Fall from 15 feet, perineal hematoma and suprapubic mass. Injury to
Correct Answer: Urethra
Description: Rupture of the membranous urethra Rupture of the membranous urethra typically occurs in association with a fractured pelvis and may be associated with an extraperitoneal rupture of the bladder. When the pelvis fractures, the membranous urethra is ruptured as it passes through the bony ring of the pelvis. The urethra is elastic at this point, and if the fracture results in only a minor displacement, then the tear may only be paial, but more typically the rupture is complete, such that the two ends are completely displaced,with the development of a significant interposing haematoma. About 1-2% of cases of fractured pelvis have an associated urethral injury and such injuries are almost universally seen in men. CLINICAL FEATURES The most common causes of pelvic fracture are road traffic accidents, severe crush injuries and falls. Typically there are multiple associated injuries that may be immediately life threatening and the overriding priority is to keep the patient alive by appropriate resuscitation. Under these circumstances the management of the other injuries takes precedence. The clinical features include urinary retention, blood at the urethral meatus and a high riding prostate on digital rectal examination. There is typically marked bruising of the pubic area, scrotum and penis. If the diagnosis is suspected, a urethrogram performed with water-soluble contrast media is confirmatory. A suprapubic catheter should be inseed as soon as practicable using the Seldinger technique. The distended bladder may be palpable, making suprapubic catheterisation straightforward, but often the bruising and swelling associated with the fracture makes this difficult and ultrasound guidance is required. When suprapubic urinary diversion has been achieved then no fuher urological management is required until the patient has stabilised. In the presence of a coexisting extraperitoneal bladder injury, no bladder will be apparent on ultrasound examination, and surgical exploration, bladder repair, suprapubic catheter placement and drainage of the retropubic space is needed. In a patient with a pelvic fracture who does not have blood at the urethral meatus but who has not yet passed urine (such that there is unceainty as to whether there is a urethral injury), a single, gentle attempt at catheterization, by an experienced doctor, is permissible. In adults a 16F soft, silicone catheter should be used. If the catheter will not pass or passes and drains only blood, the balloon should not be inflated, but the catheter should be withdrawn and a retro grade urethrogram should be performed. Complications Urethral disruption injury Urinary incontinence Erectile dysfunction. Extravasation of urine Ref: Bailey and love 27th edition Pgno : 1481
Category:
Surgery
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