Endgames Case report

A man with penoscrotal swelling and bruising

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1283 (Published 21 April 2010) Cite this as: BMJ 2010;340:c1283
  1. Manique Wijesinghe, foundation year 2, elderly care,
  2. Rajinder Singh, specialist registrar, urology
  1. 1Queen Alexandra Hospital, Portsmouth PO6 3LY
  1. Correspondence to: M Wijesinghe manique.w{at}gmail.com

    A 50 year old, morbidly obese, immobile man with a long term catheter secondary to urinary retention as a result of benign prostatic enlargement presented to his general practitioner. He had a two day history of frank haematuria and progressively worsening scrotal, penile, and suprapubic pain that occurred a few days after a routine catheter change. The doctor noted scrotal swelling and bruising and suspected urethral injury as a result of traumatic catheterisation. He became progressively more unwell, and an emergency referral to urology was made three days later.

    On admission, he was systemically unwell, with a blood pressure of 95/60 mm Hg and an irregular pulse rate of 105 beats/min. Electrocardiography confirmed atrial fibrillation. His temperature was 37.5°C and respiratory rate was 22 breaths/min, with a pulse oximeter saturation of 93% on air. Oxygen administration and aggressive fluid resuscitation were initiated. On examination, he had extensive swelling and a black-purple discoloration of the scrotum, penis, and suprapubic region, in addition to malodour.

    Laboratory results on admission showed haemoglobin 136 g/l, white cell count of 55.3×109/l, platelets 521×109/l, international normalised ratio 14, C reactive protein 272 mg/l, urea 13.3 mmol/l, and creatinine 356 µmol/l. Subsequent catheter sample urinalysis and blood cultures showed no bacterial growth.

    His arterial blood gas on 2 litres of oxygen via a nasal cannula showed pH 7.456, partial pressure of oxygen 17.2, partial pressure of carbon dioxide 3.92, base excess −2.9, and standard bicarbonate 22.7. Chest radiography was unremarkable. His medical history included morbid obesity, poorly controlled type 2 diabetes, atrial fibrillation, and chronic obstructive pulmonary disease, which was treated with steroid inhalers.

    Questions

    • 1 What is the likely diagnosis?

    • 2 What investigations may aid in diagnosis?

    • 3 What are the risk factors and common organisms associated with this condition?

    • 4 How is …

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