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

• 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