In some hospitals retrograde urethrography is performed only in patients with blood at the meatus while others perform this investigation in all patients with pelvic fractures where the pubic rami have been disrupted. If there is no blood present at
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the meatus, a gentle attempt at urethral catheterisation may be made. It has been suggested that this could convert a partial urethral rupture into a complete rupture. However, McAninch (2002) has stated, 'We and others have not seen any evidence that this can convert an incomplete into a complete transection . . . and we usually make one gentle attempt to place a urethral catheter in suspected urethral disruption' (see also Jackson and Williams 1974, Kotkin and Koch 1996). If any resistance is encountered, stop, and obtain a retrograde urethrogram. If the retrograde urethrogram demonstrates a normal urethra, proceed with another attempt at catheterisation, using plenty of lubricant. If there is a urethral rupture, most centres recommend insertion of a suprapubic catheter via a formal open approach, to allow inspection of the bladder (and repair of injuries if present) at the same time that the suprapubic catheter is placed. Radiological inspection of the bladder is not possible in such cases because the urethral rupture will have prevented performance of a cystogram. Direct inspection of the bladder is required to determine the presence/absence of a bladder injury.
Suprapubic Catheterisation Versus Open Suprapubic Cystostomy in Patients with Posterior Urethral Disruption
Why go to the trouble of taking the patient to the operating theatre, exposing the bladder, opening it, and inserting a catheter, when a suprapubic catheter could easily be passed percuta-neously in the emergency department? There are several reasons for recommending open suprapubic cystostomy for catheter placement over percutaneous suprapubic catheterisation:
1. Opening the bladder affords the opportunity of inspecting the bladder for evidence of a rupture (extraperitoneal or intraperitoneal) and of a bladder neck injury. If such an injury is found, it can be repaired.