Management of lower genitourinary tract injury

GU: genitourinary; HD: hemodynamically; CT: computed tomography.
* The lower GU tract includes the bladder, urethra, and external genitalia.
¶ A suspicion for lower GU tract injury is increased with suprapubic ecchymosis, lower abdominal tenderness, pelvic fracture, penetrating injury crossing the pelvis, hematuria, difficulty voiding, scrotal/perineal ecchymosis, high-riding prostate, and penile trauma.
Δ Retrograde cystogram is obtained for suspected bladder injury using fluoroscopy or CT. Retrograde urethrogram is obtained for suspected urethral injury. When cystogram is needed in the setting of suspected urethral trauma, retrograde urethrogram should be performed prior to cystogram and is NOT a substitute for cystogram. Antegrade filling of the bladder as seen following intravenous contrast administration is not an acceptable method to diagnose bladder injuries and will lead to missed injuries. Negative retrograde cystogram or urethrogram effectively rules out bladder or urethral injury, respectively.
◊ Avoid exploration of pelvic fracture-associated hematoma, which can result in uncontrolled venous bleeding.
§ May require intra-abdominal pelvic packing or angioembolization of bleeding from pelvic fracture.
¥ Complex injuries include: bladder neck injury; extraperitoneal bladder or posterior urethral injury associated with open pelvic fracture (or other pelvic fracture requiring operative repair) or with concurrent rectal/vaginal injury; or persistent hematuria with clots interfering with urinary drainage.
‡ Urethral drainage alone is often all that is necessary for extraperitoneal bladder injury. A suprapubic catheter can be considered for complex injuries. For posterior urethral injury, the choice of catheter drainage while awaiting definitive repair is debated; either suprapubic drainage or urethral catheter placement (urethral realignment) is used.
† Intraperitoneal bladder injury is repaired in two layers of absorbable suture. For extraperitoneal injury that requires repair, entering the bladder at the dome is suggested if there is an associated pelvic hematoma, avoiding pelvic dissection. Urgent repair/exploration of urethral injuries is not recommended unless it occurs in the setting of penetrating injury or persistent bleeding. Immediate direct repair of posterior urethral injury is associated with a high rate of complications (eg, stricture, impotence, incontinence).
** For anterior urethral injury that cannot be repaired immediately, urethral drainage is provided whenever possible; otherwise, a suprapubic catheter is placed.
¶¶ Urethral drainage is generally all that is necessary following surgical repair of intraperitoneal bladder injury. A suprapubic catheter can be considered for severe associated injuries.