Version May 2024
INTRODUCTION — Timely identification and management of penetrating genitourinary (GU) injuries minimize associated morbidity, which may include renal insufficiency, urinary incontinence, and sexual dysfunction. Prompt injury identification depends upon a systematic evaluation with consideration of the mechanism of injury, pertinent physical examination findings, analysis of the urine, and appropriate diagnostic imaging performed in the correct sequence (ie, retrograde, from distal to proximal).
The assessment and initial management of penetrating injuries to the upper and lower genitourinary tract are reviewed here. Blunt GU injuries, including straddle injuries, and other aspects of trauma management are discussed separately. (See "Blunt genitourinary trauma: Initial evaluation and management" and "Straddle injuries in children: Evaluation and management".)
EPIDEMIOLOGY — Approximately 10 percent of trauma patients sustain injury to the genitourinary (GU) system. Of these, approximately 15 percent are due to a penetrating mechanism, most commonly gunshot or stab wounds [1]. With the exception of a shattered kidney or major renal vascular laceration with significant hemorrhage, penetrating genitourinary injury is rarely life-threatening.
Up to two-thirds of cases of GU trauma involve the external genitalia. The majority of patients with penetrating penile trauma have other non-genitourinary injuries [2]. Urethral injuries frequently occur coincidentally with testicular trauma; gunshot wounds represent the most common mechanism. Penetrating trauma is responsible for up to 45 percent of all bladder injuries, and associated injury to the buttocks, bowel, and rectum are common [3,4].
Ureteral injuries are rare. In adults, penetrating injuries account for approximately 90 percent of cases and most commonly involve gunshot wounds [5-7]. Nearly all cases of penetrating ureteral trauma are associated with additional injuries, most commonly to the gastrointestinal tract, abdominal or pelvic vasculature, kidney, or bladder [5-8].
Approximately 5 to 10 percent of kidney injuries in rural settings, and 40 percent in urban settings, are due to penetrating trauma [9]. These tend to be more severe than blunt injuries and are associated with a higher overall nephrectomy rate.
ANATOMY, PHYSIOLOGY, AND MECHANISM — The anatomy and physiology of the genitourinary system are discussed separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Anatomy, physiology, and mechanism'.)
Penetrating injuries to the upper or lower genitourinary tract may be inflicted by gunshots, knives, shrapnel, or other sharp objects. Additionally, the skin of the penis, scrotum, or labia may become ensnared by a metal zipper or injured through self-mutilation. (See "Management of zipper entrapment injuries".)
PREHOSPITAL MANAGEMENT — The prehospital management of the patient with penetrating genitourinary trauma should focus on identification and stabilization of any potential life threats, beginning with the airway, breathing, and circulation.
CLINICAL FEATURES — Often a trauma history is incomplete or difficult to obtain and signs of penetrating trauma may not be obvious. Therefore, a meticulous physical examination is crucial to avoid missing occult injuries. Whenever a penetrating force is judged to have been inflicted in proximity to a portion of the genitourinary tract, an evaluation of potentially injured structures using radiographic imaging is necessary. The presence of gross or microscopic hematuria is a concerning but unreliable sign because it is frequently absent in cases of significant penetrating genitourinary trauma and, when present, does not correlate with the severity of injury. Diagnostic testing is discussed below. (See 'Approach to testing' below and 'Diagnostic tests' below.)
●External genitalia injury – Signs of penetrating injury to the external genitalia may not be obvious but can include a perineal, scrotal, penile, or labial hematoma, or injuries to adjacent structures, such as the proximal thigh or buttocks. It is important to conduct a careful and complete physical examination looking for associated and occult injuries. In one series, 80 percent of gunshot wounds to the penis were associated with injury to other structures, most commonly the upper thigh and scrotum [10].
Penetrating injury of the external genitalia may cause disruption of the tunica albuginea. This can lead to the accumulation of blood or fluid between the tunica albuginea and tunica vaginalis, resulting in a hematocele or hydrocele respectively.
Violation of the corpora cavernosa requires operative intervention and is heralded by an expanding penile hematoma, significant bleeding from a wound to the penile shaft, or a palpable corporal defect.
Whenever blood or hematoma is found at the introitus or the injuring force occurs in proximity to the vagina, a meticulous vaginal examination is mandatory. The complications of missed vaginal injuries include infection, fistula formation, and significant hemorrhage [11,12]. In one series, 25 percent of women sustaining injury of the external genitalia required red cell transfusion due to blood loss from genital injuries alone [11].
Trauma to the lower genital tract in women, including injuries sustained from sexual assault, is reviewed in greater detail separately. Genital injuries in children sustained via sexual abuse are also reviewed separately. (See "Evaluation and management of female lower genital tract trauma", section on 'Etiology' and "Evaluation and management of female lower genital tract trauma", section on 'Physical examination' and "Evaluation of sexual abuse in children and adolescents".)
●Urethra and bladder injuries – Urethral injuries are far more common in males; the shortness of the female urethra makes injury unlikely. Injuries may include contusion, partial disruption, and complete transection. Signs of injury include blood at the urethral meatus, scrotal swelling or hematoma, perineal ecchymosis, and an abnormally positioned prostate on digital rectal examination. As these clinical features are variably present in penetrating trauma, clinicians should suspect and evaluate for urethral disruption whenever the wound or trajectory occurs in proximity to the course of the urethra. Likewise, an evaluation for bladder rupture is indicated in the presence of gross hematuria or whenever the injury trajectory occurs in proximity to the bladder.
●Upper genitourinary tract injury – Penetrating ureteral injuries are uncommon and the diagnosis is frequently missed on the initial evaluation as the signs and symptoms are minimal and nonspecific. Delayed findings include fever, flank pain, and a palpable flank mass (urinoma). Urinoma is seen in up to 30 percent of patients after penetrating trauma [13]. Consider this injury in any penetrating trauma with a trajectory in proximity to the ureter. Hematuria (gross or microscopic) is NOT a reliable predictor of ureteral injury as urinalysis is normal (<5 RBC/HPF) approximately 25 percent of the time [5,6]. (See 'Urinalysis' below.)
Clinical signs of renal injury include ecchymosis, pain, or tenderness at the flank or abdomen, rib or spine fractures adjacent to the kidney, gross hematuria, abdominal organ injury, and shock. In penetrating trauma, these clinical features are variably present and renal involvement must be suspected in all cases when the injury trajectory occurs in proximity to the kidney. Greater than 90 percent of patients will have other, associated injuries with the majority of these being intraabdominal. Note that hematuria is absent in greater than 50 percent of penetrating renal injuries [14]. Renal injuries are graded from I to V according to the American Association for the Surgery of Trauma organ injury severity scale for the kidney, and range from minor contusions (Grade I) to major vascular disruptions (Grade V) (figure 1) [15].
PRIMARY EVALUATION AND MANAGEMENT
Initial assessment — The initial assessment of the patient with penetrating genitourinary (GU) trauma should focus on the rapid identification and stabilization of life-threatening injuries. (See "Initial management of trauma in adults".)
Except in the rare instance of a shattered kidney or major renal vascular laceration with significant hemorrhage, GU injuries seldom pose an immediate threat to life. Moreover, GU injuries seldom occur in isolation; associated injuries are usually intraabdominal. Therefore, in the multiply injured or unstable patient, evaluation for GU trauma is deferred until other potentially life-threatening injuries are excluded and the patient is stabilized.
During the initial assessment, note any findings that may herald GU injury, and perform appropriate studies once immediate life threats have been addressed. In the interim, apply dressings to open wounds and control hemorrhage with direct pressure. Provide isotonic intravenous fluids, analgesics, and tetanus immunization as needed. Give nothing to the patient by mouth until the need for operative intervention has been excluded.
When possible, obtain a focused history of the injury from the patient, prehospital personnel, and available bystanders. Important information includes the type of weapon (eg, size, caliber), the number and location of the wounds, any history of genitourinary injury or disease, current medications, allergies, and tetanus immunization status.
During the secondary survey, perform a careful examination of the abdomen, pelvis, and external genitalia, and note signs of possible GU injury. Pay close attention to the perineum, gluteal clefts, back, and flanks as wounds may be small and hidden by skin folds. Note the size, location, and apparent trajectory of any wounds.
The digital rectal examination may provide valuable information in the penetrating trauma patient, especially in the presence of wounds to the external genitalia, buttocks, pelvis, lower abdomen, and upper thigh. First, upon inserting the well-lubricated, gloved finger, make note of the rectal tone. Decreased tone may be seen in patients with spinal cord injuries or those who have received neuromuscular blocking agents. Next, palpate anteriorly to identify the midline and two lobes of the prostate in males. An absent or "high riding" prostate indicates a posterior urethral disruption until proven otherwise. Next, sweep your finger around the entire circumference of the rectal vault feeling for lacerations or bone fragments. Finally, remove your finger and examine it for the presence of gross blood. To prevent false positives during this last step, ensure that the glove is free of blood prior to insertion. The clinician should take care to avoid injuring their own finger from bone fragments in patients with potential bony injury from a gunshot or explosion.
