• Clinical science

Genitourinary trauma

Summary

Genitourinary trauma involves injury to the kidneys, ureters, bladder, and/or urethra. It may result in high morbidity if not properly identified and managed. The diagnosis of genitourinary trauma typically relies on patient history, physical examination, urinalysis, and imaging (CT, cystoscopy, retrograde urethrogram). Renal trauma is most often an acute condition caused by a blunt abdominal injury and may, if severe, represent a urological emergency. The classical symptoms of renal trauma are hematuria and pain in the affected side following injury. Mild trauma generally only requires monitoring, while high-grade injury may require emergency surgery and intensive care. Injury to the ureters is rare and generally iatrogenic, occurring mostly during operative procedures. Management may require stent placement with surgical repair. Bladder injuries are common in blunt abdominal trauma. Classic symptoms are gross hematuria, an inability to void, and abdominal pain. Extraperitoneal bladder injuries usually resolve with catheterization, while intraperitoneal injury requires surgery, which can help to prevent peritonitis and urosepsis. Urethral injuries may involve the posterior urethra, causing a high-riding prostate and blood at the urethral meatus, or the anterior urethra, causing perineal pain or hematoma. Treatment may be conservative or surgical depending on the severity of injury. Complications of the genitourinary tract include urinary extravasation, urinoma, abscess formation, renal hypertension, and loss of function in the affected kidney.

Etiology

Renal and ureteral injuries

  • Blunt abdominal trauma (80% of cases); : falls from a height, automobile collisions, blows to the torso, pelvic fractures
  • Blunt thoracic trauma: associated with lower rib (9th –12th) fractures
  • Penetrating trauma (gunshot or stab wounds); assault (physical or sexual)

Bladder injuries

Urethral injuries

In patients with pelvic fractures, always evaluate for possible injury to the genitourinary system!

References:[1][2][3][4][5][6][7]

Clinical features

Renal and ureteral injuries

Bladder injuries

  • Extraperitoneal and/or intraperitoneal injury
    • Gross hematuria (majority of cases)
    • Inability to void
    • Pain in the lower abdomen
  • Intraperitoneal injury

Urethral injuries

Anterior urethral injury Posterior urethral injury
Findings upon examination
  • Blood at urethral meatus and initial hematuria
  • High-riding prostate on exam
  • Inability to void despite urge palpable distended bladder
  • Suprapubic pain
Urine extravasation

Injury to the urinary system can be easily masked by multiple concurrent injuries to other organ systems and is therefore easily overlooked!


References:[1][2][8]

Diagnostics

General approach to genitourinary trauma

  • Patient history
  • Physical examination
  • Urinalysis with microscopy: macroscopic hematuria (urine not clear or yellow) or microscopic hematuria
    • The color of the urine does not correlate with injury severity!
    • Microscopic hematuria after significant (nonurethral) trauma is common; no further diagnostic tests are needed in patients who are hemodynamically stable and present without any other signs or symptoms of associated pelvic or abdominal injury.
  • Blood analysis: exclude anemia due to blood loss; assess renal function (creatinine)

Evaluate the genitourinary tract in a retrograde fashion, beginning with the external genitalia and urethra!

Renal and ureteral injury

  • CT with IV contrast of the abdomen/pelvis: to assess renal and accompanying injuries or intra-abdominal fluid retention
  • Delayed CT imaging: indicated if injury to the renal pelvis and ureters is suspected
  • IV pyelography: to assess for contrast extravasation if delayed CT images are nondiagnostic
  • Urethrocystography: if CT is unavailable

Bladder injury

Urethral injury

  • Retrograde urethrogram: to rule out suspected urethral injury
    • First diagnostic step (before catheterization) in a patient with suspected urethral injury
    • Findings: contrast extravasation from the urethra at point of injury
  • Foley catheter placement
    • Suspected urethral injury is a relative contraindication for catheterization, as it may worsen the injury.
    • In cases of gross hematuria without other clinical signs of urethral injury, a single attempt at Foley catheter placement may be performed.
    • Successful catheterization without resistance makes urethral injury an unlikely diagnosis.
    • If any resistance is met, retrograde urethrography should be performed.

A negative urinalysis does not exclude renal injury because not all injuries affect the renal pelvis and urinary tract!

References:[1][9]

Treatment

General

  • Hemodynamically stable patients with minor trauma: observe with Foley catheter placement, if needed, for hematuria and/or oliguria
  • Hemodynamically unstable patients: may require immediate surgical intervention for other injuries prior to definitive treatment of genitourinary injuries

Renal and ureteral trauma

Low-grade renal injury

High-grade renal injury

  • Stable hemodynamics
  • Unstable hemodynamics: : emergent exploration with surgical defect repair and possible nephrectomy to prevent life-threatening bleeding

Ureteral trauma

  • Cystoscopic stent placement with surgical repair over stent if needed
  • May require urinary diversion

Bladder injuries

  • Goal is to keep bladder decompressed → minimizes bladder wall tension to facilitate healing
    • No urethral injury: place Foley catheter to drain bladder; irrigate bladder to clear clots
    • Extraperitoneal injury without involvement of bladder neck: insertion of a transurethral indwelling catheter; otherwise suprapubic urinary diversion
    • Extraperitoneal injuries involving bladder neck: associated with rectal/vaginal injury and all intraperitoneal injuries (i.e., bladder dome) → open surgical repair

Urethral injuries

References:[1][10][11]

Complications

References:[2][12]

We list the most important complications. The selection is not exhaustive.