Chapter 167. Genitourinary Injuries

Genitourinary (GU) injuries frequently occur in the setting of multiple trauma, so a thorough evaluation is necessary to avoid missing significant injuries.

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 is consistent with possible bladder injury. Vaginal bleeding, high-riding prostate, perineal hematoma, and/or blood at the urethral meatus are consistent with urethral disruption.

There is no direct relationship between the degree of hematuria and the severity of renal injury. There is some evidence that gross hematuria or microscopic hematuria in patients with a blood pressure <90 mm Hg is associated with more significant injury. An IV contrast-enhanced abdominal/pelvic CT scan is the imaging “gold standard” for the stable trauma patient with suspected kidney injury (Table 167-1). A “one-shot” intraoperative IV urogram is recommended by some for the unstable patient, though this is controversial. A retrograde cystogram (plain film or CT) is the “gold standard” for demonstrating bladder injury, and a retrograde urethrogram is indicated for demonstrating urethral injury. Color Doppler ultrasonography is the preferred imaging technique for investigating closed scrotal and testicular injury.

Take a standardized approach to all multiple trauma patients to identify and treat life-threatening injuries (primary survey) and then perform a thorough secondary survey, including a GU examination, to diagnose all injuries. Obtain appropriate diagnostic imaging and laboratory testing as indicated by the initial history and examination.

Kidney

Various kidney injuries include contusions, hematomas, lacerations, and completely shattered kidneys with or without vascular injury. 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 noncontained hematoma (thought to be from an avulsion injury); and renal avulsion injury (Fig. 167-1). 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.

Ureter

Ureteral injuries are almost always due to iatrogenic complications of instrumentation or penetrating trauma. Treatment is operative, including stenting in some cases. The absence of hematuria does not exclude injury.

Bladder

Bladder injury occurs 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. Extraperitoneal rupture is most common and can usually be treated by bladder catheter drainage alone. Intraperitoneal rupture always requires surgical exploration and repair.

Urethra

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 as from a straddle injury or a direct blow to the bulbar or penile urethra. Treatment is supportive, which may include a urinary catheter. Penetrating trauma to the anterior urethra generally requires operative repair.

Testicles and Scrotum

Evaluate blunt testicular trauma with an ultrasound examination. If testicular rupture is present, exploration and repair is indicated. If the testicle is intact, then 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.

Penis

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.