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Setyo Sutanto, Rama Firmanto (2024) Anterior Urethral Rupture with Extravasation of Urine to

Penis and Scrotum: a Case Report, (06) 08,

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2684-883X

ANTERIOR URETHRAL RUPTURE WITH EXTRAVASATION OF URINE TO

PENIS AND SCROTUM: A CASE REPORT

Setyo Sutanto, Rama Firmanto

Cilandak Marine Hopital, Indonesia

Email: [email protected]

Abstract

Urethral Trauma is a discontinuity of urethra which caused by external stress (pelvic fracture

or straddle injury) or internal stress (catheter placement, urological procedures). There are

several suitable techniques, including immediate exploration or urine diversion. The treatment

used depend on the cause of the rupture, rupture length, as well as anatomical position of the

rupture. A 46-year-old male suddenly presented with swollen penile and testicle after 1 day

of hospitalization. One day before, patient suffers in high-speed motorcycle accident and

sustains blunt trauma to the perineal area, hitting the handle bar of the motorcycle and brought

to the emergency department. There was a palpable bladder distension during physical exam,

with penis and scrotum enlargement. Laboratory findings show elevated WBC and elevated

creatinine level. Urinalization test was within normal limit. Partial laceration found during

urethroscopy approximately <1cm in size. Scrotal drainage and exploration are conducted due

to scrotum being swollen progressively. There is uncertainty regarding these symptoms to be

interpreted as a urethral injury because some of the classical symptoms are missing, although

patient showed with palpable bladder distension. Due to the swollen penis and scrotum which

are enlarged progressively, urethroscopy and scrotal exploration was performed. Small

laceration on the bulbar area of the urethra is found, indicating anterior urethral rupture, the

laceration is treated conservatively with the placement of transurethral catheter. Scrotal

exploration then performed which pus and extravasation of urine is found within the scrotum.

The precision on determining anterior urethral rupture as a diagnosis decides the management,

prognosis and complication rate of anterior urethral rupture. Although, the initial urethral

trauma management remains disputed, a bulbous urethral rupture with a complication of

extravasation of urine into the penis and scrotum can be treated effectively with urine

diversion and scrotal exploration.

Keywords: Urethral Rupture, Extravasation of Urine, Penis, Scrotum

INTRODUCTION

Urethral injuries can be classified based on location as either anterior or posterior.

Anterior urethral injuries are often as a result of blunt or penetrating trauma. On the other

hand, posterior urethral injuries are most commonly as a result of pelvic fracture or iatrogenic

trauma during pelvic surgeries. Blunt trauma of the anterior urethra, often the result of a

“straddle injury” to the bulbar urethra, result in significant contusion to the spongiosus with

possible significant to the perineum. As the penetrating anterior urethral injury, the

mechanism of injury ranges from gunshot wound to self-inflicted sexual misadventures

(Doiron & Rourke, 2019).

JOURNAL SYNTAX IDEA

p–ISSN: 2723-4339 e-ISSN: 2548-1398

Vol. 6, No. 08, Agustus 2024

Anterior Urethral Rupture with Extravasation of Urine to Penis and Scrotum: a Case Report

Syntax Idea, Vol. 6, No. 08, Agustus 2024 3423

Urethral injuries are categorized in terms of the anatomical location of the injuries. In

men, the anterior section is comprised of the bulbar and penile urethra while posterior section

is comprised of the prostatic and the membranous urethra. On the other hand females only

have posterior section of the urethra due to its shorter in length (Palinrungi, Kholis, Syahrir,

Pakan, & Faruk, 2021).

Data at the Cipto Mangunkusumo Hospital during 2016-2020 shows that urethral injury

contributed 10% of all urogenital trauma cases.(3) Iatrogenic urethral trauma (43%), PFUI

(25%), Straddle injury (23%), penetrating injury (4%), penile fracture (4%) data is obtained

from Saiful Anwar General Hospital during 2016-2020. The same research shows that most of

the cases involving anterior urethral injury (70%), especially bulbar area, rather than posterior

urethral injury (30%) (Palinrungi et al., 2021).

The following is a case report conducted at the Cipto Mangunkusumo Hospital, in order

to add scientific studies to medical studies on urethral injuries. Iatrogenic trauma is the most

common cause of urethral injury, with the incidence of urethral catheterization in men is 13,4

per 1.000 insertion of catheter.(4) Trauma can be caused by forced insertion of catheter or

catheter balloon inflation inside the urethra.(5) Clinically, both of the urethral injuries have a

differences regarding etiology, clinical features, treatment, and prognosis (Shewakramani &

Reed, 2011).

Hematuria and extravasation of urine can cause edema and eccymosis on the scrotum,

penis and/or perineum, depending on the extent of the trauma. These clinical features can be

shown > 1 hour post trauma (Barratt, Bernard, Mundy, & Greenwell, 2018; Mundy &

Andrich, 2011)

RESEARCH METHOD

A 46-year-old male suddenly presented with swollen penile and testicle after 1 day of

hospitalization, patient also presented with pain in voiding but the patient’s has no complaint

of inability to void. The urine output was normal in color, with normal turbidity without

meatal bleeding. One day before, patient suffers in high speed motorcycle accident and

brought to the emergency department. As the patient ride the motorcycle, he sustained blunt

trauma to the perineal area, hitting the handle bar of the motorcycle with the chief complaint

of referred pain from the left lower back to the buttock. On the initial assessment in

emergency department, apart from the buttock pain, patient only presented with fever without

any hemodynamic disturbance (Nugrahani & Hum, 2014).

