Urinary tract injuries may result from blunt trauma, penetrating trauma, urologic procedures, or may arise spontaneously.1–14 Bladder injuries occur in up to 15% of pelvic fractures.1–3 Associated urethral injuries occur in up to 11% of males and up to 6% 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 iatrogenic or secondary urologic injury.
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. Patients with disruption of the pubic symphysis, pubic rami, or a vertically unstable pelvic fracture have a high incidence of concomitant bladder trauma. Those with an isolated acetabulum, femur, or iliac crest fracture have a low incidence of bladder injury or rupture.13 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%) and abdominal tenderness (62%).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.
Traditional teaching suggests that urethral catheterization should be avoided if a potential injury to the bladder and/or urethra is suspected. This teaching requires a retrograde urethrogram and cystogram to be performed to rule out any injuries prior to urethral catheterization. A preliminary study suggests that blind urethral catheterization despite a potential injury may be safe.15 Larger and additional studies are required before this change in practice can be safely recommended.
The lower urinary tract in males consists of the urethra and bladder (Figure 145-1). 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