This patient most likely has a pelvic fracture, which has resulted in urethra trauma, as evidenced by the scrotal and perineal ecchymosis. Before inserting a foley catheter it is important to perform a retrograde urethrogram.
Symptoms of urethral injury include an inability to urinate, urinary retention, hematuria, and abdominal pain. Findings on physical exam include evidence of blood at the urethral meatus, swelling and bruising of the penis, scrotum, or perineum, and leakage of urine into tissues surrounding the urethra may result in swelling and inflammation. A pelvic radiograph with urethrography is important to perform PRIOR to the insertion of a transurethral bladder catheter.
Cancio et al. discuss urethral catheterization of the bladder and the potential complications, including infection, injury to the urethra or bladder, and catheter malfunction. They report that prompt replacement of the urethral catheter with an alternative method of bladder drainage is the most effective way of avoiding urethral catheterization complications.
Gomez et al. review urethral trauma. Because of the anatomical relationships of the posterior urethra (piercing the perineal diaphragm in close relationship to the pubic arc of the bony pelvis), fracture disruptions of the pelvic ring can be associated with injuries to the urethra in the posterior segment. Urethral injuries can result in long-term complications including strictures, erectile dysfunction, and urinary incontinence.
Illustration A displays a cystourethrogram in which a urethral injury is present.
Answer 1: A foley catheter is needed for proper fluid management but only after urethral damage is ruled out.
Answer 2: The patient stabilized with initial volume administration and there is no evidence additional fluids are needed until urinary output can be assessed.
Answer 3: Head CT is required if there is any evidence of head trauma but only after a skeletal survey, including a pelvic radiograph.
Answer 5: While surgery will likely be necessary, the patient has stabilized and completing the primary and secondary survey is appropriate prior to proceeding with surgery.
Cancio LC, Sabanegh ES Jr, Thompson IM. Managing the Foley catheter. Am Fam Physician. 1993 Oct;48(5):829-36.
PMID:8213413 (Link to Abstract)
Gómez RG, Mundy T, Dubey D, El-Kassaby AW, Firdaoessaleh, Kodama R, Santucci R. Chapter 7: Pelvic Fracture Urethral Injuries. Urology. 2013 Nov 7. pii: S0090-4295(13)01243-0.
PMID:24210734 (Link to Abstract)