While most patients with pelvic trauma receive a digital rectal examination, the vaginal examination is often erroneously omitted. To avoid missing occult injuries that may result in significant and potentially life-threatening hemorrhage and infection, perform a careful vaginal examination to assess for lacerations or bone fragments in all injured women with penetrating injury occurring in proximity to the pelvis.
The diagnosis of injuries to the external genitalia is largely based upon the mechanism of injury and the physical examination. Consider concomitant urethral injury and perform a retrograde urethrogram to assess for urethral integrity in any male with penetrating trauma that violates Buck's fascia or when there is blood or hematoma at the urethral meatus.
Trauma to the lower genital tract in women, including injuries sustained from sexual assault, is reviewed in greater detail separately. Genital injuries in children sustained via sexual abuse are also reviewed separately. A complete examination of the traumatized lower GU tract of an infant or child may need to be performed by a clinician with suitable expertise under general anaesthesia. (See "Evaluation and management of female lower genital tract trauma", section on 'Etiology' and "Evaluation and management of female lower genital tract trauma", section on 'Physical examination' and "Evaluation of sexual abuse in children and adolescents".)
Approach to testing — Ideally, in stable patients investigation for penetrating genitourinary injury is conducted in a retrograde fashion beginning with the evaluation of the external genitalia and urethra prior to that of the bladder. The ureters and kidneys (upper genitourinary tract) are evaluated after lower tract injury is excluded, or after initiation of appropriate emergency management for an identified lower tract injury.
In cases of suspected urethral injury, it is imperative to evaluate the integrity of the urethra prior to attempting placement of a Foley (ie, urinary) catheter to avoid worsening a partial disruption. This is accomplished by retrograde urethrogram. However, the procedure is deferred when diagnostic and potentially therapeutic pelvic angiography is to be undertaken for the purpose of controlling pelvic hemorrhage by embolization. In these cases, extravasated contrast dye from the retrograde urethrogram may obscure angiography images thereby interfering with study interpretation and embolization attempts. The role of angiography in the management of pelvic trauma is discussed separately. (See "Pelvic trauma: Initial evaluation and management".)
In the presence of gross hematuria without other signs of urethral injury, it is reasonable to make one attempt at passing a urinary catheter. If resistance is encountered, abort the attempt and investigate urethral integrity by retrograde urethrography. Placement and management of urinary catheters is discussed separately. (See "Placement and management of urinary bladder catheters in adults".)
Evaluate all patients with gross hematuria or injuries in proximity to the bladder for bladder rupture [3,16,17]. This is accomplished by retrograde cystography or retrograde CT cystography. In the hemodynamically stable patient with suspected renal injury, contrast enhanced CT scanning is indicated to evaluate for the presence and extent of the injury. The performance of the tests used to assess genitourinary injury is discussed separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Diagnostic tests'.)
The diagnosis of ureteral injury is elusive. Intravenous pyelography (IVP) was the traditional test of choice, although the reported sensitivity is highly variable [5,6,8]. CT imaging has gained popularity and is generally used to identify ureteral and related non-genitourinary injuries [9,18]. Delayed CT images are required to allow time for the intravenous contrast to be excreted by the kidneys. If operative exploration is indicated, the ureters may be directly evaluated in the surgical suite. When the diagnosis remains in doubt, retrograde pyelography may be of use.
Diagnostic tests
Urinalysis — Hematuria is an important marker of injury to the genitourinary tract. However, unlike select cases involving blunt mechanisms, the absence of hematuria (gross or microscopic) is not sufficiently sensitive to exclude penetrating genitourinary injury. It is important to inspect the initial urine output to avoid missing transient hematuria that may clear with ongoing fluid resuscitation. A spontaneously voided specimen is ideal, but is frequently impractical in the multiply injured patient.
Gross hematuria is defined as urine that is any color other than clear or yellow. This conservative definition is necessary because the degree of gross hematuria often does not correlate with the severity of injury; a relatively minor urethral injury may result in frank hemorrhage while major vascular disruption may present with only slightly discolored urine.
