Blunt genitourinary trauma: Initial evaluation and management
- Michael S Runyon, MD, FAAEM, FACEP
Michael S Runyon, MD, FAAEM, FACEP
- Associate Professor of Emergency Medicine
- Carolinas HealthCare System
- Section Editors
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
Timely identification and management of blunt genitourinary injuries minimize associated morbidity, which may include impairment of urinary continence and sexual function. Prompt injury identification depends upon a systematic evaluation with consideration of the mechanism of injury, pertinent physical examination findings, analysis of the urine, and appropriate diagnostic imaging, performed in the correct sequence.
Except in the rare instance of a shattered kidney or major renal vascular laceration with significant hemorrhage, genitourinary injuries seldom pose a threat to life. Once life-threatening conditions are stabilized, investigation for genitourinary injury is conducted in a retrograde fashion beginning with evaluation of the external genitalia and urethra prior to that of the bladder. The ureters and kidneys are evaluated after lower tract injury is excluded, or after initiation of appropriate emergency management for an identified lower tract injury.
This topic review will discuss the diagnosis and management of genitourinary injury sustained through blunt trauma. Discussions of general trauma management and other specific injuries are found elsewhere. (See "Initial management of trauma in adults" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Pelvic trauma: Initial evaluation and management".)
Approximately 10 percent of patients suffering injuries severe enough to require admission to a trauma service sustain injury to the genitourinary tract. The majority of these injuries (approximately 80 percent) result from blunt trauma. Common mechanisms of injury include motor vehicle collisions (MVC), falls from height, and direct blows to the torso or external genitalia. Injuries to the female genitalia are often associated with pelvic fractures.
Other important mechanisms include physical or sexual assault, consensual intercourse, and penetrating injuries. In the adult patient, isolated blunt injury to the vulva is unusual and should prompt screening for interpersonal violence. In men, up to 85 percent of testicular injuries result from blunt trauma. Resultant injuries include hematoma, rupture, displacement, and torsion. Penile fracture is an uncommon injury resulting from rupture of the tunica albuginea, with concomitant urethral injury occurring in up to 20 percent of cases [1-4]. Overall, urethral disruption accompanies pelvic fracture in approximately five percent of cases in women and up to 25 percent in men; risk varies with the extent of the fracture [5,6]. Blunt injury accounts for the majority of bladder trauma and a pelvic fracture accompanies most cases of bladder rupture [4,7,8]. (See "Pelvic trauma: Initial evaluation and management".)
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- ANATOMY, PHYSIOLOGY, AND MECHANISM
- PREHOSPITAL MANAGEMENT
- CLINICAL FEATURES
- PRIMARY EVALUATION AND MANAGEMENT
- Initial assessment
- History, examination, and approach to testing
- Diagnostic tests
- - Urinalysis
- - Plain x-rays
- - Retrograde urethrogram
- - Retrograde cystogram
- - CT scanning
- - Intravenous pyelography (IVP)
- - Retrograde pyelography
- - Ultrasound
- PEDIATRIC CONSIDERATIONS
- SUBSEQUENT MANAGEMENT
- PITFALLS OF MANAGEMENT
- DEFINITIVE MANAGEMENT
- SUMMARY AND RECOMMENDATIONS