Version May 2024
INTRODUCTION — Injury to the genitourinary (GU) tract is overall uncommon, with an estimated incidence of <1 percent [1]. The etiology is most commonly blunt trauma (65 percent blunt versus 35 percent penetrating). Younger males are predominantly affected (mean age approximately 30 years).
While not typically lethal in themselves, lower GU tract injuries are frequently associated with severe injuries (eg, pelvic fracture) that may require critical care management.
The management of urologic injuries requires specific clinical knowledge to avoid unwanted outcomes, such as urinary incontinence, difficulty voiding, sexual dysfunction, and/or secondary psychosocial stressors. Coordination of care among urologists, general/trauma surgeons, orthopedic surgeons, and other services can be essential to improve overall outcomes.
An overview of lower GU tract injuries is provided here. A more in-depth review of individual lower GU organ injuries is provided separately. (See "Traumatic and iatrogenic bladder injury" and "Traumatic injury to the male anterior urethra, scrotum, and penis".)
Upper genitourinary tract injuries are reviewed elsewhere. (See "Overview of traumatic upper genitourinary tract injuries in adults".)
MECHANISM OF INJURY — Traumatic injury to the genitourinary (GU) system is overall uncommon, with an estimated incidence of <1 percent [1]. Overall, for the lower GU tract, blunt mechanisms predominate.
Anatomy and injury associations — The lower GU tract consists of the bladder, urethra, and external genitalia (figure 1 and figure 2).
●Bladder – Bladder injuries are broadly classified as extraperitoneal (injury confined to extraperitoneal space) or intraperitoneal (injury communicating with the peritoneum), which is important for management. The majority of traumatic bladder injuries have a blunt etiology. (See "Traumatic and iatrogenic bladder injury", section on 'Associated injuries' and "Traumatic and iatrogenic bladder injury", section on 'Anatomy and mechanism of injury'.)
●Urethra – Injuries to the urethra are classified anatomically as affecting the anterior urethra (penile and bulbar) or posterior urethra (membranous and prostate). The etiology of injury differs for each portion of the urethra; however, young males are predominantly affected with both locations. Posterior urethral injuries (males, females) are highly associated with concomitant blunt pelvic fracture, most typically due to motor vehicle accidents [2]. However, posterior urethral injuries are overall uncommon, with an incidence of approximately 1 percent. Concomitant bladder injuries are present in 15 percent of such urethral injuries [2,3]. (See "Posterior urethral injuries and management".)
Direct trauma is more likely to injure the anterior urethra. Concomitant anterior urethral injury also occurs in approximately 20 percent of penile fractures [4]. (See "Traumatic injury to the male anterior urethra, scrotum, and penis".)
●External genitalia – Injuries to the male external genitalia can involve the penis, corpora cavernosa, urethra, scrotum, and/or testicle(s). The etiologies of injury to the external genitalia are heterogeneous, including blunt trauma (degloving injury, straddle injury, testicular rupture, zipper injury, penile fracture), penetrating injury (gunshot, stab, animal bites, penile amputation), and burn injury. (See "Traumatic injury to the male anterior urethra, scrotum, and penis".)
Isolated blunt injury to the female external genitalia is unusual and may indicate sexual assault. (See "Evaluation and management of female lower genital tract trauma".)
TRAUMA EVALUATION — We perform initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma. The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal trauma is discussed in detail elsewhere.
●(See "Initial evaluation and management of blunt abdominal trauma in adults".)
●(See "Initial evaluation and management of abdominal gunshot wounds in adults".)
●(See "Initial evaluation and management of abdominal stab wounds in adults".)
The initial evaluation of abdominal trauma commonly uses focused assessment with sonography in trauma (FAST) exam and computed tomography (CT) scan of the abdomen and pelvis. The FAST exam is useful in hemodynamically unstable patients to identify the immediate need for abdominal exploration. However, it is difficult to differentiate blood from other fluids, such as urine, with ultrasound. When free fluid is identified, the presence of blood is assumed until proven otherwise.
Bladder drainage is an essential aspect of the acute management of a suspected lower genitourinary (GU) tract injury. However, blind passage of a catheter during the initial evaluation prior to genitourinary imaging is discouraged unless clinical urgency dictates otherwise. In the absence of imaging, urethral catheter passage should be limited to one attempt in lieu of multiple failed attempts. Suprapubic catheter placement is an option in select situations.
CLINICAL FEATURES AND DIAGNOSIS — The primary and secondary survey should identify individuals with findings suggestive of lower genitourinary (GU) tract injury. (See "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management".)
