpation, perineal bruising). (Choice B) Prostate examination can detect a high-riding prostate, which may occur with posterior urethral injury. However, posterior urethral injury typically occurs in the setting of pelvic fracture rather than direct penile trauma. In addition, prostate palpation via digital rectal examination is rarely performed in a preadolescent. (Choice D) In patients with penile contusion, oral analgesics and outpatient follow-up are appropriate only after underlying urethral injury has been ruled out (eg, urethrography). This patient has signs of urethral injury requiring further evaluation. (Choice F) Serious testicular injuries (eg, testicular rupture) are typically accompanied by significant testicular pain/tenderness and/or testicular swelling, the most common indications for testicular ultrasound. Although this patient has a small scrotal contusion, the absence of testicular tenderness along with normal contours and presence of bilateral cremasteric reflex (retraction with stroking of medial thighs) make testicular injury less likely. Educational objective: Hematuria in the setting of direct penile trauma is concerning for urethral injury and should prompt retrograde urethrography. References: Diagnosis and management of pediatric urethral injuries. (http://www.ncbi.nlm.nih.gov/pubmed/22433843) Diagnosis and classification of urethral injuries. (http://www.ncbi.nlm.nih.gov/pubmed/16488282)

A 10-Year-Old Boy Is Brought to the Emergency Department Due