1. Why is my scrotum leaking, doctor?
By Ashish Vaska, Rebecca Paxton and Laura Germein Med IV

2. Case Study 61yo male farmer from Eyre Peninsula
Previously fit and well

3. 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

4. Investigations
Histology: hidradenitis suppurativa
Cultures: negative

5. 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

6. Urethrogram

7. 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

8. Anatomy A- Fossa navicularis B- Penile urethra C- Bulbar Urethra
D- Membranous Urethra
E- Prostatic Urethra

9. 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

10. 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

11. 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

12. Anterior Urethral

13. Investigation
Retrograde urethrography

14. 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

15. Management

16. Acute Management Patient Resusitation Suprapubic catheter
Palpate distended bladder or
Ultrasound guidance

17. Conservative Management
Manage all patients with conservative therapy for 6-12wks
Catheterise- grade 1 or 2
Repeat urethrogram

18. 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%)

19. 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

20. References
Myers JB, McAninch JW. Management of posterior urethral disruption injuries.
Uptodate- blunt genitourinary trauma
Textbook- MD consult-
Consesus on genitourinary trauma, urethral trauma