Traumatic urethra and bladder rupture

Case contributed by RMH Core Conditions

Presentation

Driver in motor vehicle accident. Blood at external urethral meatus.

Patient Data

Age: 20 years
Gender: Male

Retrograde urethrogram

Fluoroscopy

Retrograde urethrogram (RUG) demonstrates contained extravasation of the contrast at the level of the membranous urethra consistent with a traumatic injury.

Contrast drainage into the bladder indicates partial preservation of the luminal continuity.

Pelvis

ct

On the non-contrast study, there is a small amount of extravasated contrast (from prior urethrogram) within the retropubic space (cave of Retzius), inferior extraperitoneal pelvic cavity and tracking into the perineum/perineal muscles and adductor musculature of the left thigh. This is consistent with the known urethral rupture seen on the prior urethrogram.

Post-stress cystogram, there is further contrast extravasation into the right extraperitoneal space. No intraperitoneal contrast extravasation to suggest intraperitoneal bladder rupture.

A moderate volume of extraperitoneal pelvic hematoma is demonstrated, partially mixed with the extravasated contrast and presumably urine. There is further pooling of the extravasated contrast on the intravenous-contrast enhanced study, particularly anterior to and within the right SI joint.

Small volume retroperitoneal hematoma posterior to the left psoas and anterior to the left iliacus muscle.

A comminuted, minimally displaced fracture of the left sacral body and sacral ala is present, with intra-articular extension into the left SI joint and involvement of the left S1 and S2 nerve root foraminae. 11 mm fracture fragment displaced into the left posterior pelvis anterior to the left sacral ala. There is mild widening/diastasis of the right SI joint (up to 7 mm). There is associated diastasis of the pubic symphysis with the left pubic bone superior to the right. Possible subtle left pubis fracture. Left laterally displaced L5 transverse process fracture.

Left superoposterior and lateral gluteal and suprapubic subcutaneous contusions noted.

Case Discussion

In summary, injuries sustained:

  • traumatic urethral rupture at the level of the membranous urethra
  • bladder rupture (proven at OT)
  • bony pelvis fractures and pelvic hematoma
  • pubic bone and sacro-iliac joint diastasis
  • L5 transverse process fracture

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