Not surprisingly (because it is longer), the male urethra is more likely to be injured than is the female urethra. Signs that the urethra may have been injured include blood at the meatus, gross haematuria, and perineal or scrotal bruising. Approximately 40% to 50% of patients with a pelvic fracture and ure-thral injury have blood at the external meatus (Cass 1984, Lowe et al. 1988). In the remaining patients the urethral injury is not apparent until an attempt has been made to pass a urethral catheter and has failed. A so-called high-riding prostate occurs when the prostate and bladder become detached from the membranous urethra and reach a higher than normal position. A large pelvic haematoma develops and pushes the bladder upward. When one performs a rectal examination in a patient with a highriding prostate, it may be felt just at the tip of your finger or may not be felt at all. The associated pelvic haematoma may also make it impossible to feel the prostate, so the patient may be thought to have a high-riding prostate when in fact it is in a normal position and vice versa. Thus, the presence of a highriding prostate is an unreliable sign (Elliott and Barrett 1997). A digital rectal examination may be more important as a way of establishing whether there is an associated rectal injury, in which case blood may be seen on the examining finger when it is withdrawn. However, the absence of blood on the examining finger cannot be taken as a guarantee that the rectum is intact.
Abdominal and Pelvic Imaging in Pelvic Fracture, and What to Do If Imaging Cannot or Has Not Been Done
The radiologic workup in patients with a pelvic fracture usually includes an abdominal and pelvic CT scan, a retrograde ure-throgram (to exclude or confirm a urethral injury), and, if the urethra is intact, a retrograde cystogram to assess the integrity of the bladder. The cystogram usually demonstrates the presence of a bladder perforation. The abdominal CT scan allows associated injuries to abdominal viscera to be assessed.