Urethro-venous intravasation: a rare complication of retrograde urethrogram.

To cite: Bansal A, Kumar M, Goel S, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2016215206 DESCRIPTION Case 1: A 53-year-old man presented with acute urinary retention for which suprapubic catheterisation was performed after failed multiple attempts of per urethral catheterisation. Retrograde urethrogram (RUG) revealed an anterior urethral stricture and dense intravasation and a cavernosogram and spongiogram showed a deep dorsal vein of penis along with pelvic vasculature (figure 1). The patient developed high-grade fever, chills, rigour, tachycardia and hypotension (septicaemia) after the RUG. He was managed with broad spectrum intravenous antibiotics and inotropes. He underwent excision and primary anastomosis of the anterior urethral stricture 3 weeks later. Case 2: A 46-year-old man presented with progressive lower urinary tract symptoms for the past 1 year. Uroflowmetry revealed a stricture pattern with peak flow of 3 mL/s. He underwent an RUG, which revealed a stricture at the level of the bulbar urethra with intravasation of contrast into the penopelvic venous arcade (figure 2). He did not develop any signs or symptoms of sepsis and had no contrast allergy. He underwent trocar suprapubic catheterisation under regional anaesthesia. After 3 weeks, he underwent an optical internal urethrotomy. Anterior urethral disease is best demonstrated by RUG. Urethro-venous intravasation is defined as visualisation of tributaries of veins draining the penis, a rare finding reported on RUG. The incidence of contrast intravasation on RUG is 1%. The reason for urethro-venous intravasation is breach of integrity of urothelial mucosa due to injection of the contrast agent under pressure in an inflamed and strictured urethra. Local vascularity is increased due to inflammation. Intravasation of contrast media may lead to introduction of uropathogens into the circulation resulting in bacteraemia or even sepsis. 2 The other complications of urethro-venous intravasation include contrast nephropathy, allergic reactions to contrast media and pulmonary oedema. It is necessary to take the history of previous urethral trauma, urethral instrumentation and allergy prior to performing an RUG. RUG should be carried out after an interval of 2–3 days if there is a history of prior urethral instrumentation or trauma. Urethral trauma can be minimised by performing gentle urethral catheterisation with adequate instillation of 2% lignocaine jelly (local anaesthetic) in the urethra. This complication can be averted by giving periprocedural antibiotics; urine should be sterile before the procedure and injection of the contrast agent should be carried out at low pressure under dynamic fluoroscopy.