A 24-year-old man is brought to the emergency department following a high-speed motorcycle collision. He complains of severe pelvic pain and an inability to void. Vital signs are within normal limits, and he is hemodynamically stable. Physical examination reveals blood at the urethral meatus, a scrotal hematoma, and a 'high-riding' prostate on digital rectal examination. Pelvic radiography confirms a straddle fracture of the pelvis. Arrange the following steps in the most appropriate chronological sequence for the urologic management of this patient.
- 1Perform a retrograde urethrogram
- 2Place a suprapubic cystostomy tube
- 3Observe for 3 to 6 months for scar maturation
- 4Perform a delayed posterior urethroplasty
Answer
The correct sequence is to first perform a retrograde urethrogram to diagnose the injury, followed by placing a suprapubic cystostomy tube for urinary diversion, then observing the patient for 3 to 6 months to allow the scar to mature, and finally performing a delayed posterior urethroplasty for definitive repair.
The standard of care for a suspected posterior urethral injury in a hemodynamically stable patient begins with a retrograde urethrogram to delineate the anatomy. Once the injury is confirmed, a suprapubic catheter is placed to divert urine safely. The patient is then managed conservatively for several months to allow the pelvic hematoma to resolve and the resulting urethral stricture to mature. Definitive reconstruction (delayed urethroplasty) is performed once the local tissues are healthy and stable.
Step-by-Step Solution
Key Concept
Management of posterior urethral injury associated with pelvic fracture
Estimated Time:1m 30s