Guidelines Summary

The following organizations have published guidelines on the management of urogenital trauma:

American Urological Association (AUA) ^[42]
European Association of Urology(EAU) ^[43]

In addition, the American College of Radiology has published Appropriateness Criteria for the imaging of major blunt trauma and penetrating trauma of the lower abdomen.^{[41, 40]}

Initial Imaging

ACR Appropriateness Criteria recommend the following imaging modalities for the evaluation of blunt lower genitourinary trauma^[40]:

Triage: US FAST scan of the chest, abdomen, and pelvis
Initial Imaging: Fluoroscopy retrograde urethrography, radiography trauma series, CT of the abdomen and pelvis with IV contrast, CT of the whole body with IV contrast, or CTA of the abdomen and pelvis with IV contrast. Any of these studies will provide clinical information needed to effectively manage the injury.

The ACR recommends fluoroscopy, retrograde cystography, or CT of the pelvis with bladder contrast (CT cystography) for the initial imaging of penetrating lower genitourinary trauma.^[41]

Treatment of Bladder Injuries

According to the AUA guidelines, surgical repair is recommended for intraperitoneal bladder rupture and for complicated extraperitoneal bladder injuries, followed by urethral catheter drainage without suprapubic (SP) cystostomy. For uncomplicated extraperitoneal bladder injuries, catheter drainage is recommended.^[42]

The EAU guidelines recommend conservative management of uncomplicated blunt extraperitoneal bladder injuries. Uncomplicated small intraperitoneal bladder injuries may be managed during endoscopic procedures. Surgical exploration and repair should be performed for blunt intraperitoneal bladder injuries. Injuries with bladder neck involvement and other blunt extraperitoneal injuries require surgical repair.^[43]

Treatment of Urethral Trauma

The AUA guidelines include the following key recommendations for the management of urethral trauma^[42]:

Pelvic fracture urethral injury (PFUI): Establish prompt urinary drainage; percutaneous or open suprapubic tube placement is the preferred initial management. Primary realignment may be performed in hemodynamically stable patients; however, prolonged attempts at endoscopic realignment should not be performed.
Uncomplicated penetrating trauma of the anterior urethra should be repaired surgically.
Establish prompt urinary drainage for straddle injury to the anterior urethra.
Patients should be monitored for stricture formation, erectile dysfunction, incontinence, and other complications for at least 1 year after injury.

The EAU guidelines are in concurrence with the recommendations above.^[43]

Medication

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Media Gallery

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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Author

Imad S Dandan, MD Trauma Medical Director, 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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Walid A Farhat, MD, FRCS(C), FACS, GPLLM Professor and Chief of Pediatric Urology, Department of Urology, University of Wisconsin School of Medicine and Public Health

Walid A Farhat, MD, FRCS(C), FACS, GPLLM is a member of the following medical societies: American Academy of Pediatrics, American Association of Pediatric Urologists, American College of Surgeons, American Urological Association, Canadian Urological Association, Societies for Pediatric Urology, Society for Fetal Urology

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

David S Howes, MD Professor of Medicine and Pediatrics, Residency Program Director Emeritus, Section of Emergency Medicine, University of Chicago, University of Chicago, 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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sections Lower Genitourinary (Urethral, Penile, Scrotal, Testicular) Trauma Management in the ED
Overview
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References

Lower Genitourinary (Urethral, Penile, Scrotal, Testicular) Trauma Management in the ED Guidelines

Guidelines Summary

Initial Imaging

Treatment of Bladder Injuries

Treatment of Urethral Trauma

References

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