Kidney injuries include contusions, hematomas, lacerations, and completely shattered kidneys with or without vascular injuries. Eighty percent of patients with kidney injury have additional visceral or skeletal injuries that complicate their management. Most renal injuries are handled nonoperatively, but indications for operative treatment include life-threatening bleeding from the kidney; expanding, pulsatile, or non-contained hematoma (thought to be from an avulsion injury); renal avulsion injury; and extravasation from the renal pelvis or from a ureteral injury. There are little data to support specific treatment recommendations for patients with isolated renal trauma. Patients with microscopic hematuria and no indication for imaging can be discharged home with instructions for no strenuous activity and follow-up in 1 to 2 weeks for repeat urinalysis. Those with a contusion (normal imaging and microscopic hematuria) can be discharged as above. Those with a higher-grade injury and/or gross hematuria should be admitted for observation (to include repeat hematocrit and urinalysis), hydration, and rest until gross hematuria clears, or general improvement ensues.
Ureteral injuries are almost always due to iatrogenic complications of instrumentation or penetrating trauma. Notably the absence of hematuria does not exclude an injury. In a stable patient a delayed CT scan of the abdomen and pelvis with IV contrast can identify ureteral injuries. If the CT scan is non-diagnostic and there is a high concern for an injury then an IV pyelogram or retrograde pyelogram is indicated. Treatment is operative, including stenting in some cases.
Bladder injuries occur in about 2% of blunt abdominal trauma patients and 80% are associated with pelvic fractures. Gross hematuria is present in about 95% of patients with significant injury and warrants a retrograde cystogram. Bladder injuries can also be present in pelvic fractures with only the presence of microscopic hematuria but the degree of microscopic hematuria warranting a cystogram is unclear. Extraperitoneal rupture is most common and can usually be treated by bladder catheter drainage alone. Intraperitoneal rupture always requires surgical exploration and repair. A retrograde cystogram can be performed by infusing ~350 ml of contrast material to distend the bladder. Passive bladder filling is not sensitive enough to exclude a bladder rupture. Sonographic diagnosis of a bladder injury is not accurate.
Posterior urethral injuries (membranous and prostatic urethra) are typically related to major blunt force trauma and are associated with pelvic fractures. Treatment is via suprapubic bladder drainage followed by surgical repair in several weeks. Because a urinary catheter can disrupt a partial posterior urethral injury, one should not be placed if there is suspicion of injury without first obtaining a retrograde urethrogram. Anterior urethral injuries usually occur due to direct trauma such as from a straddle injury or a direct blow to the bulbar or penile urethra. The absence of hematuria does not rule-out a urethral injury. If there is concern for an injury, then avoid placing a foley catheter and obtain a retrograde urethrogram by injecting 20 to 30 mL of contrast into the urethra and obtain a radiograph. If a foley catheter has already been placed, then a 16-gauge angiocatheter can be used to inject contrast between the catheter and urethra. Treatment is supportive, which may include a urinary catheter. Penetrating trauma to the anterior urethra generally requires operative repair.
Evaluate blunt testicular trauma with an ultrasound examination. If testicular rupture is present, exploration and repair is indicated. If the testicle is intact, conservative treatment with ice, elevation, scrotal support, and pain medication is appropriate. Hematomas and hematoceles are managed on a case-by-case basis. Penetrating testicular trauma warrants surgical exploration and repair. Scrotal lacerations can be directly repaired and scrotal avulsions require surgical repair with the testicle covered in the remaining scrotum.
Simple contusions are managed conservatively with cold packs, rest, and pain medications. Simple lacerations involving skin only can be directly repaired, but deeper lacerations and/or penetrating injuries require operative exploration and repair. Amputation requires microsurgical reimplantation if the amputated segment is viable. Penile fractures require exploration and repair.