Penile Pain and Hematuria Following a Fall

A 48-year-old man presents to the emergency department (ED) after an incident in which he tripped while working in the bed of his pickup truck, falling forward onto a log. He suffered a direct blow to his perineum and penis, which initially resulted in intense pain that lasted for approximately 5-10 minutes. The pain subsequently subsided, and he continued his activity without discomfort; however, when he attempted to urinate after his work was complete, the patient experienced severe, burning pain in his penis and noted a large amount of hematuria. His symptoms persisted with each episode of urination over the next few hours, leading him to seek evaluation in the ED.

On presentation, the patient reports no pain while at rest. He denies any trauma to his flank or abdomen as a result of the fall. He denies any abdominal pain, nausea or vomiting, difficulty or pain while walking, and scrotal swelling or bruising. There is no significant past medical history, and he does not take any medications.

On physical examination, the vital signs are normal, with a heart rate of 80 beats/min and a blood pressure of 132/76 mm Hg. The patient is afebrile and appears to be in no acute distress. The initial examination of the genitourinary and perineal region reveals blood at the urethral meatus (see Figure 1). A paper towel that the patient has been using to keep his underwear clean is soaked with a moderate amount of blood. There are no external lacerations, abrasions, or ecchymosis identified at the urethral meatus, on the remainder of the penis, or in the perineum. Inspection of the scrotum and palpation of the testicles is unremarkable. There is no tenderness to palpation in the abdomen and no flank or costovertebral area tenderness is noted. The remainder of the physical examination, including examination of the heart, lungs, and musculoskeletal system, is unremarkable for any abnormalities or evidence of additional trauma.

A urine sample at the bedside is noted to be the color of red wine, and a formal urinalysis confirms the presence of gross hematuria. A complete blood cell (CBC) count is ordered and the results are unremarkable, with a normal white blood cell (WBC) count and a hematocrit of 45% (0.45). A coagulation profile is conducted, also with unremarkable results. A series of plain radiographs of the pelvis are performed, and they are normal, with no evidence of fracture. A retrograde urethrogram is subsequently obtained (see Figure 2).

What is the diagnosis? How would you approach this patient's treatment?

Our thanks are extended to D. Brady Pregerson, MD, for providing the details of this case, and to Adam Perrin, MD, for reviewing this content.

See comment #20 for the diagnosis and a discussion of this condition.

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Figure 3: