Chapter 124

Urinary tract injuries may result from blunt trauma, penetrating trauma, urologic procedures, or may arise spontaneously. Bladder injuries occur in up to 15 percent of pelvic fractures.1–3 Associated urethral injuries occur in up to 11 percent of males and up to 6 percent of females.1–3 The role of retrograde urethrography and cystography in the trauma patient is to rule out a partial urethral rupture, complete urethral rupture, or a bladder rupture. On initial presentation to the Emergency Department there are clear indications for performing these procedures. The importance of proper training in these techniques must be stressed to avoid secondary urologic complications.

The evaluation of a traumatically injured patient should include, if appropriate, an assessment of the bony pelvis and the genitourinary system. The identification of a pelvic fracture must be followed by an examination of the lower genitourinary tract to rule out associated injury. Unfortunately, the lack of a pelvic fracture does not eliminate the possibility of a bladder or urethral injury. The most common signs seen in patients with genitourinary tract injury are gross hematuria (82 percent) and abdominal tenderness (62 percent).4 Other signs of genitourinary tract injury include blood at the urethral meatus, inability to void, swelling or ecchymosis of the perineum or penis, a boggy prostate, and a high riding prostate. In the presence of any of these signs, an evaluation of the genitourinary tract is indicated. These assessments should be made early and intervention instituted.

The lower urinary tract in males consists of the urethra and bladder (Figure 124-1). The urethra is divided into the fossa navicularis, the penile urethra, the bulbar urethra, the membranous urethra, and the prostatic urethra based on its anatomic location. The bladder neck opens into the trigonal canal and funnels into the bladder. The male posterior urethra is 5.0 to 5.5 cm long, fixed to the urogenital diaphragm, and is the area most susceptible to injury.2,5 The female urethra is short, not rigidly fixed to the pubis or pelvic floor, mobile, and much less susceptible to injury.3 The female urethra is equivalent to the membranous and prostatic (posterior) urethra in the male.6

###### Figure 124-1

Anatomy of the male genitourinary tract.

The periurethral striated sphincter is composed of muscle from the urogenital diaphragm. This muscle layer unites with the distal smooth muscle at the intermuscular incisura. This is frequently seen on the voiding cystourethrogram and may be mistaken for a stricture or posterior urethral valves. The urogenital diaphragm surrounds the membranous urethra and may compress the urethra during voiding or on retrograde flow of contrast.6

The verumontanum and urethral crest protrude into the male prostatic urethral lumen and may extend into the membranous urethra. The prostatic gland ducts, prostatic utricle, ejaculatory ducts, and urethral gland ducts usually do not ...

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