Sections

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

Sections Lower Genitourinary (Urethral, Penile, Scrotal, Testicular) Trauma Management in the ED
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Guidelines
Medication
Media Gallery
References

Medication

Medication Summary

Medications for patients with lower GU tract injuries relate to the management of patients as critically injured rather than management specific to the GU injury.

Class Summary

Used for prophylaxis against infections of the GU tract. Empiric antimicrobial therapy must be comprehensive, covering all likely pathogens in the clinical setting.

Ampicillin and sulbactam (Unasyn)

View full drug information

Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Cefotetan (Cefotan)

View full drug information

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.

Dosage and route of administration depends on condition of patient, severity of infection, and susceptibility of causative organism.

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma.

A review of opioid equivalents and conversions may be found in the following reference article:

http://emedicine.medscape.com/article/2138678-overview

Fentanyl (Sublimaze, Abstral, Actiq, Duragesic, Ionsys, Lazanda, Onsolis, Subsys)

View full drug information

A synthetic opioid that is 75-200 times more potent and much shorter half-life than morphine sulfate. Has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal-to-no associated histamine release. By itself, it causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.

Highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process.

Consider continuous infusion because of the short half-life of fentanyl.

Parenteral form is DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period.

Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.

After initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than q3h or q6h thereafter.

Transdermal form is used only for chronic pain conditions in opioid tolerant patients. When using transdermal dosage form, majority of patients are controlled with 72 h dosing intervals; however, some patients require dosing intervals of 48 h.

Easily and quickly reversed by naloxone.

Morphine sulfate (Astramorph, Duramorph, MS Contin, Avinza, Depodur, Infumorph, Kadian, MorphaBond, Arymo ER)

View full drug information

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Various IV doses are used; commonly titrated until desired effect obtained.

For chronic severe pain unremitting to alternative therapy, oral immediate–release and extended-release morphine sulfate may be warranted. Arymo ER is a morphine sulfate abuse-deterrent derivative.

