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Difficulty: MediumUrologic Surgery

A 28-year-old male is brought to the emergency department after a severe crush injury to his pelvis at a construction site. He is hemodynamically stable. Physical examination reveals a pelvic binder in place, blood at the urethral meatus, and a high-riding prostate on digital rectal examination. A FAST exam is negative. He has a palpable, distended bladder and reports a strong urge to urinate. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for the urologic management of this patient.

  1. 1Perform retrograde urethrography
  2. 2Place a suprapubic catheter
  3. 3Perform computed tomography cystography
  4. 4Perform delayed surgical urethroplasty

Answer

The correct sequence is to first perform retrograde urethrography, followed by placement of a suprapubic catheter, then computed tomography cystography, and finally, delayed surgical urethroplasty.
The management of posterior urethral injuries follows a strict protocol to prevent exacerbation of the injury and associated long-term complications. The presentation of blood at the meatus, a high-riding prostate, and a pelvic fracture suggests a posterior urethral disruption. The immediate first step is retrograde urethrography (RUG) to visualize the urethra and confirm the diagnosis. Once confirmed, urethral catheterization is strictly contraindicated, making the placement of a suprapubic catheter the next necessary step to drain the distended bladder safely. After securing bladder drainage, the bladder itself must be evaluated for rupture using CT cystography (or a conventional cystogram), as bladder injuries frequently co-occur with pelvic ring fractures. Finally, definitive surgical repair (open urethroplasty) is delayed for 3 to 6 months. This delay allows the pelvic hematoma to organize and inflammation to subside, which significantly decreases the risk of postoperative erectile dysfunction and urinary incontinence.

Step-by-Step Solution

1
Identify the suspected injury from clinical signs
The triad of blood at the urethral meatus, a high-riding prostate, and a pelvic fracture strongly indicates a posterior urethral injury.
Recognizing these classic signs is crucial to strictly avoid blind urethral catheterization, which can convert a partial tear into a complete transection.
2
Determine the first diagnostic intervention
Retrograde urethrography (RUG) must be performed immediately.
RUG is the gold standard for diagnosing and localizing urethral injuries prior to any further manipulation.
3
Determine the appropriate method of urinary diversion
Placement of a suprapubic catheter is required.
Once a significant urethral disruption is confirmed and a Foley catheter cannot be safely passed, a suprapubic tube provides the necessary bladder drainage for the patient.
4
Evaluate for concomitant injuries
Computed tomography (CT) cystography is performed through the newly placed suprapubic tube.
Pelvic fractures have a high association with bladder rupture. Securing a suprapubic tube allows for the retrograde instillation of contrast to safely evaluate the bladder.
5
Plan definitive management
Delayed surgical urethroplasty is scheduled.
Definitive repair is deferred for 3 to 6 months to allow the pelvic hematoma to organize, minimizing the severe risks of impotence and incontinence.

Key Concept

Sequential management of suspected posterior urethral injury in the setting of acute pelvic trauma.
Estimated Time:1m 30s
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Topics

Urologic Surgery

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