Definition
• Trauma to the structures of the genitourinary tract, uncommon to be life-threat unless significant renal/vascular injury
Approach
Inspection
• Blood at meatus (urethra trauma), blood in vagina, perineal lacerations (do not probe → hemorrhage), scrotal ecchymosis/lacerations, flank bruising
Palpation
• Rectal exam (high-riding prostate/boggy → membranous urethral injury, blood → rectal laceration), testicular disruption
Labs
• UA (microscopic hematuria → no eval, gross blood → serious GU trauma)
Radiology
• RUG: Males w/ blood at meatus before Foley placement (to prevent full urethral tear/false passage), inject 50 cc contrast into urethra → pelvic x-ray for extravasation
• Cystogram: Instill 400–500 cc contrast into bladder via Foley → AP film or CT scan → repeat image after contrast is washed out (posterior bladder tears)
• IV pyelogram: Rarely indicated
• CT scan (IV contrast): Complete eval of kidneys
Renal Laceration
Definition
• Laceration to kidney (major: Extend to medulla/collecting system, minor: No involvement of collecting system/medulla, no extraversion of urine)
History
• Penetrating trauma
Physical Findings
• Flank wound, gross hematuria, ± hypotension
Evaluation
• CBC, UA, other trauma labs as needed, CT scan: Eval extent of injury
Treatment
• Surgery consult, minor lacerations may be nonoperative
Disposition
• Admit
Renal Contusion
Definition
• Contusion to kidney
History
• Blunt trauma
Physical Findings
• Flank ecchymosis
Evaluation
• UA (if neg → no further testing), CT scan
Treatment
• Surgery consult, subcapsular hematoma → 24 h observation/serial HCT/serial UA/bed rest, microscopic hematuria → avoid strenuous exercise/repeat UA in 2 d + until clear
Disposition
• Admit: Major/subcapsular hematoma
• Home: Microscopic hematuria
Renal Pedicle/Vascular Injury
Definition
• Injury to renal pedicle or vasculature
History
• High-velocity deceleration, penetrating trauma
Physical Findings
• Flank ecchymosis, hypotension
Evaluation
• UA, CBC, Coags, BMP, CT scan: Nonenhancing kidney/± perirenal hematoma
Treatment
• Surgery consult for operative management → repair (20% salvage rate in pedicle lacerations) vs. nephrectomy
Disposition
• Admit
Renal Pelvis Rupture
Definition
• Rupture of the renal pelvis
History
• High-velocity deceleration, penetrating trauma
Physical Findings
• Flank ecchymosis, hypotension
Evaluation
• UA, CBC, Coags, BMP, CT scan: Extravasation of urine in perirenal space
Treatment
• Urology consult for operative repair
Disposition
• Admit
Pearl
• ↑ risk of infection in delayed repair
Ureteral Injuries
Definition
• Injury to ureter (very rare), majority are iatrogenic from gyn/uro procedures
History
• Hyperextension, penetrating trauma, forced flexion of L-spine → rupture below UPJ, delayed necrosis from microvascular injury after GSW (rare)
Evaluation
• UA, HCT, CT scan: Extravasation of urine, IVP (limited sens)
Treatment
• Urology consult for operative ureteroureterostomy
Disposition
• Admit
Intraperitoneal Bladder Rupture
Definition
• Rupture of the bladder w/ intraperitoneal spillage
History
• MVC, blunt trauma (burst injury)
Physical Findings
• Lower abdominal tenderness, ↓ UOP, hematuria
Evaluation
• UA, HCT, CT cystogram/cystogram: Extravasation of urine
Treatment
• Urology consult for urgent operative repair
Disposition
• Admit
Extraperitoneal Bladder Rupture
Definition
• Rupture of the bladder w/ extraperitoneal spillage
History
• MVC, blunt trauma
Physical Findings
• Lower abdominal tenderness, ↓ UOP, hematuria
Evaluation
• UA, HCT, CT cystogram/cystogram w/ washout: Extravasation of urine
Treatment
• Urology consult (usually nonoperative unless extends to bladder neck), Foley 10–14 d
Disposition
• Admit
Male Urethral Injuries
Definition
• Injury to posterior (prostatomembranous) urethra (a/w pelvic fractures, esp bilateral or both ipsilateral pubic rami fx & posterior disruption injuries) & anterior (bulbous/penile) urethra (a/w direct trauma to penis/penile fracture/saddle injuries/falls/GSW)
History
• Blunt or penetrating trauma
Physical Findings
• Blood at meatus, gross hematuria, inability to void
Evaluation
• UA, HCT, RUG (prior to Foley)
Treatment
• Suprapubic bladder decompression if needed, urology consult for primary repair/fluoroscopic catheter placement/suprapubic cystotomy
Disposition
• Admit
Female Urethral Injuries
Definition
• Injury to female urethra associated most commonly w/ pelvic fractures (rarely saddle injuries, falls, GSW, instrumentation)
History
• Blunt or penetrating trauma, much less common than in males
Physical Findings
• Vaginal bleeding, inability to place Foley, labial edema
Evaluation
• RUG not useful, passage of Foley precludes complete tear
Treatment
• Suprapubic bladder decompression if needed, urology consult for surgical repair
Disposition
• Admit
Testicular Contusion/Rupture
Definition
• Blunt trauma to the testicle leading to contusion or rupture (disruption of tunica albuginea)
History
• Blunt trauma, pain, swelling
Physical Findings
• Ecchymosis, edema, tenderness, inability to palpate testicle due to dislocation
Evaluation
• Testicular US (mod sens/spec for rupture)
Treatment
• Urology consult for surgical repair/clot evacuation (early intervention → ↓ morbidity)
Disposition
• Admit
Penile Fracture
Definition
• Blunt injury to the erect penis when penis is forcefully bent leading to rupture of the tunica albuginea/rupture of corpora cavernosa
History
• “Cracking sound” usually during sexual activity → severe pain
Physical Findings
• Swelling, discoloration (vascular engorgement), ecchymosis, blood at meatus (10–20% a/w urethral injury)
Evaluation
• RUG for urethral injury (concomitant injury in 15–20%)
Treatment
• Urology consult for surgical urethral repair/clot evacuation
Disposition
• Admit
Penile Amputation/Laceration
Definition
• Complete or partial amputation/laceration of the penis
History
• Penetrating trauma, zipper injury
Evaluation
• RUG or testicular US if associated injuries suspected
Treatment
• Amputation: Urology consult (best results in reimplanted in 18 h)
• Simple laceration: Repair w/ absorbable suture
• Zipper injury: Remove zipper w/ mineral oil/wire cutters at zipper median bar to break apart
Disposition
• D/C unless reimplantation required
Female Genital Injuries
Definition
• Injury to ovary, uterus, fallopian tube, vagina (difficult to Dx usually found when evaluating for other injury), a/w pelvic fractures
History
• Blunt or penetrating trauma, vaginal bleeding
Physical Findings
• Blood in vaginal vault, lower abdominal tenderness
Evaluation
• CT scan, pelvic US (in gravid pt, ↑ risk)
Treatment
• Open vaginal lacerations open → abx (ampicillin, gentamicin, Flagyl) GYN consult
• Simple vaginal lacerations: Repair w/ absorbable suture
Disposition
• Admit if needed