False positives may result from many factors, including ingestion of certain foods or dyes, select medications, or the presence of free myoglobin due to rhabdomyolysis. Microscopic hematuria is defined as greater than five red blood cells per high powered field (RBCs/HPF) or a positive urine dipstick test.
Plain radiographs — After the initial assessment and stabilization, and depending upon the specific mechanism of injury, plain anteroposterior (AP) and lateral radiographs may be useful in localizing any retained missiles and determining the trajectory of the injuring force. Placement of a radiopaque marker at the site(s) of external injury is helpful, particularly in cases of gunshot wounds or shotgun blasts.
Ultrasound — In the injured patient, ultrasound is used primarily to detect free intraperitoneal fluid, which is a marker for visceral injury. While ultrasound is useful for detecting such fluid, it cannot distinguish among the different types (eg, blood, urine, or ascites). In addition, ultrasound does not reliably exclude injury to the kidneys, ureters, or bladder [1]. Therefore, while ultrasound imaging may provide useful information in the assessment of a patient with suspected penile or scrotal injury, its role in the overall assessment of penetrating genitourinary trauma is limited. (See "Emergency ultrasound in adults with abdominal and thoracic trauma".)
Retrograde urethrogram — In cases of possible urethral injury, it is imperative to evaluate the integrity of the urethra before attempting placement of a Foley catheter in order to avoid worsening a partial disruption. A retrograde urethrogram is performed for this purpose. However, the procedure is deferred if pelvic angiography is to be performed. (See 'Approach to testing' above.)
In the presence of gross hematuria without other signs of urethral injury, it is reasonable to make one attempt at passing a urinary catheter. If resistance is encountered, abort the attempt and investigate urethral integrity. Performance of the retrograde urethrogram is described separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde urethrogram'.)
Retrograde cystogram — Once a Foley catheter has been placed, patients with a suspected bladder injury are assessed with a retrograde cystogram or retrograde CT cystography [17]. Performance of the retrograde cystogram is described separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde cystogram'.)
CT scanning — Computed tomography (CT) scanning with intravenous contrast enhancement is the modality of choice for the staging of penetrating renal trauma in the hemodynamically stable patient and for the assessment of genitourinary trauma generally [9,17-19]. The initial CT frequently misses injuries to the renal pelvis and ureters, and additional images, obtained 10 minutes after the bolus of IV contrast is given, are indicated to assess for contrast extravasation when these injuries are suspected. In patients undergoing CT scanning of other organ systems, suspected bladder injuries may be investigated with CT cystography after retrograde filling of the bladder [20].
IV pyelography — Intravenous pyelography (IVP) has long been the test of choice for evaluating the ureters, but it is time consuming and its reported sensitivity is highly variable [5,6,8]. CT has largely supplanted IVP as the imaging modality of choice for suspected renal trauma, but IVP may still be useful in select cases, such as suspected ureteral injury when delayed CT images are nondiagnostic.
The so-called "single shot IVP" is rarely indicated in the emergency department evaluation of suspected penetrating renal trauma, but may be used occasionally at the discretion of the consulting urologist. The main indication is to confirm the presence of a functioning contralateral kidney in a patient deemed too unstable for transport to the CT scanner. However, this study certainly should not delay transfer to the operating suite in such cases. The procedure is performed by rapidly injecting 2 mL/kg of intravenous contrast material and then obtaining a KUB x-ray 10 minutes later [21].
Retrograde pyelography — In select cases, such as suspected ureteral injury when other imaging modalities are nondiagnostic, the operating urologist may elect to perform cystoscopy with retrograde pyelography.
SUBSEQUENT MANAGEMENT AND CONSULTATION — After life-threatening injury has been excluded, appropriate management and consultation are performed for genitourinary injuries. Superficial lacerations to the scrotum or penis should be copiously irrigated and closed with absorbable sutures. The management of zipper entrapment injuries is discussed separately. (See "Management of zipper entrapment injuries".)
An amputated penis should be wrapped in saline moistened gauze and placed in a sealed plastic bag, which is then placed on ice in a second plastic bag (this prevents direct contact between the penis and ice) until reimplantation. Reimplantation of an amputated penis should be performed as expeditiously as possible, but has been successful after 16 hours of cold ischemia (ie, ischemia in appropriately cooled tissue) [2].
