History
In blunt trauma, history is obtained regarding the time and mechanism of injury, eg, the position of the patient in a motor vehicle accident (MVA) and whether restraints were used. The speed of the vehicle and the manner in which the accident occurred provide information about forces applied to the victim.
In penetrating trauma, knowing the size of the stabbing weapon or the caliber of the gun and the distance from which it was discharged helps in assessment. Question paramedics as to the condition of the patient immediately after injury occurred and during transport to the care facility.
In patients with GU trauma, symptoms are nonspecific and may be masked by or attributed to other injuries.
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Bladder trauma: In the ED, question the patient about suprapubic abdominal pain and the ability to void after the injury. If the patient cannot provide such information and gross hematuria is present, suspect bladder injury.
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Urethral trauma: Knowledge of associated injuries that can cause urethral injury is required for diagnosis. A history of inability to void indicates the possibility of urethral trauma.
In external genitalia trauma, a history of psychiatric problems, use of penile rings, and excessive sexual activity is pertinent in specific conditions. A history of sudden pain, loss of erection, and swelling is important.
Physical
Signs of lower GU injury are a small part of a massive conglomeration of signs related to associated injuries; therefore, always keep a high index of suspicion. [24]
Bladder trauma
Bruising or edema of the lower abdomen, perineum, or genitalia indicates bladder injury.
Always suspect urethral and bladder injuries in patients with pelvic fractures and inability to void.
Inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury.
Urethral trauma
The classic sign of urethral trauma is blood at the meatus.
Penile or perineal edema and/or hematoma are present in anterior injuries.
A distended bladder may be present in posterior injuries, as 65% of posterior injuries are complete transections. [37]
Penile trauma
Signs of penile trauma include the following:
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Loss of skin
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Edema
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Angulation
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Level of mutilation
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Viability of mutilated segment
Scrotal trauma
Signs of scrotal trauma include the following:
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Edema
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Loss of skin
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Discoloration
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Condition of testes
Causes
Bladder injuries are best classified as intraperitoneal and extraperitoneal. Extraperitoneal bladder injuries account for 65-85% of bladder injuries and are usually associated with pelvic fractures, especially pubic ramus fractures (95%). Intraperitoneal bladder injuries account for 15-35% of bladder injuries and are infrequently associated with pelvic fractures. These injuries may be due to blunt rupture of a distended bladder or penetrating injury. [33]
Blunt trauma is responsible for 60% of urethral injuries, and penetrating and iatrogenic etiologies cause 40%. Blunt injury in the anterior urethra usually is caused by a straddle-type mechanism compressing the urethra between a hard object and the symphysis pubis. In 70% of patients, penetrating trauma to the anterior urethra involves the perineum and bulbar urethra, and in 30%, the pendulous urethra is involved.
Posterior urethral injury in blunt trauma is secondary to pelvic fractures because of proximity to the bony pelvis. [38] Missiles and knives can also cause penetrating injury to the posterior urethra.
In the National Inpatient Sample, penile fractures were found to occur disproportionately during summer (30%) and weekends (37%) and were associated with a 21% risk of urethral injury. [5]
In gunshot wounds, look for associated injuries to the pelvis, bladder, rectum, and sphincter mechanism.
In an analysis of iatrogenic nonendoscopic bladder injuries over 24 years at one institution, hysterectomy and cesarean sections were the 2 most common causative procedures. A delay in diagnosis was more likely to occur during laparoscopic surgery, and complications occurred more commonly with a concomitant ureteral injury. [6]
In a study of 39 patients with clinical features of penile fracture, mechanism of injury was coital in 32 (82%) of patients. Penoscrotul ultrasound was used in 17 cases, retrograde urethrogram in 3 cases, and MRI in 1 case. At follow-up, 6 patients had complications: 2 wound infections, 2 new-onset erectile dysfunction, 1 urethral stricture, 1 fistula, and 1 wound dehiscence. Urethral injury increased the risk of postoperative complications. [7]
The main causes of bladder injury include the following:
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Motor vehicle accidents
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Bicycle accidents
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Stabbings
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Impalements
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Gunfire
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Iatrogenic
The main causes of urethral injury include the following:
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Straddle-type mechanism (eg, bicycles, skateboards, falls onto the perineum)
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Motor vehicle accidents
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Mutilation (self-inflicted or otherwise)
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Gunfire
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Stabbings
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Iatrogenic
Complications
Complications of bladder injuries include the following:
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Urinomas
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Fistulization (rectum, vagina, bowel, cutaneous)
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Pelvic hematoma infection
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Difficulties voiding
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Distal ureteral obstruction
Complications of urethral injuries include the following:
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Strictures
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Incontinence
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Impotence
Complications of penile injuries include the following:
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Angulation
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Painful erection
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Impotence
Complications of scrotal injuries include the following:
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Infection
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Loss of testes
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Skin necrosis
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Testicular atrophy
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Decreased fertility
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Normal urethrogram.
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Retrograde urethrogram showing an irregularity of the urethra indicating injury secondary to a shotgun wound.
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Normal bladder on CT scan.
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Ruptured dome of urinary bladder detected by retrograde cystogram.
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Ruptured urinary bladder detected by CT scan.
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Extravasated contrast in abdominal cavity secondary to ruptured bladder.
