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 navicularis B- Penile urethra C- Bulbar Urethra D- Membranous Urethra E- Prostatic Urethra

Causes Pelvic Fractures Gunshot wound Iatrogenic Urethral catheters 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) Others 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