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

Updated: Dec 30, 2020
  • Author: Imad S Dandan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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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]