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
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 per-
formed. No intraperitoneal injuries were identified. The
intraoperative cystogram revealed extraperitoneal extravasa-
tion of contrast near the base of the bladder.
The patient did well postoperatively. Urologic and
orthopedic consultations were obtained. Urology recom-
mended 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
Fig. 1 Computed tomography showing projectile with associated
artifact located in the rectovesical space (arrow).
0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
American Journal of Emergency Medicine (2008) 26, 842.e1–842.e2