Suspect that a severely injured patient has ruptured his posterior urethra, if he has: (1) A fractured pelvis, particularly if he has a ’butterfly fracture’ (D, Fig. 76-1), or a ’hinge fracture’ (E, in this figure). (2) Bleeding from his external meatus. (3) A distended bladder. (4) A boggy swelling displacing or partly concealing his prostate.
If a patient’s prostate is not widely displaced, and there is no boggy feeling when you examine him rectally (a difficult and unreliable sign), the rupture of his posterior urethra is probably incomplete. and will heal itself if you leave it for 3 weeks, and insert a suprapubic catheter to prevent his urine extravasating meanwhile. If a small bridge of urethral tissue survives, his urethra may reform with very little stricture—provided that the infection which may follow catheterization does not destroy it. The prevention of this infection one of the reasons why you should not try to catheterize him. The other reason is that you may make his injury worse. If his rupture heals during three weeks of waiting, it was incomplete. The best test of this is to see if he can pass urine normally when you clamp off the suprapubic tube. If he cannot, the chances are that the rupture was complete, so try to refer him for expert repair at 3 weeks. Don’t leave him longer than this because increasing fibrosis will make repair more difficult. Repair at 3 weeks is seldom easy, but it is no more difficult than it would have been immediately after the accident.
If his prostate is widely displaced, and there is a boggy feeling when you examine him rectally, his urethra is probably completely ruptured. If you cannot refer him, you will have to try to ’railroad’ him, as in the next section.
The great advantage of conservative treatment is that it will usually avoid railroading, which is difficult and bloody. Your first sight of the retropubic space of a patient with a fractured pelvis and a torn urethra will be daunting indeed.