A 44 y.o. male presents to an outside ED with penile pain and forceful urination that "sprays" per EMS.

The CT is shown below and was read as "mild stranding suggestive of pyelo"   What was missed by the teleradiologist?

The urethra is very dilated suggesting a stricture

The pt initially had  2+ LE , 3+ blood and WBC of 23K. he was treated with rocephin , diagnosed as mild pyelo and elected to be treated at home with cipro. He returned in 7 days with the CT showing the image below. 

What happened?

Our patient had a urethral stricture, and resultant urethral abscess leading to rupture of the urethra and necrotizing fasciitis of the perineum.

Urethral strictures can be difficult to diagnose because they can present with a variety of different symptoms. While about half present with symptoms of a UTI,  a quarter present with urinary retention and another quarter have urethral “spraying”, abscess, or urethral fistulae. The most frequent cause of strictures are infections with Neisseria gonorrhea and Chlamydia trachomatis. It is important to diagnose because in a large study 7% of people with strictures end up with abscess and fournier’s gangrene( necrotizing fasciitis of the perineum).

Gas in the soft tissues from necrotizing fasciitis.

 Necrotizing fasciitis  affects 0.4 to 1 person per 100,000 per year. Fascia come from the latin meaning a band or bundle;  referring to the thick connective tissue  covering muscles and internal organs.   The term came into use in 1952 although the disease has been recognized since the time of Hippocrates.

Affected patients usually complain of intense pain, often out of proportion for what looks like mild cellultitis. Patients often have a fever and appear sick.  The mortality is estimated at 73% if untreated. Common organisms include Group A Strep, Klebsiella, Clostridium, E. coli, Staph aureus and Aeromonas hydrophila.  Vibrio vulnificus can cause necrotizing fasciitis if an injury occurs in salt water. Gas may be found in the soft tissues.

Our patient underwent extensive debridement.  And 8 cm abscess was drained that grew anaerobes, a suprapubic tube was placed and a urethral tear was found 8 cm posterior to the meatus.  He did well post op and has been seen in clinic since his surgery.  Case courtesy of Dr. Steen.

The fasces appears on the left.

Useless trivia:

Fascia is related to fasces( a bundle of rods with a band around it and an axe projecting) which was used by the Romans to represent the power to rule.  This was adopted by the United States (it appears on the dime) and also by the French; progressive republics that imitated the Roman constitution. 

Fascio is the Italian word for labor unions and Mussolini used the term fascist as a play on two words: fascio and fasces.  He implied his movement was linked to the progressive government of the Romans. 

Rourke K, Hickle J.  The clinical spectrum of the presenting signs and symptoms of anterior urethral stricture: detailed analysis of a single institutional cohort.  Urology 2012 May;79(5):1163-7.

Paz Maya, S, Beltran D, Lemercier P, Leiva-Salinas C. Necrotizing fasciitis: an urgent diagnosis. 2014. Skeletal radiology. 43(5):577-89.

Hakkarainen T, Kopari N, Pham T, Evans H. Necrotizing soft tissue infection: Review and current concepts in treatment , systems of care, and outcomes. Current Problems in Surgery 51(8):344-62.

Trent J, Kirsner R. Necrotizing fasciitis Wounds. 2002  14(8): 284-92.