If a urethral injury is suspected subsequent to successful placement of a bladder (Foley) catheter, do not remove the catheter. A retrograde urethrogram may be obtained by inserting a small feeding tube alongside the catheter. Urology consultation is indicated for management of patients with an abnormal retrograde urethrogram or in cases of suspected urethral injury when a retrograde urethrogram cannot be obtained. In females with a suspected urethral injury, urologic consultation is necessary to determine whether diagnostic urethroscopy should be performed. Differences in the urethral anatomy of females make retrograde urethrography technically challenging and therefore it is not recommended [22]. (See "Evaluation and management of female lower genital tract trauma".)
With bladder injuries, the primary goal is to keep the bladder completely decompressed. If urethral injury is excluded, place a Foley catheter and irrigate the bladder as needed to clear any clots and ensure adequate drainage. Placement and management of urinary catheters is discussed separately. (See "Placement and management of urinary bladder catheters in adults".)
Because bladder injuries are frequently associated with intraabdominal trauma, a diligent search for additional injuries should be undertaken in all patients with an abnormal cystogram. When undertaking this search, keep in mind that ultrasound cannot distinguish between blood and urine. (See "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults".)
With upper genitourinary tract injuries, identification and urologic consultation are the priorities of emergency management. In cases of major renal vascular injury, emergency angiography with selective embolization can be both diagnostic and therapeutic. However, the procedure is time consuming, requires specialized equipment, and is not available in all centers.
PITFALLS OF MANAGEMENT
●Delaying transfer to definitive care to obtain imaging studies in the hemodynamically unstable patient.
●Missing significant injuries due to failure to perform careful rectal and vaginal examinations in patients with penetrating trauma in proximity to the pelvis.
●Relying on the absence of hematuria to exclude significant penetrating genitourinary injury.
●Completing a partial urethral disruption by attempting Foley catheter placement prior to ensuring urethral integrity with a retrograde urethrogram in a patient with signs of urethral injury. (In the presence of gross hematuria without other signs of urethral injury, it is reasonable to make one attempt at passing a urinary catheter. If resistance is encountered, abort the attempt and investigate urethral integrity.)
●Missing significant bladder injuries by clamping the Foley catheter and relying on passive filling of the bladder by intravenously administered contrast prior to CT cystography. An adequate study requires retrograde filling to sufficiently distend the bladder. The performance of the tests used to assess genitourinary injury is discussed separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Diagnostic tests'.)
DEFINITIVE MANAGEMENT — Most patients with significant genitourinary injuries require urgent or emergency urologic consultation in the emergency department. Many such patients have associated nonurologic (usually intraabdominal) injuries that require management by trauma surgeons. If appropriate specialists are unavailable, expeditious transfer to a referral center is indicated after the initial assessment and stabilization.
All but the most superficial penetrating injuries to the external genitalia require operative exploration, especially those that violate the corpora cavernosa. Reimplantation of an amputated penis should be performed as expeditiously as possible, but has been successful after 16 hours of cold ischemia [2]. The majority of women with vaginal injuries require operative repair or washout to prevent significant morbidity and possible mortality [11].
The optimal definitive management of urethral injuries depends upon several factors, including the location (anterior or posterior) and severity (partial or complete) of the injury, and the preference and expertise of the consulting urologist. Options vary from simple placement of a Foley catheter, which allows a partial anterior urethral injury to heal by secondary intention, to early endoscopic realignment or delayed urethroplasty of posterior urethral injuries. Often, placement of a suprapubic cystostomy tube will be required to promote decompression of the bladder and divert urine from the healing urethral injury or anastomosis. Regardless of the approach, the ultimate goal is the maintenance of urinary continence and sexual function.
Operative repair is indicated in most cases of penetrating bladder injury. Depending upon the degree and location of ureteral injury, management options include cystoscopic stent placement or surgical repair over a stent. Urinary diversion may be required.
Definitive management of penetrating renal trauma depends upon the specific pattern and severity of injury. As with blunt mechanisms, penetrating injuries may be classified according to the American Association for the Surgery of Trauma (AAST) organ injury severity scale for the kidney (figure 1). A study of 9344 renal injuries, including 18 percent due to a penetrating mechanism, demonstrated an increase in mortality, rate of operative intervention, total length of stay, and length of ICU stay with increasing injury severity as determined by the AAST organ injury severity scale for the kidney [23]. Another study of 8465 renal injuries (19 percent penetrating) found that among those injured by a penetrating mechanism increasing severity (AAST grades 3 to 5) was associated with an increased nephrectomy rate [24].
