An otherwise healthy 27-year-old male arrives at the emergency room seeking urgent evaluat… — USMLE Step 2 CK

An otherwise healthy $27$ -year-old male arrives at the emergency room seeking urgent evaluation for sudden, intense genital pain. Approximately $30$ minutes prior to arrival, he experienced a distinct "cracking" sound during vigorous intercourse, which was immediately followed by rapid detumescence and swelling. He has been in exquisite pain and has intentionally avoided voiding since the event. Triage vital signs reveal a temperature of $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure of $128/82\text{ mmHg}$ , heart rate of $94/\text{min}$ , and respiratory rate of $16/\text{min}$ . Genitourinary examination demonstrates a markedly edematous and ecchymotic penis that is visibly deviated to the left. A single drop of fresh blood is noted at the external urethral meatus. Scrotal palpation reveals normal testes bilaterally without masses or tenderness. Preliminary laboratory analysis shows a hemoglobin level of $14.2\text{ g/dL}$ and a leukocyte count of $8,500/\text{mm}^3$ . Which of the following is the most appropriate next step in the management of this patient?

Retrograde urethrographyAnswer
B
Immediate surgical exploration of the corpora cavernosa
C
Insertion of a 16-French transurethral Foley catheter
D
Color Doppler ultrasonography of the penis
E
Administration of intravenous piperacillin-tazobactam and cold compresses

Answer

Retrograde urethrography is the necessary next step before surgery due to the presence of blood at the urethral meatus.

The correct answer highlights that a retrograde urethrography (RUG) is essential. The patient presents with classic signs of a penile fracture (rupture of the tunica albuginea). While prompt surgical exploration is the standard treatment for isolated penile fractures, the presence of blood at the urethral meatus is a cardinal sign of an associated urethral injury. In this scenario, evaluating the urethra with a RUG is mandatory prior to any blind catheterization or standard surgical repair. If the RUG reveals a urethral tear, the surgeon can definitively repair both the tunica albuginea and the urethra during the same operative intervention.

Step-by-Step Solution

Diagnose the primary condition based on the classic presentation.

The history of a "cracking" sound, rapid detumescence, and an ecchymotic, deviated penis indicates a penile fracture (rupture of the tunica albuginea).

Recognizing the primary traumatic injury establishes the need for an emergent urologic response.

Identify findings that suggest complicated trauma.

The presence of a drop of fresh blood at the external urethral meatus points to a concomitant urethral injury.

Up to 20% of penile fractures are associated with urethral trauma, which dictates a change in the immediate diagnostic pathway.

Determine the most appropriate management sequence.

A retrograde urethrography (RUG) must be performed to evaluate the integrity of the urethra before proceeding with catheterization or definitive surgical repair.

Performing a RUG prevents iatrogenic damage from blind catheterization and allows the surgeon to plan for concurrent corporal and urethral repair.

Key Concept

Evaluation of suspected urethral injury in penile fracture

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