A 28-year-old man is brought to the trauma center following a high-speed motorcycle collision. His airway is intact, and his hemodynamics are stabilized with intravenous fluids. A pelvic binder is applied for a complex pelvic ring fracture. Physical examination reveals a scrotal hematoma and fresh blood at the urethral meatus. Digital rectal examination demonstrates a high-riding, nonpalpable prostate. He reports lower abdominal discomfort and a strong urge to void, but has not urinated since the accident. Arrange the following urologic interventions in the most appropriate chronological order for the evaluation and definitive management of this patient's genitourinary injury.
- 1Perform a retrograde urethrogram
- 2Place a suprapubic cystostomy tube
- 3Perform combined antegrade and retrograde urethrography
- 4Perform delayed open urethroplasty
Answer
The correct chronologic sequence is: retrograde urethrogram, followed by suprapubic cystostomy tube placement, then combined antegrade and retrograde urethrography after several months, and finally a delayed open urethroplasty.
The standard sequence for managing a posterior urethral injury begins with immediate diagnosis using a retrograde urethrogram to avoid exacerbating the injury. Once a complete disruption is confirmed, acute management consists of suprapubic bladder drainage to allow pelvic bleeding and inflammation to resolve over several months. Prior to definitive surgery, the resulting stricture is delineated using combined antegrade (through the suprapubic tract) and retrograde imaging. Finally, definitive repair is achieved via delayed open urethroplasty.
Step-by-Step Solution
Key Concept
Evaluation and sequential management of posterior urethral injuries associated with pelvic fractures.