Genitourinary Tract Trauma

Overview

The lower genitourinary (GU) tract is protected by the bony pelvis and is relatively well-protected, resulting in trauma being less common.

A history of pelvic fracture or trauma followed by an inability to pass urine should raise suspicion of a bladder or urethral injury.

Causes

Blunt trauma is the most common cause, such as motor vehicle collisions, falls, and assaults.

Other causes include:

• Penetrating trauma – such as stabbings and gunshot wounds
• Obstetric trauma – such as prolonged and/or complicated vaginal deliveries or bladder injuries during caesarean sections
• Iatrogenic trauma – such as pelvic surgery and procedures in nearby regions (e.g. taking biopsies)

Urethral Injury

Overview

Urethral injuries are more common in men and its most common cause is iatrogenic such as catheterisation, surgery, or radiotherapy (which can lead to urethral strictures). They are rare in women.

Causes

The causes, types, and management of urethral injury depend on what part of the urethra has been injured.

The anterior urethra includes the penile and bulbar urethra:

• Causes of injury:
  • Straddle injuries – an example is riding a bicycle, a direct blow to the perineum can compress the bulbous urethra
  • Blunt/penetrating trauma
• Features – a triad of:
  • Blood at the urethral meatus
  • An inability to pass urine
  • Perineal oedema/haematoma

The posterior urethra includes the membranous and prostatic urethra:

• Causes of injury:
  • Pelvic fracture
  • Blunt/penetrating trauma
• Features:
  • Perineal oedema/haematoma
  • Upwards displacement of the prostate – may be difficult to identify

Bladder Injury

Overview

Bladder injuries are most associated with pelvic fractures and are also often due to blunt trauma such as motor vehicle collisions, falls, and blows to the lower abdomen. They can be divided into:

• Extraperitoneal injuries – up to 2/3 of cases:
  • Associated with pelvic fractures
• intraperitoneal injuries:
  • Associated with direct pressure or blows to the abdomen when the bladder is full
    • Also associated with pelvic fractures, but to a lesser extent

Features

Key features include:

• Gross haematuria
• There may be an inability to irrigate the bladder or collect fluid using a Foley catheter

Penile, Scrotal, and Testicular Injury

Overview

The overall causes of penile, scrotal, and testicular injury include blunt trauma, penetrating trauma, sexual intercourse and the use of devices, and mutilation.

Injury to a flaccid penis is generally rare as it is more mobile and they are usually due to machinery accidents or penetrating trauma. Penile fractures may occur during sexual intercourse.

Common causes of testicular injuries include sports and motorcycle accidents. There are often associated injuries in surrounding structures.

Investigations

Overview

A primary survey via an ABCDE approach should be taken in all patients with trauma. Investigations depend on the mechanism of injury and clinical findings and may include:

• Ultrasound scan:
  • May help guide catheter placement
• CT scan:
  • Assesses injuries in detail
• Cystography:
  • May be considered in bladder injury
• Cystoscopy:
  • May be considered in bladder injury to directly visualise bladder trauma
• Retrograde urethrogram:
  • Performed if urethral injuries are suspected, not usually done in an emergency setting as urethral injuries alone are not life-threatening

Management

Urethral injuries

The management of urethral injuries depends on its type. This may involve surgically inserting a urethral or suprapubic catheter with the goal of maintaining patency and continence and reduce the risk of strictures.

Penile fracture

Penile fractures require urgent surgery and repair.

Extraperitoneal bladder injuries

Many extraperitoneal bladder injuries are minor and may be managed with catheter drainage (urethral or suprapubic), observation and monitoring. They usually heal within 3 weeks.

Surgery may be required for associated injuries and if this is the case, repairing the bladder may be considered at the same time.

Intraperitoneal bladder injuries

Intraperitoneal bladder ruptures can lead to sepsis and are associated with a higher mortality as urine leaks into the peritoneal cavity, resulting in distention, electrolyte disturbances, and peritonitis. They are managed with urgent surgery.