WHY IS MY SCROTUM LEAKING, DOCTOR?By Ashish Vaska, Rebecca Paxton and Laura Germein Med IV

Case Study

61yo male farmer from Eyre Peninsula Previously fit and well

Initial presentation

2/8/11 Patient underwent surgery for debridement

and drainage of a left scrotal wall abscess Wound on scrotum was loosely closed to

allow drainage Patient was discharged on flucloxacillin with

GP to remove sutures

Investigations

Histology: hidradenitis suppurativa Cultures: negative

5 weeks later...

Patient represented to surgical outpatients

Complaint of smelly discharge from scrotal wound Discharge was watery Pt noticed increased in discharge when he

was out drinking

Urgent urethrogram ordered

Urethrogram

Report

Disrupted urethra at base of penis with contrast extravasation into scrotum and out wound

No flow into bladder

Patient has no history of trauma

Anterior Urethral Disruption

Anatomy

A- Fossa navicularisB- Penile urethraC- Bulbar UrethraD- Membranous UrethraE- Prostatic Urethra

Causes

Pelvic Fractures MVAs Occupational accidents Falls from large height

Gunshot wound Iatrogenic Urethral catheters Tumour Sexual excess Penile fractures

Signs/Symptoms

Classic Triad (absence doesn’t exclude) Blood at urethral meatus Inability to pass urine Distended bladder

Others Superiorly displaced and ‘ballottable’

prostate on PR Perineal haematoma Failure to pass urinary catheter

Epidemiology

Pelvic fractures 10% of all have urethral disruption 25% if men with pelvic fractures have

urethral disruption 5% of women

Posterior disruptions are associated with complex trauma, penetrating, iatrogenic

Anterior ruptures dt penetrating injuries, instumentation, blunt

Anterior Urethral

Investigation

Retrograde urethrography

Classification of Urethral Injuries I Posterior urethra stretched but intact II Tear of the prostatomembranous urethra

above the urogenital diaphragm III Partial or complete tear of both anterior and

posterior urethra with disruption of the urogenital

diaphragm IV Bladder injury extending into the urethra IVa Injury of the bladder base with periurethral

extravasation simulating posterior urethral injury V Partial or complete pure anterior urethral

injury

Management

Acute Management

Patient Resusitation Suprapubic catheter

Palpate distended bladder or Ultrasound guidance

Conservative Management

Manage all patients with conservative therapy for 6-12wks

Catheterise- grade 1 or 2

Repeat urethrogram

Surgical Management

Endoscopic incision of stricture Formal urethral reconstruction Immediate urethral repair if:

If injury is complete penetrating or open. Repaired with fine suture material and over closure or corpus spongiosum

Complications- erectile dyfunction (50-82% dt to mech of injury, more in post disruption), recurrent stenosis (5-15%), incontinence (<4%)

Immediate Management

On consultation with urology registrar Suprapubic catheter inserted Patient discharged back to Eyre Peninsula

with weekly GP review Repeat urethrogram in 6/52 to check

healing and plan further management

References

Myers JB, McAninch JW. Management of posterior urethral disruption injuries.

Uptodate- blunt genitourinary trauma Textbook- MD consult- Consesus on genitourinary trauma,

urethral trauma