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Old 12-11-2012
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Question Urethral Injury; What to do next?

A 38-year-old man was thrown from his motorcycle and brought to the ED by emergency medical services. The paramedics report his initial vital signs were blood pressure 83/52 mm Hg, pulse 128/min, and respiratory rate 33/min. He was given 2 L of lactated Ringer’s solution en route, and medical antishock trousers were applied. His vital signs on arrival to the trauma bay were blood pressure 108/76 mm Hg, pulse 105/min, and respiratory rate 28/min. On examination, pelvic compression elicits severe pain, and blood is noted at the urethral meatus. Which of the following is the most appropriate next step in evaluation of blood at the urethral meatus?

(A) Abdominal ultrasound
(B) Digital rectal examination
(C) Foley catheter insertion and urinalysis
(D) Intravenous pyelogram
(E) Retrograde urethrogram
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Old 12-12-2012
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ans ..E.........
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(B) Digital rectal examination
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Quote:
Originally Posted by Novobiocin View Post
(B) Digital rectal examination
oh , yes again forgot . Pr first then urethrogram ...
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Originally Posted by Hitman View Post
oh , yes again forgot . Pr first then urethrogram ...
Why
What ever you find in DRE will not affect your plan to do Retrograde urethrogram, so why not going directly for doing it?
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I think DRE is a better option....there is just one pointer towards urethral injury- blood at the meatus, so its a wise move to gather more clinical signs like high-riding prostrate to be able to consolidate our suspicion towards urethral injury and proceed with Retrograde urethrogram....just my thought...
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Originally Posted by heartbeat View Post
Why
What ever you find in DRE will not affect your plan to do Retrograde urethrogram, so why not going directly for doing it?
Because the question asks for "next step in evaluation" NOT the "best step in evaluation".
Moreover, complete physical exam is always done before ordering any investigations. Doing Retrograde urethrogram before DRE is like doing an USG without eliciting Muphy's sign in a fat, fertile, female of 40 with symptoms typical of Cholecystitis.
DRE will help differentiate between anterior urethral injury and posterior urethral injury.
Blood at the meatus could be due to bladder injury and that does not require a Retrograde urethrogram but a cystoscopy.
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Originally Posted by anomali View Post
I think DRE is a better option....there is just one pointer towards urethral injury- blood at the meatus, so its a wise move to gather more clinical signs like high-riding prostrate to be able to consolidate our suspicion towards urethral injury and proceed with Retrograde urethrogram....just my thought...
What is high-riding prostrate
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Originally Posted by heartbeat View Post
What is high-riding prostrate
High riding prostate: prostate and prostatic urethra torn from membranous urethra and pulled cephalad thus the prostate feels “too far up” on per rectal examination....its a sign of posterior urethra injury.......
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Quote:
Originally Posted by Novobiocin View Post
Because the question asks for "next step in evaluation" NOT the "best step in evaluation".
Moreover, complete physical exam is always done before ordering any investigations. Doing Retrograde urethrogram before DRE is like doing an USG without eliciting Muphy's sign in a fat, fertile, female of 40 with symptoms typical of Cholecystitis.
DRE will help differentiate between anterior urethral injury and posterior urethral injury.
Blood at the meatus could be due to bladder injury and that does not require a Retrograde urethrogram but a cystoscopy.
u r absolutely correct but i think we already have the suspicion of urethral injury and doing DRE will not change the course of action . lets say that nothing is found during DRE your next step will also be E because u can not do retrograde cystogram before retrograde urethrogam. so i think we should not delay management of this pt and go straight ahead to RU. just saying
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u r absolutely correct but i think we already have the suspicion of urethral injury and doing DRE will not change the course of action . lets say that nothing is found during DRE your next step will also be E because u can not do retrograde cystogram before retrograde urethrogam. so i think we should not delay management of this pt and go straight ahead to RU. just saying
You are missing the point here--the question asks for "next step in evaluation" NOT the "best step in management".
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Old 12-14-2012
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Originally Posted by Novobiocin View Post
You are missing the point here--the question asks for "next step in evaluation" NOT the "best step in management".
i really don't know. but sometimes there is overlapping between management and overlapping. but u r probably wright.
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i really don't know. but sometimes there is overlapping between management and overlapping. but u r probably wright.
You are right but the point I am trying to make is that complete physical examination comes before any form of investigation and Digital rectal examination is a highly relavent part of a physical exam in a trauma patient with pelvic fracture. So,

Next step----> DRE

Best step----> Retrograde urethrogram
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Old 12-24-2012
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The answer is E. Doing a DRE or not doesn't change the next and more important step, which is Retrograde Urethrogram. For more info, watch Pestana's lectures. There is a similar question in Uworld as well.
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Originally Posted by vaibhavmanu View Post
The answer is E. Doing a DRE or not doesn't change the next and more important step, which is Retrograde Urethrogram. For more info, watch Pestana's lectures. There is a similar question in Uworld as well.
Are you saying that both Pestana and UW suggest doing Retrograde Urethrogram before a complete physical examination?

Remember, the question is asking for the next step not the diagnostic step.

Quote:
Diagnosis of urethral injuries requires a reasonably high index of suspicion. Urethral injury should be suspected in the setting of pelvic fracture, traumatic catheterization, straddle injuries, or any penetrating injury near the urethra. Symptoms include hematuria or inability to void. Physical examination may reveal blood at the meatus or a high-riding prostate gland upon rectal examination. Extravasation of blood along the fascial planes of the perineum is another indication of injury to the urethra. "Pie in the sky" findings revealed by cystography usually indicate urethral disruption.
The diagnosis of urethral trauma is made by with retrograde urethrography, which must be performed prior to insertion of a urethral catheter to avoid further injury to the urethra. Extravasation of contrast demonstrates the location of the tear.
I checked UW (QID 3349) where they have already done DRE as a part of physical exam and found high riding prostate. Only then, Retrograde Urethrogram was done.
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i think the NEXT step would be to do a DRE.
The best test to confirm the diagnosis would be Retrograde Urethrogram.
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Just a side question. What if the question is "What is the next appropriate step?" and the evaluation of urethral injury was not mentioned? Noting that the patient was in shock but responded to IVF infusion, should they also be investigating a possible intraabdominal hemorrhage?

Since patient is hemodynamically stable, they should probably investigate the urethral/pelvic injury first, then do an abdominal CT later. Abdominal USG (FAST) is probably not that urgent nor helpful since pt is stable. http://www.ncbi.nlm.nih.gov/pubmed/20800865

I guess the next best step is still DRE in this case, probably mainly bec. of its convenience?

But what if the pt is still in shock? Would the FAST become more urgent? (and possibly, blood tranfusion if among the choices)
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