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Genitourinary (GU) injuries frequently occur in the setting of polytrauma, so a thorough evaluation is necessary to avoid missing significant injuries.
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Injuries should be suspected with any blunt or penetrating trauma near the GU tract, including any rapid deceleration, which can cause major vascular or parenchymal injury even without specific signs or symptoms. Hematuria of any amount raises the index of suspicion for GU injury, and difficulty with urination can be due to bladder or urethral injury or associated concomitant spinal cord injury. Flank contusions or hematomas, evidence of lower rib fractures, or penetrating flank injuries raise concern for renal injury. Lower abdominal pain, tenderness, ecchymosis, or evidence of a pelvic fracture as well as perineal or scrotal edema are consistent with possible bladder injury. Vaginal bleeding, a high-riding prostate, a perineal hematoma, and/or blood at the urethral meatus are concerning for urethral disruption.
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DIAGNOSIS AND DIFFERENTIAL
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There is no direct relationship between the degree of hematuria and the severity of renal injury. There is some evidence that microscopic hematuria in patients with a blood pressure <90 mm Hg or any gross hematuria is associated with a more significant renal injury. In children where renal trauma is being considered, isolated microscopic hematuria with <50 red blood cells per high-powered field makes a significant renal injury less likely. An IV contrast-enhanced abdominal/pelvic CT scan is the imaging “gold standard” for the stable trauma patient with a suspected kidney injury. A 10-minute delayed image is needed to ascertain whether there is any urine extravasation but can be omitted if the kidney is normal and there are no fluid collections. A retrograde cystogram (plain film or CT) is the “gold standard” for demonstrating bladder injury, and a retrograde urethrogram is indicated for demonstrating urethral injuries. Color Doppler ultrasonography is the preferred imaging technique for investigating closed scrotal and testicular injuries. A focused assessment with sonography in trauma (FAST) exam can detect intra-abdominal fluid collections but cannot reliably evaluate renal, bladder, or ureteral injuries Table 167-1.
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