The findings of unilateral enlarged ovary without (or little) arterial and venous flow are said to be diagnostic of torsion. The finding of little or no venous flow is more common than no arterial flow, so persistent flow does not exclude the diagnosis. Ancillary findings include free pelvic fluid, unusual midline location of the ovary or a twisted vascular pedicle (giving the whirlpool sign). Most cases of ovarian torsion are caused by an adnexal mass (including dermoid or other cysts), with some occurring due to ovarian hypermobility. Treatment is based on early recognition and surgery, which aims to prevent necrosis and infection. Its findings should be reported urgently to the surgeons for further care, and the radiologist has an important role in this scenario.
* Macroscopic hematuria and blood at urine meatus
What is the most likely diagnosis? What should we do next?
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X-ray: Bilateral pelvis fractures discontinuity iliopectineal line most clearly left-sided
CT: Bilateral ramus superior/anterior iliac bone and ramus inferior pubic bone
Avulsion fracture symphysis pubis
Fracture sacrum on the right
Look also in soft-tissue setting!
Large hematoma posterior of symphysis pubis around urethra and perineum, lateral around the pelvic floor obturator internus muscles and cranially in the retroperitoneal Retzius space anterior of the bladder
Do a RUG: Retrograde Urethrogram. If intact, followed by CT Cystography
RUG shows contrast extravasation and complete rupture of anterior bulbous part of urethra, grade V isolated anterior injury. However, the rupture might be at the anatomic weak point, the bulbomembranous junction, meaning avulsion of the puboprostatic ligament and stretching of the membranous urethra. There is no contrast above the urogenital diaphragm (level of symphysis pubis). Contrast in the bladder is a residue from the IV contrast given for earlier total body CT.
Goldman classification urethral injury
Anterior urethra = Penile and bulbous part
Posterior urethra = Membranous and prostatic part
Type I: stretching the posterior urethra due to disruption of puboprostatic ligaments and hematoma, but urethra is intact