URETHRAL injuries are rarely lifethreatening. Cases Theresa M. Campo, DNP, RN, NP-C. Scrotal Pain After a Fall

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1 Cases O F N O T E Theresa M. Campo, DNP, RN, NP-C Advanced Emergency Nursing Journal Vol. 31, No. 3, pp Copyright c 2009 Wolters Kluwer Health Lippincott Williams & Wilkins Scrotal Pain After a Fall Johnny S. Gomes, DO, FAAEM, FACEP; Laurie Toman, FNP-C Abstract Trauma to the male urethra must be efficiently diagnosed in the emergency department setting. Many patients will need to undergo immediate surgical reconstruction. Traumatic urethral injuries are rarely life-threatening; however, they can lead to sexual dysfunction and psychological stress for the patient. For example, patients who develop urethral stricture disease from poorly managed traumatic events are likely to have significant voiding problems and recurring need for further interventions. Additionally, associated injuries to the pelvis and vascular structures also frequently occur and must be identified rapidly and treated promptly to prevent long-term complications. Specifically, a delay in diagnosing a traumatic urethral injury may significantly lead to serious long-term sequelae. Therefore, the purpose of this article is to increase the provider s awareness and understanding of urethral injuries. Using a case study approach, the assessment and management of these injuries will be discussed. In this article, the authors provide an understanding of the pathophysiology of urethra trauma and the diagnostic tests to order so as to properly examine the patient with scrotal and/or urethral injury. Key words: blunt injury, emergency department, genitourinary trauma, pelvis, retrograde, scrotal, scrotal pain, ultrasound, urethral injury, urethrogram URETHRAL injuries are rarely lifethreatening. Associated injuries to the pelvis and vascular structures also frequently occur in patients with blunt trauma. These injuries also must be identified quickly and treated promptly (Dixon, 1996; Morey, Metro, Carney, Miller, & McAninch, 2004). Delay in diagnosis may significantly worsen the prognosis. Author Affiliation: Department of Emergency Medicine, Frye Regional Medical Center, Hickory, North Carolina. Corresponding Author: Johnny S. Gomes, DO, FAAEM, FACEP, Department of Emergency Medicine, Frye Regional Medical Center, 420 N Center St, Hickory, NC (drjgomes@yahoo.com). Many patients will need to undergo surgical reconstruction. Patients who develop urethral stricture disease from poorly managed traumatic events are likely to have significant voiding problems and recurring need for further interventions. Urethral injuries that are poorly managed can lead to long-term sexual dysfunction and psychological stress (Morey et al., 2004). Therefore, trauma to the male urethra must be efficiently diagnosed from the emergency department setting and effectively treated to prevent serious long-term sequelae. The purpose of this article is to increase the provider s awareness and understanding of urethral injuries and to provide the practitioner with a basic understanding of the 214