On physical exam, patient’s found with a distended bladder and presented with swollen

penile and grossly swollen scrotum. There is no blood at the urethral meatus; Rectal toucher

was performed, with the normal tone of sphincter ani as well as normal rectum ampule, there

was no “floating prostate”; on the glove, there were feces and no blood from inside the

rectum. The patient is fully able to void, however, the patient do feel pain while voiding.

There is no hematoma over scrotum and perineum. Laboratory findings show elevated WBC

and elevated creatinine level. Urinalization test was within normal limit, In terms of the

Covid-19 screening, a chest X-ray showed no ground-glass opacity, and a Antigen rapid test

was non-reactive. Catheter then placed successfully with urine production of 200 cc.

However, due to swollen testis and swollen penis which are progressively bigger, thus

uretheroscopy and scrotal exploration are scheduled immediately due to inavaibility of

retrograde urethrogram in our.

Setyo Sutanto, Rama Firmanto

3424 Syntax Idea, Vol. 6, No. 08, Agustus 2024

During the uretheroscopy, there was a partial laceration approximately <1cm above

bulbourethral in which the urine extravasated onto the penile and scrotum through the tunica

vaginalis. After we detected the possibility of urethral rupture, urine diversion is done using

trans-urethral catheter. We proceed onto the next procedure which is exploration of scrotum.

The procedure including, making two cuts of the scrotal skin exposing the testis which urine

and pus were found during the process, therefore we irrigate the underlying tissue with

copious amount of saline water and H2O2 to treat the inevitable infectious process. We left it

wide open for the urine to evacuate and to monitor the viability of the testis and the adjacent

tissue.

After the procedure, patient left with catheterized urethra and wet dressing protecting

wide-open scrotum which expose both testis. The patient was given an two intravenous

broad-spectrum antibiotic (ceftriaxone 2gr q 12hr; Metronidazole 500mg q 8hr) that was

administered for 4 days, along with analgesics drugs (Ketorolac 30mg q 8hr). No

complication is noted regarding the procedure and the patient is discharge after 5 days of

admission.

RESULT AND DISCUSSION

Anterior urethral injury caused by non iatrogenic and iatrogenic (Mundy & Andrich,

2011). Urethra pars bulbosa become the most frequent area to receive blunt trauma, therefore,

become the most fragile area from the impact of straddle injury (Latini, McAninch, Brandes,

Chung, & Rosenstein, 2014). The significant pressure from straddle injury towards urethra

pars bulbosa resulting urethra pars bulbosa to be pressed upward to the symphysis pubis

which is damaging the urethra from the compression site. Other mechanism is direct blow to

the perineum resulting penile fracture (Barros et al., 2017; Falcone, Garaffa, Castiglione, &

Anterior Urethral Rupture with Extravasation of Urine to Penis and Scrotum: a Case Report

Syntax Idea, Vol. 6, No. 08, Agustus 2024 3425

Ralph, 2018). Classification and proper description of urethral injuries are important to

determine the treatment plans (Ghoniem, Moskowitz, & Nguyen, 2022). Several classification

is exist, perhaps the most common is the classification by American Association for the

Surgery Trauma (AAST) which divided into contusion, stretch, partial rupture, complete

rupture (Daller & Carpinito, 2022).

The current patient suddenly presented with swollen penis and scrotum during 1 day of

hospitalization after experiencing motorcycle accident 6 hours before seeking medical

attention. There was no history of bleeding from the external urethral meatus, no hematoma

over scrotum and/or perineum. Patient also shown voiding pain and distended bladder.

However, there is uncertainty regarding these symptoms to be interpreted as a urethral injury

because some of the classical symptoms are missing, although patient showed with palpable

bladder distension (Palinrungi et al., 2021). We conducted blood test and urinalization, which

showed elevated WBC indicating there is infection going on and we performed urethral

cathaterization. Due to the swollen penis and scrotum which are progressively bigger,

urethroscopy and scrotal exploration was scheduled immediately to determine whether there

is true urethral rupture.

Small laceration on the bulbar area of the urethra is found, indicating anterior urethral

rupture, the laceration is treated conservatively then transurethral catheter is placed for 1-2

weeks. Scrotal exploration then performed which pus and extravasation of urine is found

within the scrotum. After several irrigation using copious amount of saline water, the scrotum

left wide open exposing both testis and protected by wet dressing which was replaced twice a

day.

Extravasation of urine into the scrotum is a relatively uncommon occurrence (Noel &

Velchik, 1986). Buck’s fascia is penetrated and urine under pressure dissects the perineal and

abdominal fascial planes under Colles’ and Scarpa’s layers (Weems & Hillis, 1977).

