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Case 61

Traumatic urethral rupture

A man with bleeding per urethra

Li Foong Foo

A 47 year old man was admitted with a painful, swollen and bruised perineum after a direct kick during a fight. He was also bleeding per urethra and was unable to micturate.

Ultrasound demonstrated marked soft tissue swelling of the perineum only.

Findings

The patient has a suprapubic catheter in situ. There is abnormal configuration of the bulbous urethra with extravasation of contrast into the perineal soft tissues. There is also flow of contrast into the posterior urethra up into bladder cavity. There is no pelvic fracture.

Diagnosis

The patient has sustained a traumatic partial rupture of his bulbous urethra.

Differential

Discussion

Bulbar urethral injury is the most common urethral injury.

As in the above case, it is most often caused by direct trauma, where the bulbous urethra is compressed against the pelvic floor. Clinical features include perineal bruising and bleeding per urethra.

If the patient is unable to micturate, urethral catheter should not be passed prior to urethrogram as

1. it may convert a partial tear to a complete one and/or
2. it may create a false passage.

If a catheter is required in this instance, it should be inserted via the suprapubic approach.

An ascending urethrogram is the investigation of choice in urethral trauma and classifies injury into the following types:

Type I

No urethral rupture. Disruption of the puboprostatic ligaments.
There is craniad displacement of the prostate.
The posterior urethra is elongated and narrow.
The bladder may be elevated by haematoma.
There is no extravasation of contrast outwith the urethra.

Type II

Pure posterior urethral injury with rupture at the prostatomembranous junction above the urogenital diaphragm.
There is extravasation of contrast into the true pelvis.

Type III

Combined anterior and posterior urethral injury with rupture of the membranous urethra at the urogenital diaphragm.
There is extravasation of contrast into the true pelvis and the perineum +/- scrotum i.e. above and below the urogenital diaphragm.

Type IV

Bladder neck injury with extension into urethra

Type IV(A)

Injury of bladder base with periurethral extravastion simulating a true type IV urethral injury.

Type V

Pure anterior urethral injury.
There extravasation of contrast into the perineum +/- scrotum.

Types II , III and V can further be subdivided into partial and complete subtypes, depending on the presence or absence of bladder filling.

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