2 July September 2009 Vol. 31, No. 3 Scrotal Pain After a Fall 215 diagnostic tests to order to properly diagnose the patient with scrotal and/or urethral injury. This article will also outline the appropriate management of these injuries to prevent longterm morbidity and psychological stress. THE CASE Chief Complaint I fell and I think I broke my balls. History of Present Illness A 24-year-old Hispanic male presented to the emergency department late in the evening, complaining of severe scrotal pain after falling onto a wooden truss at work 1 hour prior to arrival. He reported increased pain with palpation and with walking. He had no prior history of urogenital trauma. Medical History Healthy, young man taking no medications. No allergies. Tetanus immunization status upto-date. Social History Occupation: unemployed. He denied ethanol or drug use. He smoked one half a pack of cigarette per day. Review of Systems Constitutional: No fever. No weight loss. Skin: No rashes or lacerations. HEENT: Head: No pain, swelling, or bleeding. Eyes: No blurred vision or double vision or eye pain. Ears: No pain or hearing deficit. Nose: No pain, swelling, or bleeding. Face: No pain or swelling. Mouth/ Throat: No pain, swelling, bleeding, or difficulty swallowing or speaking. Neck: No pain or swelling. Chest/Heart: No chest pain or palpitations. No shortness of breath. No cough. No coughing up blood. Abdomen: He reported nausea but no vomiting. No diarrhea. No rectal bleeding or pain. Complaint of pain in the lower abdomen in the suprapubic region. Back: No pain or swelling Pelvis: Pain to the pelvic region. Genitourinary: Pain and swelling to the scrotum. No dysuria. No incontinence. Extremities: No pain or deformity. No rectal pain or swelling. Neurologic: No loss of consciousness. No numbness or tingling. No weakness of limbs. Physical Examination Vital Signs Temperature 98.2 F (oral); blood pressure 159/98; pulse 118 and tachycardic; respirations 22; oxygen saturation 99% on room air, which was within normal limits. General The patient was an awake and alert man in obvious distress with his hands over his pelvic region. He was transported to the emergency department by private vehicle and ambulated into the triage area. Skin: Warm and dry. HEENT: Head: Normocephalic, traumatic without palpable deformities. Eyes: Pupils equal, round and reactive to light. Extraocular movements intact. No nystagmus or diplopia noted. Ears: Canals patent. Tympanic membranes were clear. No Battle s sign. Nose/Face: A traumatic. No septal hematoma. Facial bones were nontender to palpation and stable with attempts at manipulation. Mouth/Throat: No evidence of trauma. Teeth and mandible intact. Neck: Nontender, without step-off or deformity. Trachea midline. Carotids equal. No masses. Full range of motion of the neck without pain. Chest: Nontender, without crepitus or deformity. Symmetrical chest-wall movement. Excursions were normal. Lungs with good tidal volume. Clear to auscultation bilaterally. Heart: Regular rhythm; rate tachycardic. Heart tones normal. No murmur, rub, or gallop was heard. All peripheral pulses intact and equal.

216 Advanced Emergency Nursing Journal Abdomen: Bowel sounds were active in all four quadrants. Soft and nondistended. Mild tenderness over the suprapubic region. No rebound or guarding. No masses.

3 216 Advanced Emergency Nursing Journal Abdomen: Bowel sounds were active in all four quadrants. Soft and nondistended. Mild tenderness over the suprapubic region. No rebound or guarding. No masses. Back: No contusions, ecchymosis, or abrasions. No midline or paravertebral tenderness. No step-off or deformity. No costovertebral tenderness. Pelvis: Pelvis was nontender and stable to compression. Genitourinary: Circumcised. Severe swelling and tenderness to scrotum. No ecchymosis was visualized. Dried blood present at the tip of the urethral meatus. No lacerations or abrasions were noted on penis or scrotum. Rectal: Normal tone. No rectal-wall tenderness or mass. No high-riding prostate. Stool was brown and heme-negative. Extremities: Full range of motion without pain. No ecchymosis, cyanosis, swelling, or deformity. Distal motor neurovascular supply intact. Strength was 5/5 in all extremities. Neurologic: Alert and oriented X4. Glasgow Coma Scale score 15. Mentation was normal. Normal sensation of the lower extremities. Cranial nerves II XII were all grossly intact. Reflexes were symmetric. Medical Decision Making Physical examination findings in this patient revealed concerns for multiple possible processes including blunt trauma to the scrotum, which may result in hematoma, laceration, testicular rupture, damage to the epididymis, urethral injury, and/or rectal or prostatic injury. Additional concerns with this mechanism of injury included pelvic fracture, bladder laceration or contusion, and/or vascular injury to the femoral vessels (Fig 1; Dixon, 1996). Case Progression An intravenous line (IV) was established and hydromorphone (Dilaudid) 1 mg IV was administered for pain. The patient initially rated his pain as a 10 on a 10-point scale. Approx- Figure 1. Retrograde urethrogram of the patient demonstrating a urethral laceration with extravasation of contrast material. imately 30 minutes after the medication was given, the patient rated his pain as a 6 on a 10-point scale. He was maintained nothing my mouth. Laboratory test results were also obtained, including a complete blood cell count and chem-7, which were within normal range. A urinalysis was also obtained and was found positive for blood with no leukocyte esterase or nitrite. Imaging A pelvic radiograph was obtained and was negative for fracture. The patient was sent for a scrotal ultrasound, which demonstrated a scrotal hematoma but no testicular disruption. There was good bilateral blood flow to the testes. A retrograde urethrogram was also obtained. This study demonstrated a urethral laceration with extravasation of contrast material (see Fig 2). A computed tomography scan was not indicated for this patient on the basis of the mechanism of injury and clinical evaluation. A urology consultation was obtained on a stat basis from the emergency department and arrangements were made to take the patient to the operating room for definitive surgical intervention and urethral laceration repair. REVIEW OF THE LITERATURE Urethral injuries are not considered to be lifethreatening. However, their association with

