Lower Genitourinary Trauma Workup

  • Author: Imad S Dandan, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jun 7, 2011
 

Laboratory Studies

  • Complete blood count (CBC) to obtain a hematocrit and a platelet count
  • Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to check for coagulopathy
  • Blood type and crossmatch
  • Urinalysis to assess for gross hematuria[10]
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Imaging Studies

Plain radiograph of the pelvis is used to assess presence and extent of bony injury.

Retrograde urethrogram

This is indicated prior to the insertion of a Foley catheter when urethral injury is suspected.

Urethrography is performed with water-soluble contrast material and preferably under fluoroscopy. If fluoroscopy is unavailable, multiple plain films are obtained with 10-mL injections of contrast material into the distal urethra.

Extravasated contrast material indicates urethral trauma. See the image below.

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

Retrograde cystogram

Cystography is the most reliable and easily available modality. A water-soluble contrast material is used, and, initially, 250 mL are introduced through the Foley catheter.

If the patient reports no discomfort, another 150 mL are introduced, and the catheter is clamped.

Obtain and view anteroposterior and lateral radiographs of the lower abdominal area; obtain identical views after the patient empties his or her bladder. Latter views provide information about posterior extraperitoneal injuries that may not be detected when the bladder is full.

Flamelike extravasations (sunburst) superior or lateral to the bladder indicate extraperitoneal rupture.

Extravasated contrast material throughout the peritoneal cavity, which could outline the bowel and fill the cul-de-sac and the paracolic gutters, indicates intraperitoneal rupture. Pericystic hematomas may be seen on cystograms as compression or displacement of the bladder.

Gross hematuria without extravasation indicates bladder contusion. Extravasation of contrast material into the bowel lumen or into the vagina is possible in penetrating trauma. See the image below.

Ruptured dome of urinary bladder detected by retroRuptured dome of urinary bladder detected by retrograde cystogram.

CT scan of abdomen and pelvis

CT scanning is specific in aiding in the diagnosis of bladder injuries but carries low sensitivity.

CT scanning is useful for diagnosis of associated abdominal and pelvic injuries.

See the images below.

Normal bladder on CT scan. Normal bladder on CT scan. Ruptured urinary bladder detected by CT scan. Ruptured urinary bladder detected by CT scan.

CT cystography is an emerging imaging modality for use in the diagnosis of bladder injuries.

Ultrasonography

Ultrasonography is used as a screening tool to indicate bladder wall abnormalities or presence of fluid in the abdomen but suffers from low sensitivity in excluding bladder injury. Although Ultrasonography has a low sensitivity, it is a fast and cost effective early screening measure, and when positive can expedite patient care.

It is also used in assessing the condition of the testes.

Ultrasonography may be useful in the acute setting of abdominal trauma as part of the focused abdominal sonography in trauma (FAST) examination of the injured patient.

Simultaneous suprapubic cystography and retrograde urethrography

If the urethrogram is inconclusive and the patient still cannot void with a distended bladder, a suprapubic cystostomy catheter is inserted pending further investigation.

This is the procedure of choice about a week after the injury.

Radionuclide scan

This is used to assess the viability of the testes, especially after blunt trauma.

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Procedures

  • Bladder irrigation: Bladder rupture is indicated by inability to retrieve the total amount of the irrigant.
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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

  1. Walsh PC. Genitourinary trauma. In: Campbell's Urology. 6th ed. WB Saunders Co; 1992:2574.

  2. Guerriero WG. Trauma to the kidneys, ureters, bladder, and urethra. Surg Clin North Am. Dec 1982;62(6):1047-74. [Medline].

  3. American College of Surgeons Committee on Trauma. Initial assessment and management. Advanced Trauma Life Support Program for Physicians;1993:9-46.

  4. Cutinha P, Chapelle CR. Bladder injuries. Surg Int. 1997;37:107-12.

  5. Png D, Chapelle CR. Urethral injuries. Surg Int. 1997;37:97-101.

  6. James MJ. Investigation of the lower urinary tract. Surgery. 1995;13(2):37.

  7. Peterson NE. Traumatic posterior urethral avulsion. Monogr Urol. 1986;7:61.

  8. Patel A, Harrison SCW. Scrotal trauma. Surg Int. 1997;37:118-20.

  9. 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].

  10. Styles RA. Hematuria. Surgery. 1996;14:213.

  11. Trunkey D. Initial treatment of patients with extensive trauma. N Engl J Med. May 2 1991;324(18):1259-63. [Medline].

  12. Peterson NE. Current management of urethral injuries. Urol Annual. 1988;143-79.

  13. Ishak C, Kanth N. Bladder trauma: multidetector computed tomography cystography. Emerg Radiol. Apr 27 2011;[Medline].

  14. Krieger JN, Algood CB, Mason JT, et al. Urological trauma in the Pacific Northwest: etiology, distribution, management and outcome. J Urol. Jul 1984;132(1):70-3. [Medline].

  15. Richardson JR Jr, Leadbetter GW Jr. Non-operative treatment of the ruptured bladder. J Urol. Aug 1975;114(2):213-6. [Medline].

  16. Wu TS, Pearson TC, Meiners S, Daugharthy J. Bedside Ultrasound Diagnosis of a Traumatic Bladder Rupture. J Emerg Med. Mar 24 2011;[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.
Extravasated contrast in abdominal cavity secondary to ruptured bladder.
 
 
 
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