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Acute scrotum
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Acute scrotum

 

7/6/20

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

 

astride injury
  • 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.

  • EXAMINATION

    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

      Diff:testicular injury

    • PLAN
      1. FAST
      2. Urine diversion
      3. Lab investigations- FBC, GXM, BuE,Cr
      4. Antibiotics
      5. Analgesia
      6. 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

Suprapubic csytostomy

  • 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

Postoperative state 

Scrotal swelling drastically reduced 24hrs afterwards. Drains were removed except the suprapubic bladder catheter

Follow up

  • 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

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