Urethral Injuries Introduction diagnosis

Diagnosis of urethral injuries

1. Urethral Injuries Stas Bushik, PGY1

2. Signs and Symptoms Blood at urethral meatus Gross hematuria Inability to void Absent or abnormally positioned prostate on DRE Ecchymosis and/or hematoma involving penis, scrotum (in males), vulva (in females), and perineum Findings may be absent in up to 57% of cases of urethral injury Have high suspicion with pelvic fractures, especially fractures of multiple pubic rami, as well as penetrating injuries to the lower abdomen/genitalia ~3-6% of patients with pelvic fractures have concomitant urethral injuries

3. Diagnosis Urinalysis Plain X-Rays – if there are pelvic fractures suspicion should go up Retrograde urethrogram (RUG) Voiding cystourethrogram (VCUG)

4. Retrograde Urethrogram Most commonly used test in suspected urethral injury Simple to perform and quick to obtain Patient positioned in semi-oblique position and scout film obtained 60mL syringe filled with 40mL of water-soluble contrast and 20mL of lidocaine Using sterile technique a syringe with Christmas tree adapter (if available) placed inside the meatus, and contrast injected slowly under fluoroscopy until contrast is seen to enter bladder Patient then voids while under fluoroscopy which provides voiding phase of RUG

5. Normal RUG

6. Injuries identified on RUG

7. Voiding Cystourethrogram Similar to RUG, but also evaluates bladder and timing is different Bladder filled with contrast through a catheter under fluoroscopy, and then patient voids under fluoroscopy while bladder and urethra are evaluated Can identify bladder injuries, urethral injuries, and also vesicoureteral reflux

8. CT Urography Preferred imaging modality in patients with unexplained hematuria Evaluates entire GU tract Sensitive for nephrolithiasis, tumors, and obstruction Essentially a CT of the abdomen/pelvis with and without contrast with a specific protocol for the GU tract