Radiographic imaging is recommended for almost all forms of GU trauma to confirm and grade the injury. Both computed tomographic (CT) cystography and abdominal/pelvic CT are often necessary following pelvic trauma. In such a situation, CT cystogram should be performed after the corticomedullary phase (to assess possible kidney injury) or the arterial phase (to assess other injuries). Performing the abdominal/pelvic CT scan first will prevent extravasated bladder contrast during CT cystography from obscuring abdominal vascular injuries that may benefit from urgent angioembolization [5]. For patients requiring urgent exploratory laparotomy in whom injury is either not identified or exploration of the pelvis was not possible (eg, major pelvic trauma), imaging can be performed postoperatively.
The most relevant clinical and diagnostic imaging findings are summarized as follows:
●Bladder injury – Gross hematuria, suprapubic tenderness, and/or difficulty voiding are the main signs associated with bladder injury. Other clinical presentations include peritonitis related to intraperitoneal leakage of urine. Retrograde cystography demonstrating extravasation of contrast from the bladder confirms the diagnosis. (See "Traumatic and iatrogenic bladder injury".)
●Urethral injury – Clinical features associated with a urethral injury include blood at the meatus, difficulty voiding, scrotal/perineal ecchymosis, scrotal hematoma, pelvic fracture, and/or high-riding prostate in males (rarely encountered). Retrograde urethrography demonstrating extravasation of contrast from the urethra confirms the diagnosis. (See "Posterior urethral injuries and management" and "Traumatic injury to the male anterior urethra, scrotum, and penis".)
●External genitalia
•Males – Clinical inspection of the external genitalia is generally all that is required to determine the presence of genital trauma. Imaging is used to identify and stage a urethral injury. A retrograde urethrogram is recommended following penetrating injury to the penis to rule out an associated urethral injury (eg, associated with blood at meatus). Following blunt trauma, the clinical presentation determines the need for further imaging. When there are clinical findings suggestive of testicle/epididymal injury, scrotal ultrasound can be useful in the absence of obvious penetration of the tunica albuginea or dartos fascia on initial examination. Following a diagnosis of a penile fracture, urethrography or urethroscopy is recommended because of the high association with anterior urethral injury. (See "Traumatic injury to the male anterior urethra, scrotum, and penis", section on 'Clinical evaluation'.)
•Females – Bruising, linear tears, or abrasions affecting the mons, clitoris, or labia prompt closer evaluation for GU injury. Hematuria, vaginal bleeding, or pain are other important physical exam findings. Trauma to the lower genital tract in females, including injuries sustained from sexual assault, is reviewed in greater detail separately. (See "Evaluation and management of female lower genital tract trauma", section on 'Physical examination'.)
Rectal and/or vaginal injuries in the setting of a pelvic-fracture-associated urethral injury should also be assessed given the risk of concomitant injury. Urology and/or gynecology consultation can be helpful to assist with the evaluation. A digital rectal exam can be performed at the initial presentation to assess for rectal injury; however, a pelvic exam to assess for vaginal injury should be delayed if the pelvic fracture is unstable. (See "Pelvic trauma: Initial evaluation and management" and "Severe pelvic fracture in the adult trauma patient".)
Injury grading — While the American Association for the Surgery of Trauma (AAST) injury scoring scales are commonly used for defining solid organ injury, these may be less useful for defining an approach to management [6]. The AAST grading system for bladder injuries (table 1) is difficult to implement clinically. Bladder injury is best simply described as intraperitoneal or extraperitoneal without regard to size. Urethral injuries are classified anatomically as affecting the anterior versus posterior urethra and further classified as partial or complete [7]. Bladder neck injuries and posterior urethral injuries that involve the rectum or vagina are regarded as complex. A simple description of injury to the external genitalia, which may include injury to the anterior urethra, is usually sufficient.
Differential diagnosis — Following trauma, lower GU tract injury needs to be distinguished from upper GU tract injury (ie, bladder, urethra), particularly since both are associated with hematuria. Often the mechanism of injury or penetrating injury tract will aid with increasing or decreasing suspicion of one over the other. Imaging studies will identify the origin of the injury, though at times both the upper and lower GU tract may have suffered injury, more likely in association with pelvic fracture.
COORDINATION OF CARE — The management strategy of urinary drainage following pelvic-fracture-associated urethral injuries is controversial. When considering open reduction and internal fixation of pelvic fractures, orthopedic surgeons can be reluctant to perform internal fixation in the setting of a suprapubic tube.
Urotrauma guidelines from the American Urological Association assert that either urethral catheter drainage or suprapubic catheter drainage is an acceptable method to drain the bladder following pelvic-fracture-associated urethral injuries [8]. This statement was based upon two papers; however, neither study was designed to resolve this issue. The first article did not assess the incidence of suprapubic catheter morbidity in the setting of concomitant pelvic fracture fixation [9]. The other study did not assess whether suprapubic catheter presence affected pelvic fixation [10]. Instead, the authors of the later article noted that recovery from pelvic fracture was delayed when only a suprapubic catheter (instead of a urethral catheter) was placed. No attempt was made to assess if the desired orthopedic procedures could have been performed in the setting of a suprapubic tube.
