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Difficulty: HardUrologic Surgery

Match each patient's genitourinary trauma presentation to the most appropriate definitive management strategy or next required intervention.

  • A 42-year-old man with a pelvic ring fracture. Retrograde cystography demonstrates flame-shaped contrast extravasation confined to the perivesical soft tissues in the space of Retzius.Urethral catheter drainage alone
  • A 27-year-old man presents after a direct blow to a distended lower abdomen. Retrograde cystography reveals contrast material freely outlining the loops of the small intestine.Exploratory laparotomy and primary closure
  • A 35-year-old man presents with a rapidly expanding perineal hematoma and blood at the urethral meatus after forcefully straddling a metal bar.Retrograde urethrography prior to catheterization
  • A 24-year-old man presents with flank ecchymosis and gross hematuria. CT scan shows a 2-cm deep parenchymal renal laceration without urinary extravasation; vital signs are stable.Conservative management with strict bed rest

Answer

Extraperitoneal bladder ruptures require only catheter drainage; intraperitoneal ruptures require surgical closure; anterior urethral injuries require immediate retrograde urethrography; and stable intermediate-grade renal lacerations require conservative observation.
Appropriate urologic trauma management requires distinguishing between extraperitoneal bladder ruptures (which heal well with simple catheter decompression) and intraperitoneal ruptures (which require laparotomy to prevent peritonitis). Urethral injuries must be visualized radiographically before any instrumentation to avoid permanent strictures or complete transection. Solid organ renal trauma is managed conservatively as long as the patient remains hemodynamically stable without active bleeding.

Step-by-Step Solution

1
Analyze the cystogram findings to classify the bladder rupture.
Flame-shaped extravasation indicates extraperitoneal rupture (managed non-operatively), whereas contrast outlining bowel defines intraperitoneal rupture (managed operatively).
Anatomic containment of urine dictates whether spontaneous healing is possible versus the risk of chemical peritonitis.
2
Evaluate the clinical signs of urethral injury.
Blood at the meatus and a perineal hematoma suggest a structural urethral tear.
Identifying potential urethral disruption is critical because blind catheterization can exacerbate the injury, necessitating imaging first.
3
Assess the severity and patient stability in renal trauma.
A 2-cm parenchymal laceration in a stable patient without contrast leak is a Grade III injury.
High-grade renal injuries only require surgery if there is hemodynamic instability, an expanding pulsatile hematoma, or severe avulsion; otherwise, conservative management is standard.

Key Concept

Radiographic diagnosis and staged management of traumatic genitourinary injuries
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Topics

Urologic Surgery

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