Urethral obstruction due to the passage of a retained projectile into the genitounrinary system

Urethral foreign bodies are relatively rare. When seen, they are usually the result of entry via the urethral meatus. Several reports in the literature have documented the passage of retained bullets into the genitourinary system. The vast majority of these were ultimately expelled spontaneously via the urethra. Very few cases of urethral obstruction and accompanying urinary retention due to bullet migration have been described. The presented case details distal urethral obstruction due to the migration of a retained firearm projectile presenting 1 month after initial gunshot wound. No such case exists in the emergency medicine literature. A 32-year-old man was transported by ambulance to an urban, level I trauma center after being shot in the left flank by a firearm of unknown caliber. The gunshot wound occurred from an estimated distance of 5 ft. No further history about the event was known. No hemodynamic instability was reported en route. A trauma resuscitation was initiated and was a joint effort involving the trauma service and the emergency medicine team. The patient was in a mild amount of distress on arrival secondary to pain. The airway was intact, breath sounds were present bilaterally, and there were palpable distal pulses and a blood pressure of 149/91 mm Hg. He was alert and oriented and had a nonfocal neurological examination. The only obvious external trauma was a 0.5-cm wound located in the left lower flank. The wound was consistent with a projectile injury. No soot or tattooing of the skin was visible. The abdomen was soft, nondistended, and mildly tender to palpation. The genitourinary examination was unremarkable. A foley catheter was placed and gross hematuria was noted. A computed tomography evaluation of the abdomen/pelvis was obtained. Multiple projectile fragments were noted within the left buttock and adjacent to the bladder (Fig. 1). There were mildly displaced fractures of the left iliac wing, superior left acetabulum, and the left superior pubic ramus. A moderate amount of blood was present in the extraperitoneal space on both sides of the bladder. No extravasation of contrast from the bladder was noted, but the bladder was not well distended. A decision was made by the trauma team to take the patient to the operating room for exploratory laparotomy and intraoperative cystogram. A midline laparotomy was performed. No intraperitoneal injuries were identified. The intraoperative cystogram revealed extraperitoneal extravasation of contrast near the base of the bladder. The patient did well postoperatively. Urologic and orthopedic consultations were obtained. Urology recommended foley catheter drainage for 2 weeks. Orthopedics recommended nonoperative treatment including weight bearing as tolerated and participation in physical therapy. The patient was discharged on posttrauma day 4 and continued to progress well after discharge. The foley catheter was removed on schedule, and progress was made with physical therapy. One month after laparotomy, the patient presented to a low-volume, small-hospital emergency department (ED) with a chief complaint of not being able to urinate. He stated that he had gone many hours without being able to urinate and complained of fullness and mild pain in the suprapubic region. Physical examination was significant for suprapubic tenderness and a firm, palpable mass in the glans of the penis. A penile x-ray was obtained and showed a radiopaque foreign body in the shape of a firearm projectile (Fig. 2). Subsequently, the patient was transferred to an ED at a tertiary care hospital for further evaluation. The history and physical examinations were confirmed and the x-rays reviewed. In addition, the medical record relating to the patient's recent hospitalization for gunshot wound was reviewed. It was felt that the retained projectile had eroded into genitourinary system with resultant blockage of the penile urethra. Urology was consulted and evaluated the patient in the ED. A penile block was performed, and forceps were used to dilate the distal urethra. A firearm projectile was subsequently removed. A foley catheter was placed and a large amount of urine returned. The patient was discharged from the ED with outpatient follow-up arranged with urology. Expulsion of firearm projectiles via the genitourinary system is quite rare. Several reports exist in the literature in which a retained projectile has been passed spontaneously via the urethra [1-6]. In these cases, many months or years may have passed from the time of the initial injury to the time of foreign body expulsion. Even rarer still is the occurrence of urinary retention due to a projectile becoming lodged in the urethra. Three cases of urethral obstruction occurring years after the original injury have been reported, and 1 report exists regarding urethral obstruction occurring shortly after injury [7-10]. Several possibilities exist to explain the passage of the retained projectile into the genitourinary tract in this case. The patient definitely had a bladder injury, as evidenced by the extraperitoneal extravasation of contrast on the intraoperative cystogram. It is possible that the projectile passed into the bladder via the original injury. Another perhaps more likely mechanism involves the erosion of the retained rectovesical projectile through the bladder wall. Such has been the postulated mechanism in some of the previously reported cases [9]. Urethral foreign bodies are not commonly encountered. When they are seen, it is usually in the context of external entry via the urethral meatus. The treating physician must remember that other mechanisms exist. One must inquire about prior gunshot wounds to the flank or abdomen, and in such cases, the possibility of bullet migration into the genitourinary tract must be entertained.