To maximally benefit the patient, working closely with the orthopedic surgeons is important to create a comprehensive management plan. If there is a concern that the suprapubic tube placement may secondarily infect internally fixed fractures of the anterior pelvis, we favor endoscopic realignment of the urethra to facilitate internal fixation. An alternative to endoscopic realignment includes tunneling the suprapubic catheter tract more superiorly toward the umbilicus. (See "Posterior urethral injuries and management", section on 'Our approach'.)
MANAGEMENT — The management of lower genitourinary (GU) tract injuries is according to anatomic injury classification and depends on the nature of associated injuries.
The mainstay of management of bladder and urethral injuries is urinary drainage via a urethral catheter or suprapubic catheter. Depending on the location of the injury and presence of associated injuries, surgical repair may be warranted.
Bladder injury — Extraperitoneal bladder injuries are predominately managed nonoperatively, while intraperitoneal bladder injuries are repaired surgically (algorithm 1). However, there are clinical situations (ie, complex injuries) that dictate surgical management of extraperitoneal bladder injury. (See "Traumatic and iatrogenic bladder injury", section on 'Approach to management' and "Traumatic and iatrogenic bladder injury", section on 'Surgical repair'.)
Repeat cystography is recommended prior to catheter removal to assess healing, regardless of whether the injury was managed conservatively or required surgery [11].
Urethral injury — Acute management of most urethral injuries involves bladder drainage with or without delayed repair (algorithm 2). Certain clinical scenarios can mandate open exploration and repair following acute urethral injury.
Posterior urethra — Concomitant pelvic fractures are common in the setting of a posterior urethral injury.
●Partial injury – Partial injuries can be managed with a urethral catheter. (See "Posterior urethral injuries and management", section on 'Our approach'.)
●Complete injury – Initial suprapubic tube placement or urethral realignment is recommended following complete injury of the posterior urethra. Ultrasound guidance prior to suprapubic tube placement can be useful to ensure correct placement, as a pelvic hematoma can push the bladder more cephalad than expected. Early endoscopic realignment of the urethra is an option for select circumstances. As an example, when internal fixation of a pubic fracture is planned, potential infection of internally placed hardware is a concern in the setting of a suprapubic tube, and endoscopic alignment of the distracted urethral injury may be considered. Alternatively, an external pelvic fixator can be placed alongside the suprapubic tube if endoscopic realignment is not possible. The definitive success of early endoscopic realignment of the urethra is generally poor, and suprapubic catheter placement should be performed (if not already in place) at the time of urethral catheter removal due to high rates of urethral stricture progression (approximately 90 percent) [12,13]. (See 'Coordination of care' above.)
At our center, the urethral catheter is not removed until after a minimum of two months following orthopedic repair and after urethral extravasation has resolved to prevent potential infection in presence of pelvic hardware for pelvic fracture management. During this time, the urethral catheter is often exchanged in the office over a guidewire, or blindly, depending on the clinical situation. We will typically place a suprapubic catheter if endoscopic realignment was performed, based on the dismal success of endoscopic realignment. The patient can then be followed with the suprapubic catheter in place with a plan for delayed open reconstruction. Referral to a reconstructive center for reconstruction should be considered following acute management of a posterior urethral injury. Urethral dilation and/or internal urethrotomy are not recommended for definitive management. (See "Posterior urethral injuries and management", section on 'Management'.)
Anterior urethra — Contusion or partial injury to the anterior urethra is best managed with a urethral catheter. If a catheter is unable to be placed, cystoscopy and/or retrograde urethrogram can be used as an aid. Suprapubic catheter drainage with delayed urethral reconstruction is an option following complete anterior urethral disruption.
Penetrating urethral injuries and blunt urethral injury with persistent bleeding (ie, straddle injuries (picture 1)) are examples of anterior urethral injuries that may require open exploration with repair. Penetrating gunshot wounds to the penis/perineum with a concomitant anterior urethral injury require surgical exploration for closer examination and possible debridement. Bladder drainage in the form of a urethral catheter and/or suprapubic catheter is recommended. Urinary diversion proximal to the injured urethra should be considered in the setting of significant associated tissue injury with plans for delayed urethral reconstruction (picture 2).
Perineal injury — Ecchymosis in the absence of perineal laceration can be managed with perineal pressure (ie, scrotal support with gauze packing). Perineal lacerations in the setting of a urethral/bladder injury should be closely followed to ensure that a urethrocutaneous/vesicocutaneous fistula does not develop. Perineal exploration following penetrating perineal trauma can be helpful for the management of any persistent bleeding. Delayed reconstruction of concomitant injuries to the urethra is often necessary. Definitive management of concomitant injury to the testicles can often be performed in the acute setting. Follow-up to assess impact to sexual and voiding function is recommended.
