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So, we have a hemodymanically normal patient with good vitals. He has stopped bleeding and his physical examination is normal except for the GSW to the base of the penis and an exit wounds to his perineum. CT of the abdomen and pelvis with IV, PO and rectal contrast are negative. There may be a small chip fracture of the anterior pubic bones but nothing that will require an orthopaedis pelvis operation to repair that chip. The trajectory looks like it hit the most anterior portion of the pelvis, chipped off a small piece of bone and the bullet fragmented leaving a small piece of fragment in his soft tissue anterior to the pelvis and a small fragment on the right side farther distal in the base of the penis.
Now there is no blood from the penile meatus. What we must make sure is that the urethra is okay and CT does not give you that information. A retrograde urethrogram will. This means that a foley ballon is passed through the penile meatus and partially inflated with 3 to 4 cc's of fluid. Under fluoroscopy dye is injected retroograde into the urethra and then into the bladder. A/P, lateral and oblque views are obtained. The bladder is also inspected for extravasation of contrast. Once completed the foley ballon is deflated and the Foley is passed into the bladder and ballon inflated to look for blood (blast injury to bladder) and left for now. It may be discontinued in an few hours or the next day or even immediately once the urine is found to not have heamturia.
Dressing changes, pain control and follow-up are essential for the patient. Looking for cellulitis is also important as one worries about necrotizing infections in patients injured in the groin and especially in a war zone.
This patient was very lucky indeed. But do not let the nature of the injury obscure what needs to be done. ABCDE's and so on.
The images show RUG 1 of the prep, RUG 2 of the Foley inserted and the contrast being pushed, and RUG 3 of the column of dye into the bladder and two foreign bodies (fragments) that will be retained. The RUG 3 shows a straight column without any extravasation. Just remember to get obliques and laterals.
DD
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