Practice Essentials
The lower genitourinary (GU) tract is composed of the bladder, urethra, and external genitalia. Significant injury to the lower genitourinary system can occur from both blunt and penetrating trauma. Initial evaluation of the injured patient suspected of having GU trauma should not differ from that of other trauma patients. Providers should follow the Advanced Trauma Life Support protocols of the American College of Surgeons.. Often management of other injuries takes priority and may initially postpone a complete urologic assessment. While fatality related to GU trauma is not common, identifying injury to the GU system and appropriate management of these injuries is essential to avoid complications such as urinary incontinence/retention and sexual dysfunction. [1, 2, 3, 4, 5, 6, 7, 8, 9]
Up to 15% of patients who experience abdominal trauma will have injuries to the renal and urogenital systems. Bladder injuries are most frequently due to blunt trauma such as a motor vehicle accident. Approximately 30% of pelvic fractures have an associated bladder injury. Between 60-90% of bladder injuries have associated pelvic fracture. [10] Male external genitalia injury is the most common occurrence. Typically, genital trauma is from blunt or penetrating mechanisms such as motor vehicle accidents or gunshot wounds, though injuries such as straddle injury, zipper/entrapment injury, and animal bites are also seen. Penile fracture is a rare urologic emergency caused by rupture of the corpus cavernosum. Female external lower GU trauma is more often associated with childbirth than other trauma mechanisms. The majority of traumatic bladder injuries have a blunt mechanism of injury, though are overall uncommon. While trauma is the leading cause of death among persons aged 1-40 years and is the third-ranked cause of mortality in all age groups; mortality specifically from lower GU trauma is uncommon. When mortality occurs, it is often seen in patients with concurrent pelvic fractures. [9, 10, 11, 12, 13, 14, 15, 18, 20, 21, 22, 23, 33, 34, 35, 36]
Signs and Symptoms
Patients with GU trauma will likely have localized pain in the area of injury. However, signs of lower GU injury can easily be missed within the extensive but rapid assessment that occurs during a trauma evaluation. Therefore, it is important to always keep a high index of suspicion and be sure to assess the abdomen and genitalia carefully. [24] Bladder trauma may present with bruising or edema of the lower abdomen, perineum, or genitalia, an inability to void, hematuria, and an inability to retrieve all fluid used to irrigate the bladder through a Foley catheter. [4, 6, 9] Urethral trauma may be indicated by blood at the meatus, penile or perineal edema and/or hematoma, high-riding prostate, and a distended bladder. Signs of penile and scrotal trauma include loss of skin, edema, discoloration, and angulation. [5, 7, 8, 11, 12]
Workup
The majority of lower GU injuries will be identified on exam and imaging. Work up may include basic trauma laboratory studies including a complete blood count (CBC), coagulation studies (PT/INR), type and screen, and urinalysis.
Focused Assessment with Sonography in Trauma (FAST) Ultrasound exam is used in trauma evaluation to assess for intraperitoneal free fluid. A positive FAST exam can be caused by injury to the GU organs such a bladder rupture. However, FAST exam does not identify the source of the blood or free fluid in the peritoneum. Plain radiography is used to assess pelvis injury.
CT imaging can identify abdominal/pelvic organ injury. Perform cystography and retrograde urethrography as needed to identify extent of injuries. Cystography is recommended to evaluate for bladder injury. If there is concern for urethral trauma, retrograde urethrogram (RUG) is performed. Urethral and bladder injuries are identified if extravasation of contrast is seen. If there is concern for urethral trauma, imaging should be completed prior to attempting to pass a urethral catheter. Ultrasound is used for assessment of testicular trauma. [9, 10, 11, 13, 25, 26, 27, 28, 29, 30, 31]
Management
Administer oxygen and ventilatory support if needed. Resuscitate with crystalloids (lactated Ringer solution or isotonic sodium chloride solution) and blood (O-negative packed red blood cells) if indicated. Life-threatening injuries (eg, tension pneumothorax, open pneumothorax, cardiac tamponade) should be addressed emergently in the ED.
Bladder contusion is the most common type of bladder injury and results in focal thickening of the bladder wall which are managed conservatively. The management strategy of more significant bladder injuries depends on whether it is intraperitoneal or extraperitoneal, with many extraperitoneal bladder injuries treated non-operatively. Management of urethral injuries is related to the type of injury sustained, but in the acute setting, the bladder should be drained with a suprapubic catheter to prevent further extravasation. Delayed repair of urethral injuries is standard of care. Management of genital injuries depends on the severity of trauma and the extent of tissue damage. Genital skin injuries are treated by debridement and split-thickness skin grafting. Scrotal or testicular injuries may require follow-up hormonal studies and semen analysis. [32, 33, 35, 36, 37, 42]
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Normal urethrogram.
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Retrograde urethrogram showing an irregularity of the urethra indicating injury secondary to a shotgun wound.
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Normal bladder on CT scan.
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Ruptured dome of urinary bladder detected by retrograde cystogram.
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Ruptured urinary bladder detected by CT scan.
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Extravasated contrast in abdominal cavity secondary to ruptured bladder.
