A man with penoscrotal swelling and bruising

A 50 year old, morbidly obese, immobile man with a long term catheter secondary to urinary retention as a result of benign prostatic enlargement presented to his general practitioner. He had a two day history of frank haematuria and progressively worsening scrotal, penile, and suprapubic pain that occurred a few days after a routine catheter change. The doctor noted scrotal swelling and bruising and suspected urethral injury as a result of traumatic catheterisation. He became progressively more unwell, and an emergency referral to urology was made three days later.

On admission, he was systemically unwell, with a blood pressure of 95/60 mm Hg and an irregular pulse rate of 105 beats/min. Electrocardiography confirmed atrial fibrillation. His temperature was 37.5°C and respiratory rate was 22 breaths/min, with a pulse oximeter saturation of 93% on air. Oxygen administration and aggressive fluid resuscitation were initiated. On examination, he had extensive swelling and a black-purple discoloration of the scrotum, penis, and suprapubic region, in addition to malodour.

Laboratory results on admission showed haemoglobin 136 g/l, white cell count of 55.3×10⁹/l, platelets 521×10⁹/l, international normalised ratio 14, C reactive protein 272 mg/l, urea 13.3 mmol/l, and creatinine 356 µmol/l. Subsequent catheter sample urinalysis and blood cultures showed no bacterial growth.

His arterial blood gas on 2 litres of oxygen via a nasal cannula showed pH 7.456, partial pressure of oxygen 17.2, partial pressure of carbon dioxide 3.92, base excess −2.9, and standard bicarbonate 22.7. Chest radiography was unremarkable. His medical history included morbid obesity, poorly controlled type 2 diabetes, atrial fibrillation, and chronic obstructive pulmonary disease, which was treated with steroid inhalers.