RUPTURE OF THE URETHRA, A NEW DIAGNOSTIC SIGN

VINCENT VERMOOTEN, LT. CoL., MC

One of the common complications of crushing injuries of the lower half of the
abdomen involving the bony pelvis is an injury to the urethra or bladder.
Whether the urethra has received a severe contusion, whether it has been
lacerated or completely torn across (ruptured) or whether the injury has re-
sulted in a contusion, laceration or rupture of the bladder is, as a rule, a very
difficult differential diagnosis to make.
The fact that new methods of diagnosis are offered with the advent of each
new diagnostic aid would tend to confirm this.
Since the introduction of the organic iodides for the purpose of studying the
urinary tract radiographically, this has also been used to determine whether the
patient has a ruptured bladder with extravasation or a ruptured or lacerated
urethra. If an extensive laceration or rupture of the bladder is present, then
after the intravenous injection of the organic iodide, extravasation at the site
of the injury may be seen in the roentgenogram. However, if one or other of
the organic iodides is used to make a urethrogram it will frequently clearly
demonstrate a tear in the urethra, and may show extravasation above the
urogenital diaphragm which will suggest either a complete division of the urethra
at the apex of the prostate or an extraperitoneal rupture of the bladder.
The passing of a catheter through the urethra in the hope of passing it into the
bladder and in that way determining whether either the urethra or the bladder
is ruptured, especially when subsequently a known quantity of sterile liquid is
introduced through the catheter and the return flow measured, is not only
definitely harmful and injurious but it can only give wrong information. It is
the one diagnostic method, above all others that should never be used. If it is
believed necessary, for diagnostic purposes, that any instrument is to be passed,
it should be a cystourethroscope or a panendoscope.
When an individual receives a crushing injury which involves the bony pelvis,
there is, as a rule, so much shock and local trauma that most diagnostic pro-
cedures, especially those involving moving the patient, should be avoided, yet
the diagnosis of a ruptured bladder or urethra should not be delayed. Any
degree of urethrorrhagia is significant; a desire, yet an inability to void is an
important and valuable symptom. The knowledge as to whether the patient
had a full or an empty bladder just before the injury may aid in making a differ-
ential diagnosis. In Young's Practice of Urology, there are beautiful illustra-
tions showing the mechanism of intra- and extraperitoneal ruptures of the
bladder.
In his discussion of the Diagnosis of Injuries of the Urethra, Young states;
"If a swelling can be felt by rectum, obscuring the prostate, the extravasation
(urine or blood or both) has reached above the trigone." On the other hand,
Lowsley and Kirwin say: "The diagnosis of rupture of the urethra is usually
made on rectal palpation after careful scrutiny of the perineum and lower part
228