Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management
- Michael S Runyon, MD, FAAEM, FACEP
Michael S Runyon, MD, FAAEM, FACEP
- Associate Professor of Emergency Medicine
- Carolinas HealthCare System
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.
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- 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