Blunt genitourinary trauma: Initial evaluation and management
- Michael S Runyon, MD, MPH
Michael S Runyon, MD, MPH
- 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
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts 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".)
- Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: external genitalia. BJU Int 2004; 94:507.
- Mydlo JH, Harris CF, Brown JG. Blunt, penetrating and ischemic injuries to the penis. J Urol 2002; 168:1433.
- Swanson DE, Polackwich AS, Helfand BT, et al. Penile fracture: outcomes of early surgical intervention. Urology 2014; 84:1117.
- Lumen N, Kuehhas FE, Djakovic N, et al. Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol 2015; 67:925.
- Chapple CR, Png D. Contemporary management of urethral trauma and the post-traumatic stricture. Curr Opin Urol 1999; 9:253.
- Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999; 161:1433.
- Serafetinides E, Kitrey ND, Djakovic N, et al. Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol 2015; 67:930.
- Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int 2004; 94:27.
- Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radiographics 2000; 20:1373.
- Siram SM, Gerald SZ, Greene WR, et al. Ureteral trauma: patterns and mechanisms of injury of an uncommon condition. Am J Surg 2010; 199:566.
- Koifman L, Barros R, Júnior RA, et al. Penile fracture: diagnosis, treatment and outcomes of 150 patients. Urology 2010; 76:1488.
- Andrich DE, Mundy AR. The nature of urethral injury in cases of pelvic fracture urethral trauma. J Urol 2001; 165:1492.
- Dorschner W, Biesold M, Schmidt F, Stolzenburg JU. The dispute about the external sphincter and the urogenital diaphragm. J Urol 1999; 162:1942.
- Gerstenbluth RE, Spirnak JP, Elder JS. Sports participation and high grade renal injuries in children. J Urol 2002; 168:2575.
- Gottenger EE, Wagner JR. Penile fracture with complete urethral disruption. J Trauma 2000; 49:339.
- Goldman HB, Idom CB Jr, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol 1998; 159:956.
- Lev RY, Mor Y, Golomb J, et al. Missed female urethral injury complicated by myonecrosis of the thigh. J Urol 2001; 165:1216.
- Lowe MA, Mason JT, Luna GK, et al. Risk factors for urethral injuries in men with traumatic pelvic fractures. J Urol 1988; 140:506.
- Basta AM, Blackmore CC, Wessells H. Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma. J Urol 2007; 177:571.
- Aihara R, Blansfield JS, Millham FH, et al. Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures. J Trauma 2002; 52:205.
- Watnik NF, Coburn M, Goldberger M. Urologic injuries in pelvic ring disruptions. Clin Orthop Relat Res 1996; :37.
- Pokorny M, Pontes JE, Pierce JM Jr. Urological injuries associated with pelvic trauma. J Urol 1979; 121:455.
- Avey G, Blackmore CC, Wessells H, et al. Radiographic and clinical predictors of bladder rupture in blunt trauma patients with pelvic fracture. Acad Radiol 2006; 13:573.
- Morey AF, Iverson AJ, Swan A, et al. Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma 2001; 51:683.
- Morgan DE, Nallamala LK, Kenney PJ, et al. CT cystography: radiographic and clinical predictors of bladder rupture. AJR Am J Roentgenol 2000; 174:89.
- Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol 2003; 170:1213.
- Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med 2007; 50:25.
- Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma 2005; 59:1314.
- Ball CG, Jafri SM, Kirkpatrick AW, et al. Traumatic urethral injuries: does the digital rectal examination really help us? Injury 2009; 40:984.
- Johnson MH, Chang A, Brandes SB. The value of digital rectal examination in assessing for pelvic fracture-associated urethral injury: what defines a high-riding or nonpalpable prostate? J Trauma Acute Care Surg 2013; 75:913.
- Shlamovitz GZ, McCullough L. Blind urethral catheterization in trauma patients suffering from lower urinary tract injuries. J Trauma 2007; 62:330.
- Spencer Netto FA, Hamilton P, Kodama R, et al. Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury. J Am Coll Surg 2008; 206:322.
- Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol 2014; 192:327.
- Haas CA, Brown SL, Spirnak JP. Limitations of routine spiral computerized tomography in the evaluation of bladder trauma. J Urol 1999; 162:51.
- Hsieh CH, Chen RJ, Fang JF, et al. Diagnosis and management of bladder injury by trauma surgeons. Am J Surg 2002; 184:143.
- Morey AF, McAninch JW, Tiller BK, et al. Single shot intraoperative excretory urography for the immediate evaluation of renal trauma. J Urol 1999; 161:1088.
- Bandi G, Santucci RA. Controversies in the management of male external genitourinary trauma. J Trauma 2004; 56:1362.
- Jones AE, Mason PE, Tayal VS, Gibbs MA. Sonographic intraperitoneal fluid in patients with pelvic fracture: two cases of traumatic intraperitoneal bladder rupture. J Emerg Med 2003; 25:373.
- Fraser JD, Aguayo P, Ostlie DJ, St Peter SD. Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int 2009; 25:125.
- http://www.auanet.org/common/pdf/education/clinical-guidance/Urotrauma.pdf (Accessed on January 16, 2017).
- Santucci RA, McAninch JW, Safir M, et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma 2001; 50:195.
- Sangthong B, Demetriades D, Martin M, et al. Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank. J Am Coll Surg 2006; 203:612.
- ANATOMY, PHYSIOLOGY, AND MECHANISM
- PREHOSPITAL MANAGEMENT
- CLINICAL FEATURES
- PRIMARY EVALUATION AND MANAGEMENT
- Initial assessment
- History, examination, and approach to testing
- Diagnostic tests
- - Urinalysis
- - Plain radiographs
- - Retrograde urethrogram
- - Retrograde cystogram
- - CT scanning
- - Intravenous pyelography (IVP)
- - Retrograde pyelography
- - Ultrasound
- PEDIATRIC CONSIDERATIONS
- SUBSEQUENT MANAGEMENT
- PITFALLS OF MANAGEMENT
- DEFINITIVE MANAGEMENT
- SUMMARY AND RECOMMENDATIONS