Lower Genitourinary Trauma

Author: Imad S Dandan, MD; Chief Editor: Rick Kulkarni, MD more...

Updated: Jun 7, 2011

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Background
Pathophysiology
Epidemiology
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Background

Injuries to the lower genitourinary (GU) tract alone are not life threatening, but their association with other potentially more significant injuries necessitates an organized approach to diagnosis and management. Because trauma is a multisystem disease, multiple injuries may be present in the trauma patient. Other injuries often take priority over injuries to the GU system and may initially interfere or postpone a complete urologic assessment. Coordinated efforts between various services caring for the patient are crucial to ensure comprehensive care.^{[1, 2]}

Initial evaluation of the injured patient suspected to have GU trauma should not differ from that of other trauma patients. Follow the protocols of the Advanced Trauma Life Support program of the American College of Surgeons.^[3]

See the image below.

Extravasated contrast in abdominal cavity secondary to ruptured bladder.

Pathophysiology

The lower GU tract comprises the urinary bladder, urethra, and external genitalia.

Most bladder injuries occur in association with blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures, with the remaining 15% occurring with penetrating trauma and blunt mechanism not associated with a pelvic fracture (ie, full bladder blowout).^[4]

Urethral injury is predominantly a male problem. In males, the urethra is divided into the proximal (posterior) segment and the distal (anterior) segment by the urogenital diaphragm. The anterior urethra is further divided into membranous (sphincteric) and prostatic segments. About 3 cm long, the posterior urethra extends from the bladder to the urogenital diaphragm.

Injuries to the posterior urethra are mostly secondary to pelvic fractures, while injuries to the anterior urethra are caused by straddle-type (eg, bicycles, skateboards) or penetrating (often self-inflicted) injuries. Urethral injuries from trauma constitute only 10% of all GU injuries, with iatrogenic etiology constituting a significant fraction of all urethral injuries.^[5]

Injuries to the external genitalia (ie, the penis and the scrotum) are usually secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation (self-inflicted or otherwise).

Frequency

United States

Three to ten percent of all trauma patients have injuries involving the GU tract, while 10-15% of trauma patients with abdominal injuries have associated GU tract involvement. Urethral injuries constitute 10% of all injuries to the GU tract, with bladder injuries comprising another 40%.

Mortality/Morbidity

Mortality from lower GU trauma is attributed to associated injuries, especially pelvic fractures.

Sex

Urethral trauma is primarily a male problem.

Age

Urethral trauma affects all age groups but seems to have a higher incidence in persons aged 15-25 years.

Proceed to Clinical Presentation

Contributor Information and Disclosures

Author

Imad S Dandan, MD Consulting Surgeon, Department of Surgery, Trauma Section, Scripps Memorial Hospital

Imad S Dandan, MD is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, American Medical Association, American Trauma Society, California Medical Association, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Walid A Farhat, MD, FRCS(C) Associate Professor, Department of Surgery, University of Toronto; Staff Physician, Division of Urology, The Hospital for Sick Children

Walid A Farhat, MD, FRCS(C) is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, College of Physicians and Surgeons of Ontario, and International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Specialty Editor Board

David S Howes, MD Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

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Cutinha P, Chapelle CR. Bladder injuries. Surg Int. 1997;37:107-12.
Png D, Chapelle CR. Urethral injuries. Surg Int. 1997;37:97-101.
James MJ. Investigation of the lower urinary tract. Surgery. 1995;13(2):37.
Peterson NE. Traumatic posterior urethral avulsion. Monogr Urol. 1986;7:61.
Patel A, Harrison SCW. Scrotal trauma. Surg Int. 1997;37:118-20.
Ziran BH, Chamberlin E, Shuler FD, Shah M. Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J Trauma. Mar 2005;58(3):533-7. [Medline].
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Ishak C, Kanth N. Bladder trauma: multidetector computed tomography cystography. Emerg Radiol. Apr 27 2011;[Medline].
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Richardson JR Jr, Leadbetter GW Jr. Non-operative treatment of the ruptured bladder. J Urol. Aug 1975;114(2):213-6. [Medline].
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Normal urethrogram.

Retrograde urethrogram showing an irregularity of the urethra indicating injury secondary to a shotgun wound.

Normal bladder on CT scan.

Ruptured dome of urinary bladder detected by retrograde cystogram.

Ruptured urinary bladder detected by CT scan.