A 35 yo male presents with penile pain, blood at the meatus, inability to void and bruising of his perineum after a surfing injury where he landed on a rock in straddle position.  Imaging is done including a retrograde urethrogram shown below.  What's the diagnosis?  Scroll down for answer.

Answer: Urethral injury.

• More common in males due to length of the urethra
• Mechanism often straddle injury, penetrating truama (GSW, stab, dog bite), crush injury with pelvic fracture
• Classic symptoms: blood at the metus, inability to void

• Diagnosis: Retrograde urethrogram
• How to perform:   insert small foley catheter (10F) into tip of penis, inflate balloon slightly so contrast does not leak, inject contrast and take xray to observe if contrast reaches the bladder or if there is blockage or extravasation.  CT cystogram can also be done, but is less sensitive for urethral injury.
• Treatment: may try to gently place a foley ONE time in ED.  If resistance is met, stop and consult urology.  Urology may try to pass a wire to the bladder or take patient for cystoscopy to place foley.  If unable to place foley patient will need suprapubic catheter and then delayed surgical repair of urethra.

The case:  this patient's retrograde urethrogram shows that the contrast does not enter the bladder suggesting complete blockage or transection.  The faint contrast in the bladder is from prior CT cystogram.  Urology emergently placed a suprapubic catheter and patient was scheduled for reconstructive surgery later in the week.

Reference:

Doiron CR, Rourke KF.  An overview of urethral injury.  Can Urol Assoc J.  2019 Jun: 13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565404/