A 45-year-old man is brought to the emergency department following a motor vehicle collision. He has pain in his lower abdomen and right groin. The patient is unable to move his right lower extremity due to pain. Temperature is 37 C (98.6 F), blood pressure is 130/82 mm Hg, pulse is 100/min, and respirations are 16/min. There is fullness in the suprapubic region. The right lower extremity is adducted, flexed, and internally rotated. Bruising is present around the scrotum and perineum, and blood is seen at the urethral meatus. The testes are nontender on palpation. Digital rectal examination reveals a high-riding prostate. Which of the following is the best next step in management of this patient?

Question

A 45-year-old man is brought to the emergency department following a motor vehicle collision.  He has pain in his lower abdomen and right groin.  The patient is unable to move his right lower extremity due to pain.  Temperature is 37 C (98.6 F), blood pressure is 130/82 mm Hg, pulse is 100/min, and respirations are 16/min.  There is fullness in the suprapubic region.  The right lower extremity is adducted, flexed, and internally rotated.  Bruising is present around the scrotum and perineum, and blood is seen at the urethral meatus.  The testes are nontender on palpation.  Digital rectal examination reveals a high-riding prostate.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d95d_e96a_bc81_a7a12b88c536_MD0003_00 This patient has evidence of a pelvic fracture (eg, adducted and internally rotated right lower extremity, perineal bruising), accompanied by blood at the urethral meatus and a high-riding prostate on digital rectal examination. This presentation is most concerning for posterior urethral injury (PUI) and should prompt retrograde urethrography. Because of the length and positioning of the male urethra, men with pelvic fractures are at significant risk for PUI. Abrupt upward shifting of the bladder and prostate can lead to urethral tearing, most commonly at the bulbomembranous junction (transition point between the anterior and posterior urethra). Findings consistent with PUI include blood at the urethral meatus, inability to void (due to urethral discontinuity), perineal bruising, and a high-riding prostate on digital rectal examination. In patients with suspected urethral injury, retrograde urethrography should be performed. This diagnostic test 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 it can worsen the injury, potentially converting a partial urethral tear into a complete urethral laceration (Choice A). (Choice B) In all cases of urethral injury, urethrography or urethroscopy is recommended prior to surgery to both confirm the diagnosis and aid operative planning. After imaging, anterior urethral injuries (eg, penile fracture, straddle injury) are typically repaired urgently (eg, within 24 hours), whereas most PUIs are treated with temporary urinary diversion via suprapubic catheter, followed by delayed repair. (Choice C) Retrograde cystography images (eg, via CT or fluoroscopy) the bladder after it has been passively filled with radiopaque contrast via Foley catheter. Bladder rupture, as in PUI, is commonly associated with pelvic fracture and could also be present in this patient. However, urethral injury should be ruled out prior to any attempts at urethral catheterization for cystography in this patient with signs of likely urethral injury. (Choice E) Ultrasound is appropriate for evaluating for testicular pathology (eg, torsion, rupture). Although this patient has scrotal ecchymosis, which may be seen in testicular injury, the lack of testicular tenderness suggests that the ecchymosis is more likely due to a nontesticular (eg, urethral) injury. Educational objective: Pelvic fractures in men may be complicated by posterior urethral injury. Patients with suspected urethral injury (eg, blood at the urethral meatus, high-riding prostate) should undergo retrograde urethrography. References: Treatment of posterior urethral distractions defects following pelvic fracture. (http://www.ncbi.nlm.nih.gov/pubmed/29988844) Diagnosis and classification of urethral injuries. (http://www.ncbi.nlm.nih.gov/pubmed/16488282)

A 45-Year-Old Man Is Brought to the Emergency Department Following