Extravasated urine cannot pass posteriorly because of the origin of Colles’ fascia, is limited

laterally by the attachment of it to the ischiopubic ligament, and cannot find its way into the

thigh because of the attachment of Scarpa’s fascia to Poupart’s ligament. Thus, urine can only

be escape to the scrotum and penis, and finally into the anterior abdominal wall beneath

Scarpa’s fascia (Ishimatsu, Yoshizato, Kurokawa, Kawakami, & Okura, 2021). According to

the W. L. Weems et al, When the extravasation involves the scrotum the suffused

subcutaneous tissues of the scrotum are resected, leaving the testis intact. The scrotum then

packed with gauze (Weems & Hillis, 1977) (Makama, Haruna, Stephen, & Aminu, 2021).

Extravasation involving the penis usually necessitates debridement of part or all of the

penile skin

Setyo Sutanto, Rama Firmanto

3426 Syntax Idea, Vol. 6, No. 08, Agustus 2024

CONCLUSSION

Despite rarety of the urethral trauma, with the staggering incidence rate of 4% of all

total urogenital trauma, urethral trauma can not be ignored. Prompt diagnosis and

management are important in order to prevent later morbidity and mortality. The choice of

urine diversion using trans urethral catheter and scrotum exploration is preferred in this case,

given the complication shown in this patient which is extravasation of urine to the scrotum

and penis. The catheter is expected to be monitored until 1-2 weeks after the procedure.

BIBLIOGRAPHY

Barratt, Rachel C., Bernard, Jason, Mundy, Anthony R., & Greenwell, Tamsin J. (2018).

Pelvic fracture urethral injury in males—mechanisms of injury, management options

and outcomes. Translational Andrology and Urology, 7(Suppl 1), S29.

Barros, R., Silva, M. I. S., Antonucci, V., Schulze, L., Koifman, L., & Favorito, L. A. (2017).

Primary urethral reconstruction results in penile fracture. The Annals of the Royal

College of Surgeons of England, 100(1), 21–25.

Daller, Meir, & Carpinito, Gennaro. (2022). Genitourinary Trauma and Emergencies.

Handbook of Urology.

Doiron, R. Christopher, & Rourke, Keith F. (2019). An overview of urethral injury. Canadian

Urological Association Journal, 13(6 Suppl4), S61.

Falcone, Marco, Garaffa, Giulio, Castiglione, Fabio, & Ralph, David J. (2018). Current

management of penile fracture: an up-to-date systematic review. Sexual Medicine

Anterior Urethral Rupture with Extravasation of Urine to Penis and Scrotum: a Case Report

Syntax Idea, Vol. 6, No. 08, Agustus 2024 3427

Reviews, 6(2), 253–260.

Ghoniem, Gamal, Moskowitz, Dena, & Nguyen, Catherine. (2022). Urological Care After

Spinal Cord Injury. Current Physical Medicine and Rehabilitation Reports, 10(2), 89–

97.

Ishimatsu, Masato, Yoshizato, Toshiyuki, Kurokawa, Yusuke, Kawakami, Kosuke, & Okura,

Naofumi. (2021). A Case of Urinary Extravasation and Urolithiasis During Pregnancy.

The Kurume Medical Journal, 68(1), 33–38.

Latini, Jerilyn M., McAninch, Jack W., Brandes, Steven B., Chung, Jae Yong, & Rosenstein,

Daniel. (2014). SIU/ICUD consultation on urethral strictures: epidemiology, etiology,

anatomy, and nomenclature of urethral stenoses, strictures, and pelvic fracture urethral

disruption injuries. Urology, 83(3), S1–S7.

Makama, Baje Salihu, Haruna, Liman, Stephen, Yusuf, & Aminu, Umar. (2021). Penile

fracture with complete urethral rupture and urine extravasation: a case report. Journal of

West African College of Surgeons, 11(2), 31–34.

Mundy, Anthony R., & Andrich, Daniela E. (2011). Urethral trauma. Part I: introduction,

history, anatomy, pathology, assessment and emergency management. BJU

International, 108(3).

Noel, Arthur W., & Velchik, Michael G. (1986). Urine extravasation into the scrotum.

Journal of Nuclear Medicine, 27(6), 807–809.

Nugrahani, Farida, & Hum, Muhammad. (2014). Metode penelitian kualitatif. Solo: Cakra

Books, 1(1), 3–4.

Palinrungi, Muhammad Asykar, Kholis, Khoirul, Syahrir, Syakri, Pakan, Adriani Purnasakti,

& Faruk, Muhammad. (2021). Primary anastomosis for complete bulbar urethral rupture

with rectal laceration caused by straddle injury: A case report. International Journal of

Surgery Case Reports, 82, 105848.

Shewakramani, Sanjay, & Reed, Kevin C. (2011). Genitourinary trauma. Emergency

Medicine Clinics, 29(3), 501–518.

Weems, W. L., & Hillis, R. S. (1977). Spontaneous extravasation of urine from the anterior

urethra. The Journal of Urology, 117(1), 61–64.

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