Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management
- Michael S Runyon, MD, MPH
Michael S Runyon, MD, MPH
- Associate Professor of Emergency Medicine
- Carolinas HealthCare System
- Section Editor
- 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
- 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 penetrating genitourinary (GU) injuries minimize associated morbidity, which may include renal insufficiency, urinary incontinence, and sexual dysfunction. 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.
Ideally, in stable patients, the investigation for GU injury is conducted in a retrograde fashion beginning with evaluation of the external genitalia. The upper GU tract (ureters and kidneys) is evaluated after injury to the lower tract (bladder and urethra) is excluded, or after initiation of appropriate emergency management for an identified lower tract injury.
Except in rare instances (eg, shattered kidney or major renal vascular laceration), GU injuries seldom pose a threat to life. As such, in the multiply injured or unstable patient, evaluation for GU injury is deferred until other, potentially life-threatening, injuries are excluded, and the patient is stabilized.
The assessment and initial management of penetrating injuries to the upper and lower genitourinary tract are reviewed here. Blunt GU injuries, including straddle injuries, and other aspects of trauma management are discussed separately. (See "Blunt genitourinary trauma: Initial evaluation and management" and "Straddle injuries in children: Evaluation and management".)
Approximately 10 percent of trauma patients sustain injury to the genitourinary (GU) system. Of these, approximately 15 percent are due to a penetrating mechanism, most commonly gunshot or stab wounds . With the exception of a shattered kidney or major renal vascular laceration with significant hemorrhage, penetrating genitourinary injury is rarely life-threatening.
- Jankowski JT, Spirnak JP. Current recommendations for imaging in the management of urologic traumas. Urol Clin North Am 2006; 33:365.
- Bandi G, Santucci RA. Controversies in the management of male external genitourinary trauma. J Trauma 2004; 56:1362.
- Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int 2004; 94:27.
- Cinman NM, McAninch JW, Porten SP, et al. Gunshot wounds to the lower urinary tract: a single-institution experience. J Trauma Acute Care Surg 2013; 74:725.
- Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol 2003; 170:1213.
- Carver BS, Bozeman CB, Venable DD. Ureteral injury due to penetrating trauma. South Med J 2004; 97:462.
- Best CD, Petrone P, Buscarini M, et al. Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale. J Urol 2005; 173:1202.
- Perez-Brayfield MR, Keane TE, Krishnan A, et al. Gunshot wounds to the ureter: a 40-year experience at Grady Memorial Hospital. J Urol 2001; 166:119.
- Lynch TH, Martínez-Piñeiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol 2005; 47:1.
- Hall SJ, Wagner JR, Edelstein RA, Carpinito GA. Management of gunshot injuries to the penis and anterior urethra. J Trauma 1995; 38:439.
- 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.
- Al-Qudah HS, Santucci RA. Complications of renal trauma. Urol Clin North Am 2006; 33:41.
- Kansas BT, Eddy MJ, Mydlo JH, Uzzo RG. Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center. J Urol 2004; 172:1355.
- 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.
- Hsieh CH, Chen RJ, Fang JF, et al. Diagnosis and management of bladder injury by trauma surgeons. Am J Surg 2002; 184:143.
- Ramchandani P, Buckler PM. Imaging of genitourinary trauma. AJR Am J Roentgenol 2009; 192:1514.
- Srinivasa RN, Akbar SA, Jafri SZ, Howells GA. Genitourinary trauma: a pictorial essay. Emerg Radiol 2009; 16:21.
- Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radiographics 2000; 20:1373.
- 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.
- Rosenstein DI, Alsikafi NF. Diagnosis and classification of urethral injuries. Urol Clin North Am 2006; 33:73.
- Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008; 207:646.
- Kuan JK, Wright JL, Nathens AB, et al. American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy, dialysis, and death in patients with blunt injury and nephrectomy for penetrating injuries. J Trauma 2006; 60:351.
- Santucci RA, Wessells H, Bartsch G, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int 2004; 93:937.
- ANATOMY, PHYSIOLOGY, AND MECHANISM
- PREHOSPITAL MANAGEMENT
- CLINICAL FEATURES
- PRIMARY EVALUATION AND MANAGEMENT
- Initial assessment
- Approach to testing
- Diagnostic tests
- - Urinalysis
- - Plain radiographs
- - Ultrasound
- - Retrograde urethrogram
- - Retrograde cystogram
- - CT scanning
- - IV pyelography
- - Retrograde pyelography
- SUBSEQUENT MANAGEMENT AND CONSULTATION
- PITFALLS OF MANAGEMENT
- DEFINITIVE MANAGEMENT
- SUMMARY AND RECOMMENDATIONS