July September 2009 Vol. 31, No. 3 Scrotal Pain After a Fall 217 other more significant injuries necessitates an organized approach to recognition, diagnosis, and management of these injuries.

4 July September 2009 Vol. 31, No. 3 Scrotal Pain After a Fall 217 other more significant injuries necessitates an organized approach to recognition, diagnosis, and management of these injuries. Knowledge regarding the associated injuries is required to make a rapid and accurate diagnosis. Male urethral anatomy, classification of injuries, confirmation of the diagnosis, and initial management of urethral injuries are discussed here in. Male Urethral Anatomy The male urethra is divided into two segments by the urogenital diaphragm. These sections are known as the posterior and anterior sections. The posterior urethra begins at the interface of the bladder and extends through the prostate to the urogenital diaphragm. The anterior urethra extends from the urogenital diaphragm and encompasses the bulbous urethra, which extends from the urogenital diaphragm/bulb of the penis to the external urethral meatus (Chapple et al., 2004; Smith & Schauberger, 2009). The posterior urethra extends from the bladder-neck to the internal urethral orifice and then becomes the prostatic urethra, which is contained within the prostate and continues to the membranous urethra. The membranous urethra, located in the anterior urogenital diaphragm, becomes the proximal portion of the anterior urethra once it passes through the perineal membrane. The urogenital diaphragm is the primary mechanism of continence with the external sphincter (Chapple et al, 2004; Smith & Schauberger, 2004). The bulbar and penile urethra compose the anterior urethra. Extending from the membranous urethra through the bulb of the penis, the bulbar urethra is the proximal section and the penile urethra is the distal section, which extends to the external urethral meatus. The penile urethra lies adjacent to the two corpora cavernosa (Chapple et al., 2004; Smith & Schauberger, 2004). Figure 2. Sagittal section of the male pelvis. The peritoneum drapes over the relatively simple topology of the bladder and rectum. The prostate gland, which is subject to hyperplasia with advancing age, can be palpated via the rectum. From Clinically Oriented Anatomy (5th ed., Figure 3.17A, p. 397), by K. L. Moore and A. F. Dalley, 2006, Baltimore: Lippincott Williams & Wilkins. Reprinted with permission.

