Presenting complaint: acute scrotal pain 24hrs
- A 52 year old male with no known chronic illness was in his usual state of health until he slipped and fell astride on a culvert while working on a well.
- He felt pains in the scrotum and immediately started bleeding from his scrotum and was sent to a nearby hospital where the laceration on his scrotum was sutured and he was sent home.
- He started feeling pains while urinating and also saw bloody stained urine. The sutured site was bleeding and the scrotum gradually got swollen.
- He reported to nearby Government Hospital and was referred here for further management.
- There was no documented injury to head , neck , chest , abdomen or limbs. He did not lose consciousness nor experience any breathing difficulty
- He wasn’t intoxicated prior to injury , wasn’t on any medication that alters consciousness , injury sustained being purely accidental
- The only overt bleeding being from a cut he had sustained on the scrotum after the injury
- Patient noticed progressive painful swelling of the scrotum , penis with the passing hours. He also noted a painful swelling of the lower abdomen associated with failure to void .
- He had not passed blood stained stools and was continent of urine as well as stools
- He could walk though with a crab gait due painful swollen scrotum
- PMHx: No known chronic illness, no previous admissions, no history of surgeries.
Drug Hx: No long term medications, no history of herbal medications, no food or drug allergies.
Fam Hx: No family history of chronic illness.
Social Hx: 52 year old Mason, married with 6 children. Non alcoholic and no smoking. Not insured.
Middle aged man lying supine in bed, in pain, mildly pale, anicteric, well hydrated
Head , cspine , was intact
CHEST:RR-18cpm, Chest is clinically clear.
No Pelvic compression tenderness
CNS: Conscious And Alert, GCS-15/15, Normal tone and power in all limbs
CVS:HR-141/75mmHg Pulse-69bpm reg good v
ABDOMEN: Soft , flat, moves with respiration but tender at the suprapubic region, swelling at the suprapubic region(more on the right), no organomegaly, no previous surgical scars seen
- Status localis
- Swollen scrotum and perinuem
- 16cm x 12cm in size,
- 4cm laceration on the left hemiscrotum sutured with Silk suture ,Leakage of blood stained fluid
- Blood at the urethral meatus
- Penis was grossly oedematous.
- Tender scrotum
- Pelvic comp tenderderness neg, no lower limb tenderness , or deformity
- Dre : healthy perianal region , anal sphincter tone normal, test of bulbocavernosus reflex deferred , no blood on examining finger .Diagnosis
Astride Injury involving the Scrotum complicated by urethral disruption
- Urine diversion
- Lab investigations- FBC, GXM, BuE,Cr
- Doppler USG of the testes
- Focused Abdominal Ultrasound of Trauma (FAST) )
- Urinary Bladder was full and intact with urine.
- Scrotum had haematoma and also had urine at some sides.
- There was extravesical urine collection
- No free intraperitoneal fluid collection
- Full Blood Count
- Hb 9.7
- Wbc 6.4 Neut 6,
- Plt 172
Patient couselled for urine diversion ( suprapubic cystostotomy), informed consent obtained
- Condition explained and informed consent obtained
- Lower abdomen scanned and bladder verified
- Lower abdomen and perinuem cleaned with antiseptic slolution and draped
- Iv antibiotic prophylaxis given
- 10mls of 1 % plain xylocain used to infiltrate skin , subcut
- 4cm tranverse incison placed placed 4cm ceph to pubic bone
- dissection carried down to anterior wall of bladder , test spiration yielded clear urine
- Median anterior cystotomy done and size 18F latex bladder catheter inserted into bladder
- Catheter inflated to 10mls using sterile water , connected to urine bag and left to gravity drain
- a closed passive extravesical drain introduced via separate suprapubic incision
- Woound irrigated and closed routinely and sterile dressing applied
- Scrotal wound suture removed , wound irrigated and closed passive drain introduced via same .
- Scrotal wound bandaged and elevated
Scrotal swelling drastically reduced 24hrs afterwards. Drains were removed except the suprapubic bladder catheter
- RUG + MCUG in 6/52
- Scrotal Doppler yet to be done
- Urethroplasty in 6/12
- Evaluation of erectile function in 6/52
Dr Richard Ametih , Urology resident, KATH
Dr Silvia Osei -Akoto , House Officer , Urology, KATH