ATLS Subcommittee., American College of Surgeons’ Committee on Trauma., International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May. 74 (5):1363-6. [QxMD MEDLINE Link].
Kortbeek JB, Al Turki SA, Ali J, et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma. 2008 Jun. 64 (6):1638-50. [QxMD MEDLINE Link].
American College of Surgeons Committee on Trauma. Initial assessment and management. Advanced Trauma Life Support Program for Physicians. 1993:9-46.
Dayal M, Gamanagatti S, Kumar A. Imaging in renal trauma. World J Radiol. 2013 Aug 28. 5(8):275-84. [QxMD MEDLINE Link]. [Full Text].
Pariser JJ, Pearce SM, Patel SG, Bales GT. National Patterns of Urethral Evaluation and Risk Factors for Urethral Injury in Patients With Penile Fracture. Urology. 2015 Jul. 86 (1):181-5. [QxMD MEDLINE Link].
Cordon BH, Fracchia JA, Armenakas NA. Iatrogenic nonendoscopic bladder injuries over 24 years: 127 cases at a single institution. Urology. 2014 Jul. 84 (1):222-6. [QxMD MEDLINE Link].
Phillips EA, Esposito AJ, Munarriz R. Acute penile trauma and associated morbidity: 9-year experience at a tertiary care center. Andrology. 2015 May. 3 (3):632-6. [QxMD MEDLINE Link].
Dalton DM, Davis NF, O'Neill DC, Brady CM, Kiely EA, O'Brien MF. Aetiology, epidemiology and management strategies for blunt scrotal trauma. Surgeon. 2014 Aug 20. [QxMD MEDLINE Link].
Manjunath AS, Hofer MD. Urologic Emergencies. Med Clin North Am. 2018 Mar. 102 (2):373-385. [QxMD MEDLINE Link].
Bryant WK, Shewakramani S, Zaurova M. Emergency management of renal and genitourinary trauma: best practices update [digest]. Emerg Med Pract. 2017 Aug 22. 19 (8 Suppl Points & Pearls):S1-S2. [QxMD MEDLINE Link].
Nelson Q, Leslie SW, Baker J. Urethral Injury. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Bourke MM, Silverberg JZ. Acute Scrotal Emergencies. Emerg Med Clin North Am. 2019 Nov. 37 (4):593-610. [QxMD MEDLINE Link].
Panella P, Pepe P, Pennisi M. Diagnosis and treatment of penile injury: ten years experience of an emergency department. Arch Ital Urol Androl. 2020 Oct 1. 92 (3):[QxMD MEDLINE Link].
Leslie SW, Sajjad H, Taylor RS. Penile Zipper and Ring Injuries. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Mankowitz SL. Laceration Management. J Emerg Med. 2017 Sep. 53 (3):369-382. [QxMD MEDLINE Link].
Dawood O, Tabibi S, Fiuk J, Patel N, El-Zawahry A. Penile ring entrapment - A true urologic emergency: Grading, approach, and management. Urol Ann. 2020 Jan-Mar. 12 (1):15-18. [QxMD MEDLINE Link].
Oquist M, Buck L, Michel K, Ouellette L, Emery M, Bush C. Comparative analysis of five methods of emergency zipper release by experienced versus novice clinicians. Am J Emerg Med. 2017 May. 35 (5):783-784. [QxMD MEDLINE Link].
Puvvada S, Kasaraneni P, Gowda RD, et al. Stepwise approach in the management of penile strangulation and penile preservation: 15-year experience in a tertiary care hospital. Arab J Urol. 2019. 17 (4):305-313. [QxMD MEDLINE Link].
Patel NH, Schulman A, Bloom J, et al. Penile and Scrotal Strangulation due to Metal Rings: Case Reports and a Review of the Literature. Case Rep Surg. 2018. 2018:5216826. [QxMD MEDLINE Link].
Barros R, Schul A, Cavalcanti AG, Favorito LA, Koifman L. Findings regarding non-sexual penile fracture in a referral emergency hospital. Int Braz J Urol. 2021 Mar-Apr. 47 (2):388-394. [QxMD MEDLINE Link].
Diaz KC, Cronovich H. Penis Fracture. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Offenbacher J, Barbera A. Penile Emergencies. Emerg Med Clin North Am. 2019 Nov. 37 (4):583-592. [QxMD MEDLINE Link].
Cozzi D, Verrone GB, Agostini S, et al. Acute penile trauma: imaging features in the emergency setting. Radiol Med. 2019 Dec. 124 (12):1270-1280. [QxMD MEDLINE Link].
James MJ. Investigation of the lower urinary tract. Surgery. 1995. 13(2):37.
American Urological Assocation. Urotrauma: AUA guideline. J Urol. 2014 Aug. 192 (2):327-35. [QxMD MEDLINE Link].
Weatherspoon K, Polansky S, Catanzano T. Ultrasound Emergencies of the Male Pelvis. Semin Ultrasound CT MR. 2017 Aug. 38 (4):327-344. [QxMD MEDLINE Link].
Whitson MR, Mayo PH. Ultrasonography in the emergency department. Crit Care. 2016 Aug 15. 20 (1):227. [QxMD MEDLINE Link].
Blaivas M, Brannam L. Testicular ultrasound. Emerg Med Clin North Am. 2004 Aug. 22 (3):723-48, ix. [QxMD MEDLINE Link].
Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010 Jan. 29 (1):11-21. [QxMD MEDLINE Link].
Blaivas M, Batts M, Lambert M. Ultrasonographic diagnosis of testicular torsion by emergency physicians. Am J Emerg Med. 2000 Mar. 18 (2):198-200. [QxMD MEDLINE Link].
Badea R, Lucan C, Suciu M, Vasile T, Gersak M. Contrast enhanced harmonic ultrasonography for the evaluation of acute scrotal pathology. A pictorial essay. Med Ultrason. 2016 Mar. 18 (1):110-5. [QxMD MEDLINE Link].
Peterson NE. Current management of urethral injuries. Urol Annual. 1988. 143-79.
Cutinha P, Chapelle CR. Bladder injuries. Surg Int. 1997. 37:107-12.
Matlock KA, Tyroch AH, Kronfol ZN, McLean SF, Pirela-Cruz MA. Blunt traumatic bladder rupture: a 10-year perspective. Am Surg. 2013 Jun. 79(6):589-93. [QxMD MEDLINE Link].
Durrant JJ, Ramasamy A, Salmon MS, Watkin N, Sargeant I. Pelvic fracture-related urethral and bladder injury. J R Army Med Corps. 2013 Mar. 159 Suppl 1:i32-9. [QxMD MEDLINE Link].
Png D, Chapelle CR. Urethral injuries. Surg Int. 1997. 37:97-101.
Peterson NE. Traumatic posterior urethral avulsion. Monogr Urol. 1986. 7:61.
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. 2005 Mar. 58(3):533-7. [QxMD MEDLINE Link].
Styles RA. Hematuria. Surgery. 1996. 14:213.
[Guideline] Expert Panel on Major Trauma Imaging., Shyu JY, Khurana B, Soto JA, Biffl WL, Camacho MA, et al. ACR Appropriateness Criteria® Major Blunt Trauma. J Am Coll Radiol. 2020 May. 17 (5S):S160-S174. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Expert Panel on Urological Imaging., Heller MT, Oto A, Allen BC, Akin O, Alexander LF, et al. ACR Appropriateness Criteria® Penetrating Trauma-Lower Abdomen and Pelvis. J Am Coll Radiol. 2019 Nov. 16 (11S):S392-S398. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Morey AF, Brandes S, Dugi III DD, et al. Urotrauma Guideline. American Urological Association. Available at https://www.auanet.org/guidelines/urotrauma-guideline. Published 2014; Amended 2017, 2020; Accessed: November 21, 2020.
[Guideline] Kitrey ND, Djakovic N, Hallscheidt DP, et al. Urological Trauma Guidelines. European Association of Urology. Available at https://uroweb.org/guideline/urological-trauma/. 2020; Accessed: November 21, 2020.
Trunkey D. Initial treatment of patients with extensive trauma. N Engl J Med. 1991 May 2. 324(18):1259-63. [QxMD MEDLINE Link].
Walsh PC. Genitourinary trauma. Campbell's Urology. 6th ed. WB Saunders Co; 1992. 2574.
Guerriero WG. Trauma to the kidneys, ureters, bladder, and urethra. Surg Clin North Am. 1982 Dec. 62(6):1047-74. [QxMD MEDLINE Link].
Patel A, Harrison SCW. Scrotal trauma. Surg Int. 1997. 37:118-20.
Ishak C, Kanth N. Bladder trauma: multidetector computed tomography cystography. Emerg Radiol. 2011 Apr 27. [QxMD MEDLINE Link].
Krieger JN, Algood CB, Mason JT, et al. Urological trauma in the Pacific Northwest: etiology, distribution, management and outcome. J Urol. 1984 Jul. 132(1):70-3. [QxMD MEDLINE Link].
Richardson JR Jr, Leadbetter GW Jr. Non-operative treatment of the ruptured bladder. J Urol. 1975 Aug. 114(2):213-6. [QxMD MEDLINE Link].
Wu TS, Pearson TC, Meiners S, Daugharthy J. Bedside Ultrasound Diagnosis of a Traumatic Bladder Rupture. J Emerg Med. 2011 Mar 24. [QxMD MEDLINE Link].