Most patients with penetrating renal injuries who are hemodynamically stable without evidence of progressive blood loss or urinary extravasation may be managed nonoperatively; however, renal injuries inflicted by gunshot wounds are at increased risk of complications and the threshold for operative intervention is generally lower in these patients. Moreover, stab wounds resulting in Grade III or higher renal injuries have an increased risk of complications if treated non-operatively, further reinforcing the need for prompt consultation with a urologic surgeon. Delayed nephrectomy may be indicated in the small subset of patients who develop hypertension [9].
A minority of hemodynamically stable patients with no other indications for admission may be considered for discharge from the emergency department after telephone consultation with the urologist assuming responsibility for follow-up care. Such cases include minor lacerations and zipper injuries not requiring formal wound exploration and minor, isolated, partial injuries of the anterior urethra in the presence of a functioning Foley catheter. Counsel these patients on the signs and symptoms of infection and Foley catheter dysfunction, and tell them to return to the ED if they develop these or any other concerning symptoms. Finally, ensure that they understand the importance of complying with the scheduled follow-up plan.
OUTCOMES — Timely recognition and appropriate treatment of penetrating genitourinary trauma are paramount to minimizing associated morbidity. Early complications include bleeding, infection, abscess formation, urinary extravasation and fistulas, and urinoma formation.
Delayed complications include bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension, arteriovenous fistulas, pseudoaneurysms, urethral strictures, urinary incontinence, and sexual dysfunction. Renal failure may occur, most commonly in patients requiring unilateral nephrectomy secondary to hemodynamic instability. A subset of patients will require short-term renal replacement therapy, but the vast majority will regain sufficient renal function to avoid long-term dialysis [14].
Hypertension may occur following renal trauma, although the rates given for this complication vary considerably among case series [13]. Transient hypertension is seen in up to 10 percent of patients, but generally resolves within several weeks. Chronic hypertension may occur within days or up to several years following renal injury.
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: General issues of trauma management in adults" and "Society guideline links: Genitourinary tract trauma in adults" and "Society guideline links: Thoracic and lumbar spine injury in adults".)
SUMMARY AND RECOMMENDATIONS
●Principles of care – Injury identification, appropriate consultation, and supportive care are the mainstays of the emergency management of penetrating genitourinary (GU) injuries. With the exception of a shattered kidney or major renal vascular laceration with significant hemorrhage, penetrating GU injury is rarely life-threatening. Assessment is based upon the mechanism of injury, examination findings, urinalysis, and diagnostic imaging. (See 'Initial assessment' above.)
●Clinical findings and physical examination – Signs of penetrating injury to the external genitalia may not be obvious but can include a perineal, scrotal, penile, or labial hematoma, or injuries to adjacent structures, such as the proximal thigh or buttocks. It is important to perform a careful physical examination looking for associated and occult injuries. Digital rectal and vaginal examinations should be performed whenever there is an injury in proximity to the pelvis (and should be performed cautiously if there is suspicion of pelvic fracture fragments). Hematuria increases the probability of penetrating GU injuries, but its absence does NOT exclude them. (See 'Clinical features' above and 'Initial assessment' above.)
●Diagnostic testing – Testing for penetrating GU injury is indicated when there are clinical signs of trauma or the injury trajectory courses in proximity to the GU tract. In stable patients, imaging studies are performed in retrograde fashion beginning with the evaluation of the external genitalia and urethra prior to that of the bladder. Evaluate the ureters and kidneys after lower tract injury is excluded, or after initiation of appropriate emergency management for an identified lower tract injury. (See 'Approach to testing' above.)
If signs of penile or urethral injury are present, perform a retrograde urethrogram prior to insertion of a Foley catheter. In cases of gross hematuria or injury proximate to the urethra, obtain a retrograde cystogram or retrograde CT cystogram to evaluate the bladder. Following evaluation for lower tract injury, suspected upper tract injury is assessed with contrast enhanced CT scan, including delayed images to evaluate possible collecting system involvement.
●Associated injuries and urologic consultation – Most patients with significant GU injuries require urgent or emergency urologic consultation. Many such patients have associated nonurologic injuries (usually intraabdominal) that require assessment by trauma surgery. Expeditious transfer is necessary after the initial assessment and stabilization when specialist care is not available. Do not delay transfer to definitive care to obtain imaging studies in unstable patients. (See 'Subsequent management and consultation' above and 'Definitive management' above.)
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