5 218 Advanced Emergency Nursing Journal Mechanism of Injury The etiology of a urethral injury can be classified as blunt or penetrating, (e.g., consequence of foreign body in urethral lumen). Urethral injury usually occurs as a result of blunt trauma. The most common age group affected are men ages years. Most urethral injuries are associated with well-defined events, such as motor vehicle crashes, falls, or straddle injuries (Chapple et al., 2004; Lee, Bak, Choi, Lee, Lee, & Yoon, 2007). Blunt trauma accounts for 60% of the urethral injuries and penetrating and iatrogenic account for 40%. Blunt trauma to the anterior urethra is most often caused by a straddletype injury (e.g., bicycle, skateboard, and fall). Blunt trauma to the posterior urethra is usually caused by a pelvic fracture due to the proximity of the bony pelvis (e.g., falls and motor vehicle crashes; Dandan & Farhat, 2009). Penetrating trauma to the anterior urethra, occurs in approximately 70% of the cases involving penetrating injury and involves the perineum and bulbar urethra. In the remaining 30% of penetrating cases to the anterior urethra, injuries are to the penile urethra. Stab and gunshot wounds and missile injuries are associated with penetrating injuries to the posterior urethra. The practitioner must be suspicious for accompanying bladder, pelvic, and rectal injuries. Iatrogenic injuries are caused internally from obstruction or by the patient through self-mutilation or rough intercourse (Dandan & Farhat, 2009). Classifications of Urethral Injuries Urethral injuries are classified as contusions, partial disruptions, or complete disruptions, and they may involve the anterior and or posterior urethral segments. Blunt injury to the anterior urethra most often occurs from a blow to the bulbar segment, such as when straddling an object or from direct strikes or kicks to the perineal region. Blunt anterior urethral trauma is sometimes observed in the penile urethra in the setting of penile fracture. Anterior urethral injuries are often not diagnosed emergently, because of less significant symptoms and delay in seeking care, and the actual incidence is, at times, difficult to determine (Dixon, 1996). Symptoms include pain with voiding or inability to void, and swelling. Blood at the urethral meatus is the most important sign of a urethral injury. Additional signs include local hematoma, perineal, scrotal, and penile ecchymosis, edema, or both and a high-riding prostate on rectal examination (i.e., difficult to palpate; Dixon, 1996; Morey et al., 2004; Webster, Mathes, & Selli, 1983). In the posterior urethra, blunt injuries are almost always related to deceleration events, such as falls from a significant height or motor vehicle accidents. Posterior urethral injuries are most commonly associated with pelvic fracture, with an incidence of 5% 10%. Injury to the posterior urethra occurs most often from shearing forces (Dixon, 1996). Diagnosis and Management of Patients With Urethral Trauma The approach to diagnosing the patient with urethral injuries begins with a thorough history and physical examination. Diagnostic studies should be based on the mechanism of injury and patient presentation. Diagnostic studies will include a urinalysis and may include a complete blood cell count, prothrombin and partial prothrombin time, blood type and cross match analysis, plain radiograph of the pelvis, retrograde urethrogram, computed tomography scan of the abdomen and pelvis, and scrotal ultrasound (Dandan & Farhat, 2009). Scrotal ultrasound is readily available and is noninvasive. It is the most sensitive and specific test for detecting intrascrotal injuries. The goals of ultrasound are to visualize the testicles and assess for integrity and vascularity as well as testicular rupture. If scrotal rupture or torsion is suspected or confirmed by ultrasound, prompt surgical intervention must occur to prevent a poor outcome of infection, infertility, and/or chronic pain (Lee et al., 2007; Morey et al., 2004).

