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Why is my scrotum leaking, doctor?

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

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Why is my scrotum leaking, doctor?

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  1. Why is my scrotum leaking, doctor? By AshishVaska, 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 • 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) • 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 periurethralextravasation 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

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