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.

of 6

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
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Guidelines
Medication
Media Gallery
References

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

Medication Summary

Antibiotics

Class Summary

Ampicillin and sulbactam (Unasyn)

Ampicillin and sulbactam (Unasyn)

Cefotetan (Cefotan)

Cefotetan (Cefotan)

Analgesics

Class Summary

Fentanyl (Sublimaze, Abstral, Actiq, Duragesic, Ionsys, Lazanda, Onsolis, Subsys)

Fentanyl (Sublimaze, Abstral, Actiq, Duragesic, Ionsys, Lazanda, Onsolis, Subsys)

Morphine sulfate (Astramorph, Duramorph, MS Contin, Avinza, Depodur, Infumorph, Kadian, MorphaBond, Arymo ER)

Morphine sulfate (Astramorph, Duramorph, MS Contin, Avinza, Depodur, Infumorph, Kadian, MorphaBond, Arymo ER)

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

Medication Summary

Antibiotics

Class Summary

Ampicillin and sulbactam (Unasyn)

Ampicillin and sulbactam (Unasyn)

Cefotetan (Cefotan)

Cefotetan (Cefotan)

Analgesics

Class Summary

Fentanyl (Sublimaze, Abstral, Actiq, Duragesic, Ionsys, Lazanda, Onsolis, Subsys)

Fentanyl (Sublimaze, Abstral, Actiq, Duragesic, Ionsys, Lazanda, Onsolis, Subsys)

Morphine sulfate (Astramorph, Duramorph, MS Contin, Avinza, Depodur, Infumorph, Kadian, MorphaBond, Arymo ER)

Morphine sulfate (Astramorph, Duramorph, MS Contin, Avinza, Depodur, Infumorph, Kadian, MorphaBond, Arymo ER)

References

Tables

Contributor Information and Disclosures

What would you like to print?