GENITOURINARY TRAUMA

Mark Boyko EM
 Objectives
1. Key aspects of GU trauma in an
anatomical approach:
External Genitalia
Urethral Injury
Bladder Injury
Ureteral Injury
Renal Injury
 GU Trauma
80% of GU trauma is BLUNT trauma
Very rarely is life threatening, so take a step
back and move through your systems
anatomically
Assessing for concomitant pelvic fracture
is one of the most important points
 Anything can happen

Eur J Emerg Med. 2004 Aug;11(4):223-4.

A human bite to the scrotum: a case report and review of the literature.
Kerins M, Greene S, O'Connor N.

Emergency Department, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH,
UK. mkerins_fahey@hotmail.com

Human bites to the scrotum are rare and can be associated with a high morbidity rate if poorly managed. We report a case
of a human bite to the scrotum that was successfully treated with a 5-day course of antibiotics, surgical debridement and
healing by secondary intention.
 External Genitalia
Trauma here is rare in females
In males, injury is often obvious
Look for swelling, ecchymoses, deformity
Testicular torsion can occur with trauma
Testicular rupture occurs in 50% of patients
with a direct blow to a testicle, have a low
threshold to ultrasound
 Male External Genitalia
Penile Fracture
Usually a sexual accident
Immediate pain, often hear
a popping sound, early
swelling
Is a rupture of the tunica
albuginea surrounding the
corpora cavernosa
20% association with
urethral injury
Requires operative repair
 Question
A penile fracture is classically described
using what vegetable?
 Penile Fracture
Eggplant Deformity
 Urethral Injuries
Again, rare in females
In males, divided into anterior and
posterior urethra, divided by urogenital
diaphragm
 Urethral Injury
In males, 25% of all pelvic fractures have
urethral injury (vs only 5% in females),
more commonly the posterior division
Gross hematuria and pelvic fracture =
posterior urethral injury until proven
otherwise
The big 4 clues to urethral injury:
Blood at meatus
Gross hematuria
Inability to void
Ecchymoses, swelling of penis
 Question
What 4 things are necessary before you can
attempt to pass a foley catheter?
 The Great Foley Debate
Textbook answer:
4 things allowing you to pass a foley safely:
1. No pelvic and suprapubic tenderness / #
2. No penile, scrotal, or perineal hematoma
3. No blood at the urethral meatus
4. No abnormal findings on DRE
 The Great DRE Debate
Textbook answer:
high riding prostate or boggy prostate is
concerning for a posterior urethral injury
blood causes the prostate to lift superiorly
Is any of this true?? EM Rap 2008
The Great Foley Debate:
Initial concept came from 1977 paper by a British urologist entitled
A Personal View of Immediate Management of Pelvic Fracture and
Ureteral Injury - no references
UCLA retrospective review of 7 years trauma patients, 46 urethral
injuries, 50% of blind passes were successful
The classic signs of urethral injury were extremely non-sensitive
One small retrospective review of 13 cases of urethral injury
demonstrated no evidence that a blind attempt to insert a urinary
catheter worsened the initial injury.
No case reports that passing a foley caused/worsened urethral injury

The Great DRE Debate:

-same UCLA retrospective review, 0 had high riding prostates
-UCLA 1400 trauma patients, more false + DREs than true + (for tone,
for sensation, for blood)
 Urethral Injury - Imaging
If any concern for a urethral injury, do a
retrograde urethrogram
Will either be:
Normal
Partial urethral injury (some dye in bladder, some
extravascation)
Complete urethral injury (no dye in bladder)
Urethral Injury - Management
If no concern for injury, or retrograde urethrogram
normal, put a foley in.

If a partial urethral tear, textbooks say one

careful attempt to pass a 12- or 14-Fr Foley can be
undertaken. Most urologists disagree with this,
and wish to be consulted.

If a complete tear suprapubic catheter, urology

consult for operative repair.
 Bladder Injury
Question: Which part of the bladder is the
weakest and most likely to rupture?
A) Trigone
B) Lateral walls
C) Dome (superior wall)
D) Posterior wall
 Bladder Injury
80% of bladder injuries associated with
pelvic #
Injuries classified as:
Contusions
Intra-peritoneal ruptures (through the dome)
Extra-peritoneal ruptures (seen exclusively with
pelvic fractures)
 Bladder Injury
Signs
GROSS hematuria (95% of cases)
Microscopic hematuria with a pelvic fracture
No pelvic fracture + No gross hematuria
excludes injury to bladder
What about pelvic # and microscopic
hematuria? --> Do a retrograde CT
cystography
 Bladder Injury - Imaging
Retrograde cystography (either CR or CT)
is imaging modality of choice
Very sensitive
Bladder Injury
 Bladder Injury - Management
Contusions conservative
Intra-peritoneal operative repair
Extra-peritoneal many are now managed
non-operatively with an indwelling foley
catheter, will usually heal spontaneously.
 Ureteral Injury
Extremely rare, gunshot is most common
No reliable Phx findings! Usually a
retrograde diagnosis
Urinalysis is normal 25% of the time, do
not rely on it
Being suspicious for it is the only way you
will catch it
Imaging: Delayed CT with IV contrast
Management: Requires OR
 Renal Injury
90% blunt trauma, 10% penetrating

Again, relax. Something else will kill them

(less than 0.1% of trauma death)
Classification of Renal Injury
 Hematuria and Renal Injury
Poor correlation with degree of injury
Microscopic hematuria on its own is not a
concern. Repeat urinalysis in 3 weeks
You should image if the following:
Microscopic hematuria with shock
GROSS hematuria
Rapid deceleration without hematuria or shock
(rare, but important)
Penetrating trauma in the region
 Renal Imaging
CT with IV contrast is 90-100% SENS
Remember, FAST ultrasound is not good for
solid organ injury, do not use it in this
setting
Formal ultrasound not as sensitive as CT
 Renal Injury - Management
If no rapid deceleration mechanism (how
rapid?) and no gross hematuria, can d/c
home with f/u urinalysis
Grade I and II injuries non-operative.
Bed rest until gross hematuria clears.
Grade III and up decision point for
urology
 Ask Me For References

Questions?