Upper genitourinary (GU) tract:
Lower GU tract:
- External genitalia
- Approximately 3%–10% of hospitalized trauma patients have an injury to the GU system.
- Penetrating injuries (i.e. gunshot and stab wounds) account for 15% of all GU injuries.
- Uncommon and rarely life threatening, unless kidney vascular structures are involved
- The kidneys are the most injured GU organs, usually by blunt trauma.
- Ureteral trauma is very rare, most commonly due to penetrating injury (most cases are iatrogenic).
- Bladder injuries usually are associated with pelvic fractures.
- Urethral injuries are rare and occur almost exclusively in men.
- Direct blow to the flanks or the back
- Falling down from a height
- Car accident (rapid deceleration injury)
- Surgical trauma (iatrogenic injury)
Injuries to the Upper GU Tract
- Kidneys are protected by lower ribs, back musculature, and perinephric fat.
- Significant force is required to injure kidneys.
- Common mechanisms:
- Motor vehicle collision (MVC)
- Direct blows
- Lower rib fractures
- Flank pain/tenderness
- Hematuria (gross or microscopic)
- Flank ecchymosis
- Often in association with posterior rib or spine fractures
- May be associated with other intra-abdominal injuries
- Detects hematuria
- Less sensitive for penetrating trauma
- Degree of hematuria does not always correlate with severity.
- Plain X-ray:
- For associated injuries (e.g., rib fractures)
- Retained bullets/foreign bodies in penetrating trauma
- Ultrasound: for detection of intraperitoneal fluid (blood)
- Computed tomography (CT) scan:
- Test of choice in a hemodynamically stable patient
- Delayed images needed to detect contrast extravasation (bleeding)
- Also detects other associated injuries
- Plain X-ray:
- 1st step: stabilization, resuscitation, and identification of other life-threatening injuries
- Renal injuries themselves are rarely life threatening except for major avulsions of renal vessels.
- Management depends on severity.
- American Association for the Surgery of Trauma (AAST) grade Ⅰ and Ⅱ injuries usually managed non-operatively
- Grade Ⅲ–Ⅳ: may require nephrectomy, angiographic embolization, or stenting for vascular injuries
- Grade Ⅴ: frequently requires nephrectomy
|III||Renal parenchymal laceration > 1 cm depth without collecting system rupture or urinary extravasation|
- Ureteral injury is rare.
- 75% are iatrogenic (during gynecologic, urologic, or general surgical procedures).
- Most common blunt trauma is avulsion of uretero-pelvic junction (deceleration injury).
- May have minimal initial symptoms and often missed
- Delayed symptoms: fever, flank pain, and palpable mass (urinoma)
- Urinalysis may or may not show hematuria.
- Can be picked up on abdominal CT scan
- Intravenous pyelography (IVP) if CT is non-diagnostic
- Definitive management should be undertaken after other immediately life-threatening injuries have been addressed.
- Ureteral injuries usually require some reconstruction:
- Cystoscopic stent placement
- Operative repair over stent
- Urinary diversion
- Urine extravasation can cause urinomas, abscesses.
- Calculus formation
- Renal hypertension
- Loss of renal function
Injuries to the Lower GU Tract
- Injuries to the lower GU tract include:
- Highly associated with pelvic fractures
- Confined to extraperitoneal space (the anterior bladder wall or the bladder neck)
- Scrotal swelling
- Localized lower abdominal pain
- Inability to urinate
- Gross hematuria
- Retrograde cystogram
- Retrograde CT cystography
- CT abdomen and pelvis: shows contrast extravasation from the bladder
- Continuous prolonged bladder drainage with a Foley catheter
- Communicating with the peritoneum (the dome of the bladder)
- No desire to urinate
- Peritonitis and rebound tenderness
- Referred pain to the shoulder due to diaphragmatic irritation
- Ultrasound, usually part of focused assessment with sonography in trauma (FAST exam)
- Abdominal CT scan
- Management: surgical repair
- Blood at the urethral meatus
Anterior urethral injuries:
- Injury to bulbar (spongy) urethra
- Associated with perineal saddle injury
- Blood accumulates in scrotum → scrotal hematoma, ecchymosis
Posterior urethral injuries:
- Injury to membranous urethra
- Associated with pelvic fracture
- Urine leaks into retropubic space.
- High-riding prostate on digital rectal exam (DRE)
Diagnosis: retrograde urethrogram (RUG)
- Bladder drainage (suprapubic catheter) with or without delayed repair
- Urethral catheterization is contraindicated if blood is seen at the urethral meatus.
- Ecchymosis with no laceration is managed with perineal pressure (scrotal support with gauze packing).
- Perineal lacerations with urethral or bladder injury need urology consult to exclude the presence of urethrocutaneous or vesicocutaneous fistula.
- Suspected testicular rupture/torsion: surgical management to evaluate the salvageability of the tissue
Penile and scrotal injury
- Ultrasound is the preferred imaging.
- Non-operative: if tunica albuginea and dartos fascia are intact
- Penetration requires surgical exploration/repair.
- Urinary incontinence
- Sexual dysfunction
- Urethral stricture
- Runyon, M. (2020). Blunt genitourinary trauma: Initial evaluation and management. Retrieved December 19, 2020 from https://www.uptodate.com/contents/blunt-genitourinary-trauma-initial-evaluation-and-management
- Voelzke, B. (2020). Overview of traumatic lower genitourinary tract injuries in adults. Retrieved December 19, 2020 from https://www.uptodate.com/contents/overview-of-traumatic-lower-genitourinary-tract-injury
- Voelzke, B. (2020). Overview of traumatic upper genitourinary tract injuries in adults. Retrieved December 19, 2020 from https://www.uptodate.com/contents/overview-of-traumatic-upper-genitourinary-tract-injuries-in-adults
- Runyon, M. (2020). Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management. Retrieved December 19, 2020 from https://www.uptodate.com/contents/penetrating-trauma-of-the-upper-and-lower-genitourinary-tract-initial-evaluation-and-management
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