Retrograde Urethrogram

1. Indications: Suspected Urethral Trauma (perform prior to Foley Catheter placement)
   1. Perineal or scrotal Hematoma
   2. Blood at uretheal meatus
   3. High riding Prostate
   4. Pelvic Fracture or Pubic Symphysis Diastasis suspected
   5. Inability to void
2. Contraindications
   1. Contrast allergy
3. Preparations: Water Soluble Contrast
   1. Diatrizoate (no dilution needed)
   2. Iohexol (Omnipaque) diluted 50% with Normal Saline (1:1)
   3. Iodaxanol (Visipaque) diluted to 10% with Normal Saline
4. Technique: Bedside Emergency Department Procedure (where urology not available)
   1. Preparation
      1. Obtain consent
      2. Obtain Contrast Material and catheter set-up
      3. Operator should wear a lead apron, to remain in position for imaging during injection
      4. Sterilize the Urethral entry site and apply a drape
   2. Insert 8 Fr Foley Catheter until balloon is inside the distal Urethra (1 to 2 cm)
      1. Gently inflate balloon with 1 to 1.5 ml saline, air or contrast (just enough to secure in place)
         1. However, this risks Urethral injury, and some authors recommend against balloon inflation
         2. As alternative, pinch meatus closed to prevent leakage, or use Toomey Type syringe
      2. Catheter-tip syringe (Toomey-Type Syringe) may be used as an alternative to 8 Fr
         1. Secure by gently compressing glans (with hand) around catheter tip
   3. Hold the penis gently outstretched
      1. Hold the Urethral meatus closed around the catheter
   4. Slowly inject contrast via catheter
      1. Use water-soluble contrast options (see list above)
      2. Inject slowly and gently
         1. Venous extravasation may occur with high pressure (appears similar to Urethral injury)
   5. Image with XRay or Fluoroscopy
      1. Perform imaging while injecting last 10 ml of contrast
      2. Obtain images in 2 opposing views (i.e. anteroposterior and lateral view)
   6. Consider repeat Imaging in 10 minutes
      1. Indicated in non-diagnostic imaging or venous plexus present
5. Complications
   1. Genitourinary infection
   2. Urethral injury (from catheter placement)
      1. May result in contrast extravasation with secondary inflammation
6. References
   1. Herbert and Inaba in Herbert (2014) EM:Rap 14(3): 5-6
   2. Davis in Roberts (2014) Clinical Procedures in Emergency Medicine, 6th Ed, Saunders Elsevier, p. 1113-54
   3. Warrington (2016) Crit Dec Emerg Med 30(12): 12