A 25-year-old male was involved in a motor vehicle crash in which he was clearly intoxicated. On presentation to the emergency department he is tachycardic and hypotensive and has suffered bilateral superior and inferior pubic rami fractures, with resulting acute blood loss anemia. He is transfused two units of packed RBCs. On presentation to the ICU, his blood pressure remains 100/70 mm Hg. On complete evaluation of the patient, you notice a small amount of blood at the penile meatus and no foley had been placed in the ED.
What is the NEXT appropriate management of this patient?
A. No need for foley placement as he is alert with stable vital signs. Once he voids, send for urinalysisCorrect Answer: D
Bladder injury occurs in approximately 3.4% of patients with pelvic trauma, whereas urethral injury occurs in only 1% of these patients. Males are 10 times more likely to have a urethral injury in such situations. If the physical examination reveals any signs of genital bruising, blood at meatus, high riding prostate, and gross hematuria, urethral injury should be suspected and ruled out. Advance Trauma Life Support recommends ruling out a urethral injury before inserting a Foley to avoid further injury, although the data on this are sparse. A systematic review of a thousand pediatric patients revealed the total incidence of genitourinary injury to be approximately 11% to 12%. Of these patients, 26.4% had urethral injury. As the severity of the pelvic injury worsened, the percentages appropriately increased. It is important to recognize this and have a high suspicion of injury during the examination of such patients. The first two choices involve placing a Foley catheter before any investigative work. CT Cystogram is ideal to rule out bladder injury. Retrograde Urethrogram is the test of choice to rule out urethral injury.
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