Penile injury — Soft tissue injury without penetration of the tunica albuginea of the corporal bodies or the dartos fascia of the scrotum can be usually be managed nonoperatively. Penetration requires exploration and repair of the tunica albuginea or formal exploration of the scrotum to rule out testicular or epididymal injury. (See "Traumatic injury to the male anterior urethra, scrotum, and penis", section on 'Clinical evaluation' and "Traumatic injury to the male anterior urethra, scrotum, and penis", section on 'Penile repair/replantation' and "Traumatic injury to the male anterior urethra, scrotum, and penis", section on 'Testicular repair/orchiectomy'.)
MORTALITY — Mortality associated with lower genitourinary (GU) tract injury is primarily related to bleeding from associated pelvic fractures [14-16]. (See "Severe pelvic fracture in the adult trauma patient".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Genitourinary tract trauma in adults" and "Society guideline links: Thoracic and lumbar spine injury in adults".)
SUMMARY AND RECOMMENDATIONS
●Lower genitourinary injury – Injury to the genitourinary (GU) tract is overall uncommon. Lower GU tract injuries from blunt or penetrating mechanisms can involve the bladder, urethra, or the external genitalia. (See 'Introduction' above and 'Anatomy and injury associations' above and 'Injury grading' above.)
•Bladder injuries are broadly classified as extraperitoneal (ie, injury confined to extraperitoneal space) or intraperitoneal (ie, injury communicating with the peritoneum).
•Urethral injuries are classified anatomically as affecting the posterior urethra or affecting the anterior urethra (men).
•The etiology of injuries to the male external genitalia is heterogeneous, and these may involve the anterior urethra. Isolated blunt injury to the female external genitalia is unusual and may indicate sexual assault.
●Mechanism of injury – The mechanism of injury or signs of obvious trauma to the lower abdomen, perineum, or external genitalia may suggest injury to the lower GU tract. Pelvic fractures are highly associated with lower GU tract injuries, particularly bladder and posterior urethral injuries. Other clinical features that increase suspicion for lower GU tract injury include suprapubic tenderness, hematuria, blood at the urethral meatus, and difficulty voiding, though these are nonspecific. (See 'Mechanism of injury' above and 'Clinical features and diagnosis' above.)
●Diagnosis – The diagnosis of bladder and urethral injuries requires retrograde imaging (cystography, urethrography). When computed tomography (CT) of the abdomen/pelvis and CT cystogram are both needed for the evaluation of pelvic trauma, the CT cystogram should be performed after the corticomedullary phase of the CT scan (to assess possible kidney injury) or the arterial phase (to assess other injuries). Waiting will prevent extravasated bladder contrast from obscuring vascular injuries that may benefit from urgent angioembolization. (See 'Clinical features and diagnosis' above.)
●Urinary drainage – Urinary drainage is an essential aspect of the acute management of a suspected lower GU tract injury. Blind catheter passage prior to lower GU tract imaging is discouraged. In the absence of imaging, urethral catheter passage should be limited to one attempt in lieu of multiple failed attempts. It is important to address any concerns orthopedic surgeons may have regarding the placement of any suprapubic catheters in patients who are likely to need surgery to repair pelvic fractures. Repeat imaging is recommended prior to catheter removal to ensure that bladder or urethral healing has occurred, regardless of whether the injury was managed conservatively or required surgery. (See 'Trauma evaluation' above and 'Coordination of care' above and 'Management' above.)
●Management – The management of lower GU tract injuries is according to anatomic injury classification and depends on the location of the injury and the nature of associated injuries. (See 'Management' above and 'Anatomy and injury associations' above.)
•Bladder injury – Extraperitoneal bladder injuries are predominately managed in a nonoperative fashion, while intraperitoneal bladder injuries warrant surgical repair (algorithm 1). Complex injuries, which include bladder neck injury, or those associated with pelvic fracture or rectal or vaginal injury necessitate surgical management.
•Urethral injury – Acute management of most urethral injuries involves bladder drainage with or without delayed repair (algorithm 2). For patients with posterior urethral injury, suprapubic catheter or urethral realignment are options for acute management. Definitive repair at a later date is often necessary.
•Soft tissue injury – Soft tissue injury without penetration of the tunica albuginea of the corporal bodies or the dartos fascia of the scrotum can be usually be managed nonoperatively; otherwise, exploration and repair are required. If penetration cannot be easily determined on clinical examination, penile or scrotal ultrasound can be useful.
●Mortality –Mortality associated with lower GU tract injury is primarily related to bleeding from associated pelvic fractures. (See 'Mortality' above.)
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