Diagnosis

Posterior urethral disruption injuries are suspected in patients presenting with the entire spectrum of pelvic fractures and multiple visceral injuries. The classic presenting clinical picture of a posterior urethral injury includes urinary retention, blood at the urethral meatus, a palpable bladder, or a »high-riding« or nonpalpable prostate. A small number of patients will present with scrotal and perineal ecchymosis in the anal triangle.

The clinical presentation, however, may be misleading. In review of 47 patients with traumatic urethral injuries, Cass noted that a urethral injury could only be diagnosed clinically in four patients [15]. Elliott noted in a study of 57 patients that blood was documented at the urethral meatus in 57% of those injured and an abnormal rectal exam identified in only 35% [16]. Physical findings may require delayed observation since most patients seen in under 2 h following the trauma will fail to have abnormal physical findings [12].

A retrograde urethrogram is the key study for determining the presence of a posterior urethral rupture and is performed in any patient with any of the above findings. It is performed in a 38- to 40-degree oblique position with the penis placed perpendicular to the femur unless the patient is hemodynamically unstable. Extravasation of contrast material after gently injecting 20-30 cc of intravenously compatible contrast material without bladder visualization is characteristic of a complete urethral rupture. The presence of contrast material in the bladder associated with extravasation signifies a partial disruption. A diagnostic catheterization should be avoided in this clinical setting since it may infect a sterile hematoma or convert a partial urethral tear into a complete separation injury, although this is a debatable concept. An abdominal and pelvic CT scan will aid immensely in identifying other visceral injuries along with a bladder injury, which has been reported to occur in 10%-20% of cases, but will not be of any use in identifying a posterior urethral traumatic injury [17]. The role of MRI has not been completely defined in posterior urethral disruption trauma during the acute phase, when it is particularly difficult to position the patient with multiorgan injury, pelvic hematoma, hemodynamic or pelvic instability.

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