6 July September 2009 Vol. 31, No. 3 Scrotal Pain After a Fall 219 Retrograde urethrogram is the study of choice for the diagnosis of urethral injury. This study is simple, fast, and reliable. This test should be performed if the patient is unable to void, blood is present at the meatus, and/or any hematuria is present. The diagnosis is confirmed by retrograde urethrography, which should be done before catheterization. Problems arise if a urethral injury is unrecognized and the urethra is further damaged by attempts at blind catheterization (Chapple et al., 2004; Dixon, 1996; Morey et al., 2004). Initial Management When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm. DISCUSSION This patient presented with obvious signs of urogenital trauma. He was thoroughly examined for other associated injuries, including bony fractures, vascular injury, abdominal trauma, and testicular or prostatic injury. Life threatening injuries take precedence over urethral injuries, and delayed surgical repair is often the norm. There was blood at the meatus in this patient. Blood at the meatus is a key finding and should raise a high index of suspicion for urethral injury. Urology consultation was obtained in the emergency department to assist in further assessment and treatment decisions. Additional consultations should be obtained, as indicated, based on other findings on examination or diagnostic studies. The key to the initial management of a urethral injury is prompt diagnosis, accurate identification of the injury, and properly selecting an intervention that minimizes the overall chances for the debilitating complications of incontinence, impotence, and urethral stricture (Brandes, 2006; Jordan, Virasoro & Eltahawy, 2006). Although somewhat controversial, blunt traumatic posterior injuries generally are managed best by primary realignment (when feasible), straddle injuries of the bulbar urethra by suprapubic urinary diversion, and penetrating urethral injuries by primary repair and urinary diversion (Brandes, 2006; Jordan et al., 2006). Contusions can be safely treated with 10 days of indwelling transurethral catheterization (Brandes, 2006). Complications Complications of urethral injuries, if undiagnosed, may result in stricture formation, infection, erectile dysfunction, and incontinence (Dixon, 1996). Blood at the meatus is a key finding and should raise suspicion for urethral injury, and if left undiagnosed, and untreated, long-term complication may result in further problems, including impotence, urethral strictures, and urinary obstruction. SUMMARY AND CONCLUSION In summary, this patient presented with obvious signs of urogenital trauma. Blood at the meatus is a key finding and should raise suspicions for urethral injury. A search must be made for other associated injuries, including bony fractures, vascular injury, abdominal trauma, and testicular or prostatic injury. These other injuries will often take precedence over the urethral injury, and delayed surgical repair is often the norm. Men with urethral injuries have an excellent prognosis when managed correctly. Left undiagnosed, and untreated, however, long-term complications from urethral injuries may occur. It is important to obtain the retrograde urethrogram for definitive diagnosis. This will often require consultation with the radiologist. Urology consultation also needs to be obtained immediately to assist in further assessment and treatment decisions. Additional consultations should be obtained, as indicated, based on other findings on examination or diagnostic

7 220 Advanced Emergency Nursing Journal studies. In conclusion, trauma to the male urethra must be efficiently diagnosed from the emergency department setting and effectively treated to prevent serious long-term sequelae in these patients. REFERENCES Brandes, S. (2004). Initial management of anterior and posterior urethral injuries. Urologic Clinics of North America, 33(1), Chapple, C., Barbagli, G., Jordan, G., Mundy, A. R., Rodrigues-Netto, N., Pansadoro, V., et al. (2004). Consensus statement on urethral trauma. BJU International, 93(9), Dandan, I. S., & Farhat, W. (2009). Trauma, lower genitourinary. emedicine. Retrieved May 4, 2008, from overview Dixon, C. M. (1996). Diagnosis and acute management of posterior urethral disruptions. In J. W. McAninched (Eds.), Traumatic and reconstructive urology (pp ). Philadelphia: Saunders. Jordan, G. H., Virasoro, R., & Eltahawy, E. A. (2006). Reconstruction and management of posterior urethral and straddle injuries of the urethra. Urologic Clinics of North America, 33(1), Lee, S. H., Bak, C. W., Choi, M. H., Lee, H. S., Lee, M. S., & Yoon, S. J. (2007). Trauma to male genital organs: A 10-year review of 156 patients, including 118 treated by surgery. BJU International, 101(2), Morey, A. F., Metro, M. J., Carney, K. J., Miller, K. S., & McAninch, J. W. (2004). Consensus on genitourinary trauma: External genitalia. BJU International, 94(4), Smith, J. K., & Schauberger, J. S. (2004). Urethral, trauma. emedicine. Retrieved May 2, 2009, from overview Tunc, H. M., Tefekli, A. H., Kaplancan, T., & Esen, T. (2000). Delayed repair of post-traumatic posterior urethral distraction injuries: Long-term results. Urology, 55(6), Webster, G. D., Mathes, G. L., & Selli, C. (1983). Prostatomembranous urethral injuries: A review of the literature and a rational approach to their management. Journal of Urology, 130(5),

Canadian Undergraduate Urology Curriculum (CanUUC): Genitourinary Trauma. Last reviewed June 2014

Canadian Undergraduate Urology Curriculum (CanUUC): Genitourinary Trauma Last reviewed June 2014 Session Objectives 1. Recognize hematuria as the cardinal symptom of urinary tract trauma. 1. Outline the