Simon, a 28-year-old man, asked for an emergency appointment on a busy Monday morning. He clearly needed to be seen as he was complaining of haematuria.
He looked sheepish as he described what had happened. He was at a training session for his local rugby club the day before, and they were using a rugby scrum sled - an upright wooden frame with four padded sections, attached to a wooden sled by heavy timbers at an angle supporting the back.
They were 'messing around' as he put it, when he fell astride one of the angled timbers. He received a blow to his penis and perineum that was, as he modestly put it, 'pretty painful'.
His friends thought it was hilarious, and after about 10 minutes he recovered sufficiently to continue with the training session.
When he was drying himself in the shower afterwards he noticed some bright blood at the end of his penis, but didn't think much of it.
However, slight bleeding continued throughout the evening, and before he went to bed he noticed blood in his urine.
He felt OK otherwise, and being a stoical sort of fellow, he thought he would wait and see if it went away. When he woke he noticed blood staining his pyjamas and passed more blood in his urine, and urination was uncomfortable. He decided it was time to seek some advice.
The urine sample hardly needed testing as it was so red. Examination was completely normal. As might be expected in a fit sportsman, he was in good shape with a normal cardiovascular system. He had no pain at all, his abdomen and pelvis appeared normal, there was no scrotal swelling or bruising, and no obvious damage to the penis.
The explanation
Despite the history of recent trauma with haematuria, Simon said he felt well and was quite comfortable.
Although he told me he had not fallen onto his back or side, I was wondering about kidney damage. I always remember a fellow medical student who ignored haematuria and finished a game with a renal laceration that nearly cost him his kidney.
The urology SHO was helpful when I spoke to him and offered to see the patient in the medical assessment unit.
It turned out I was not the only one who was perplexed. In hospital they checked for blood dyscrasias and bleeding tendencies and X-rayed his pelvis. Everything appeared normal.
The haematuria continued throughout the day. When the urology consultant came out of theatre at the end of the afternoon, he asked for a retrograde urethrogram, which gave the answer.
To understand the report, I had to remind myself about the sections of the male urethra - the anterior, consisting of the penile and bulbar segments, and the posterior, consisting of the membranous urethra (as it passes through the external urethral sphincter) and the prostatic urethra.
The retrograde urethrogram showed extravasation of contrast medium from a laceration of the distal end of the anterior urethra.
Injuries to this section of the urethra are relatively uncommon, accounting for about a third of urethral lacerations. Most occur in the posterior urethra as a result of pelvic fracture. Fresh blood at the meatus is a significant warning sign, but is only present in about half of cases.
The treatment
Because anterior urethral injuries are not common, a particular approach to treatment has not been established.
The cautious passage of a catheter to act as a splint with analgesia and antibiotics has been recommended, but because of the risk of converting a partial tear into a complete disruption, a temporary transcutaneous suprapubic catheter is often put in place first. The definitive treatment is surgical repair, but this is often delayed until the results of conservative treatment are known.
Simon was treated with a catheter inserted personally by the consultant, followed by a 10 day course of ciprofloxacin. He took all this in his stride and was soon back playing rugby, although he promised not to horse around in training sessions again.
- Dr Barnard is a former GP in Hampshire.
