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Difficulty: MediumTrauma and Burns

A 29-year-old male arrives at the trauma center after a severe crush injury caused by a tractor rolling over his lower body. He is awake and in significant pain. Vital signs reveal a blood pressure of 115/75115/75 mm Hg, heart rate of 9898/min, and respiratory rate of 1818/min. Primary survey is intact, and a FAST examination is negative for intraperitoneal fluid. Pelvic radiography confirms a displaced butterfly fracture of the pubic rami. On genitourinary examination, there is severe perineal ecchymosis and frank blood visible at the urethral meatus. The patient reports a strong urge to urinate but is unable to void. A digital rectal examination demonstrates a high-riding, nonpalpable prostate. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient's genitourinary injuries.

  1. 1Perform a retrograde urethrogram (RUG)
  2. 2Place a suprapubic cystostomy tube
  3. 3Perform a retrograde cystogram via the newly placed tube
  4. 4Perform delayed surgical urethroplasty

Answer

The correct sequence is: 1) Perform a retrograde urethrogram (RUG), 2) Place a suprapubic cystostomy tube, 3) Perform a retrograde cystogram, and 4) Perform delayed surgical urethroplasty.
The correct chronological sequence safely establishes the diagnosis of urethral injury without causing further harm, provides necessary urinary diversion, evaluates adjacent structures for concurrent injury, and finally provides definitive repair at the safest operative interval.

Step-by-Step Solution

1
Identify clinical signs of posterior urethral injury.
Recognize that blood at the urethral meatus, a high-riding prostate, and inability to void in the setting of a pelvic fracture highly suggest a posterior urethral disruption.
Recognizing these hard signs prevents the practitioner from mistakenly attempting blind transurethral catheterization.
2
Select the initial diagnostic modality for the urethra.
Order a retrograde urethrogram (RUG).
RUG allows for visualization of the urethral defect and confirms the diagnosis safely.
3
Establish safe urinary drainage.
Place a suprapubic cystostomy tube.
Because the urethra is disrupted, bypassing it via a percutaneous suprapubic approach prevents converting a partial urethral tear into a complete transection.
4
Evaluate for associated bladder injuries.
Perform a retrograde cystogram using the suprapubic tube.
Pelvic fractures often cause concurrent bladder ruptures, which must be diagnosed and managed accordingly.
5
Plan definitive management.
Schedule a delayed urethroplasty.
Immediate open repair in the setting of an acute pelvic hematoma carries an unacceptably high risk of bleeding, stricture formation, and impotence.

Key Concept

The standard diagnostic and treatment algorithm for suspected posterior urethral injury in blunt pelvic trauma.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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