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Difficulty: MediumUrologic Surgery

Following a mountain biking accident, a 32-year-old man arrives at the emergency department reporting severe perineal pain. He fell forcefully onto the crossbar of his bicycle 2 hours ago and has been unable to void since the incident. Vital signs are temperature 37.0°C (98.6°F), blood pressure 130/80 mm Hg, and pulse 88/min. Inspection of the genital region reveals pronounced swelling and a characteristic butterfly-shaped ecchymosis confined to the perineum. A distinct drop of blood is visualized at the urethral meatus. Digital rectal examination demonstrates a non-tender, normally positioned prostate with intact rectal tone. Which of the following is the most appropriate next step in management?

  1. Perform retrograde urethrographyAnswer
  2. B
    Attempt blind transurethral catheterization
  3. C
    Obtain contrast-enhanced cross-sectional imaging of the pelvis
  4. D
    Proceed directly to operative perineal exploration
  5. E
    Administer intravenous piperacillin-tazobactam and observe

Answer

The most appropriate next step is to perform retrograde urethrography.
The patient presents with classic signs of an anterior (bulbar) urethral injury, characterized by a straddle mechanism, blood at the urethral meatus, and a butterfly-shaped perineal ecchymosis. In any patient with suspected urethral trauma, retrograde urethrography must be performed to evaluate urethral integrity before attempting to insert a transurethral catheter.

Step-by-Step Solution

1
Analyze the mechanism of injury and physical exam findings.
The patient experienced a straddle injury resulting in perineal pain, inability to void, blood at the urethral meatus, and a butterfly-shaped perineal ecchymosis.
These findings are classic for an anterior urethral injury (specifically, the bulbar urethra). The butterfly pattern occurs when Buck's fascia is torn, allowing blood and urine to extravasate into the superficial perineal space contained by Colles' fascia.
2
Determine the safest diagnostic sequence for a suspected urethral injury.
Retrograde urethrography must be selected before any attempt at passing a urethral catheter.
Blind catheterization can convert a partial urethral tear into a complete transection, causing severe iatrogenic harm. Contrast imaging safely maps the defect.

Key Concept

Diagnosis and management of anterior urethral trauma
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Topics

Urologic Surgery

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