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

The lower GU tract comprises the urinary bladder, urethra, and external genitalia.

Most bladder injuries occur in association with blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures, with the remaining 15% occurring with penetrating trauma and blunt mechanism not associated with a pelvic fracture (ie, full bladder blowout).[33, 34, 35]

Urethral injury is predominantly a male problem. In males, the urethra is divided into the proximal (posterior) segment and the distal (anterior) segment by the urogenital diaphragm. The posterior urethra is further divided into membranous (sphincteric) and prostatic segments. About 3 cm long, the posterior urethra extends from the bladder to the urogenital diaphragm.

Injuries to the posterior urethra are mostly secondary to pelvic fractures, while injuries to the anterior urethra are caused by straddle-type (eg, bicycles, skateboards) or penetrating (often self-inflicted) injuries. Urethral injuries from trauma constitute only 10% of all GU injuries, with iatrogenic etiology constituting a significant fraction of all urethral injuries.[36]

Injuries to the external genitalia (ie, the penis and the scrotum) are usually secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation (self-inflicted or otherwise).

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.

• 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.

• 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.

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:

• Loss of skin

• Edema

• Angulation

• Level of mutilation

• Viability of mutilated segment

Scrotal trauma

Signs of scrotal trauma include the following:

• Edema

• Loss of skin

• Discoloration

• Condition of testes

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:

• Motor vehicle accidents

• Bicycle accidents

• Stabbings

• Impalements

• Gunfire

• Iatrogenic

The main causes of urethral injury include the following:

• Straddle-type mechanism (eg, bicycles, skateboards, falls onto the perineum)

• Motor vehicle accidents

• Mutilation (self-inflicted or otherwise)

• Gunfire

• Stabbings

• Iatrogenic

Complications of bladder injuries include the following:

• Urinomas

• Fistulization (rectum, vagina, bowel, cutaneous)

• Pelvic hematoma infection

• Difficulties voiding

• Distal ureteral obstruction

Complications of urethral injuries include the following:

• Strictures

• Incontinence

• Impotence

Complications of penile injuries include the following:

• Angulation

• Painful erection

• Impotence

Complications of scrotal injuries include the following:

• Infection

• Loss of testes

• Skin necrosis

• Testicular atrophy

• Decreased fertility

Lab studies include the following:

• 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[39]

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

Retrograde urethrogram

Retrograde urethrography 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 cystogram

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

If the patient reports no discomfort, another 150 mL is 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.)

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.)

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.

Ultrasonography may be useful in the acute setting of blunt abdominal trauma as part of the focused abdominal sonography in trauma (FAST) examination of the injured patient.[40]  However, it is not recommended for the evaluation of penetrating traumas.[41]

According to major US and European guidelines, ultrasonography is the imaging modality of choice for the diagnosis of testicular trauma.[42, 43]   In a retrospective analysis of 27 patients presenting to the ED with blunt scrotal trauma, median age was 19 years (range 8-65 yr), and 26 of the patients underwent scrotal ultrasound on presentation. Sixteen patients (59%) presented with scrotal trauma secondary to a sports-related injury.[8]

The American Urologic Association guidelines support the use of ultrasonography in cases of blunt scrotal trauma. Ultrasound is often the first-line modality for evaluation of male pelvic emergencies. Testicular torsion, Fournier gangrene, and testicular dislocation are surgical emergencies and should not be missed or misdiagnosed, which could delay urgently needed treatment. In the case of testicular trauma, the main goal of US is to assess vascular perfusion and integrity of the testes and identiy testicular rupture. Sensitivity and specificity have been reported to be as high as 95-100% for testicular rupture. FAST can identify sources of intra-abdominal bleeding.[25, 26, 27, 28, 29, 30, 31]

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

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

For more information on lower genitouinary trauma imaging, see Bladder Trauma Imaging, Urethral Trauma Imaging and Testicular Trauma Imaging.

Advancement of prehospital care for the trauma patient is one of the biggest leaps forward in trauma care. Principles do not change with varying organ injuries.[3, 44]

Paramedics quickly assess the patient and mechanism of injury, especially for patency of ABCs.

• Establish an airway if needed and/or administer oxygen.

• Establish 2 large-bore IVs.

• Take cervical spine precautions (eg, hard collar, back-board).

• Leave the scene as soon as possible and quickly transport the patient to the trauma center.

Administer oxygen and ventilatory support if needed. Resuscitate with crystalloids (lactated Ringer solution or isotonic sodium chloride solution) and blood (O-negative packed red blood cells) if indicated. Life-threatening injuries (eg, tension pneumothorax, open pneumothorax, cardiac tamponade) should be addressed emergently in the ED.

Perform cystography and retrograde urethrography as needed.

Further outpatient care in the patient with lower GU tract trauma mainly depends on the extent of associated injuries. The need for rehabilitation secondary to either orthopedic or neurologic injuries must be assessed on a patient-by-patient basis.

Arrange for follow-up care for delayed repair of urethral injuries.

Penile injuries require close follow-up care, especially if skin grafting was performed.

Perform follow-up hormonal studies and semen analysis on patients with scrotal or testicular injuries.

Bladder contusion

Adequate drainage of the bladder should result in resolution within a few days.

Follow-up cystography is recommended to assess integrity of the bladder wall.

Intraperitoneal rupture

Intraperitoneal rupture is surgically repaired with a watertight stitch and absorbable suture.

Adequate drainage with a urethral catheter and suprapubic cystostomy catheter for 10 days should be provided.

A cystogram should be performed to assess the integrity of the repair before removing catheters.

The urethral catheter should be removed and the postvoid residuals should be checked to ensure adequate bladder evacuation before removing the suprapubic cystostomy catheter the following day.

Extraperitoneal rupture

Cystography should be performed after 7-10 days with adequate bladder drainage and broad-spectrum antibiotics.

The catheter should be removed if extravasation has resolved, but if the extravasation is persistent, surgical intervention is required.

Persistent severe hematuria and infection of the pelvic hematoma are contraindications to conservative therapy.

Surgical repair is performed by opening the dome of the bladder and repairing the laceration from within.

Penetrating injuries

The preferred method for penetrating injuries is surgical intervention; open the dome of the bladder and perform a full inspection. Indigo carmine IV injection is used to help identify distal ureters.

Management of urethral injuries is related to the type of injury sustained, but basic principles apply[32]  The bladder should be drained with a suprapubic catheter percutaneously or open technique to prevent further extravasation. Initial urethral repair is not recommended because of risk of hemorrhage, impotence, and infection of pelvic hematoma. Commence definitive management of urethral injuries after stabilizing the patient and attending to associated injuries. Repair can be performed as immediate primary closure, delayed primary closure (10-14 days), or late primary closure (>3 mo).

Management of penile injuries depends on the severity of trauma and the extent of tissue damage. Treat penile skin injuries by debridement and split-thickness skin grafting. Penile fractures are ruptures of the Buck fascia and the corpus cavernosum that occur when the penis is subjected to trauma during erection. Symptoms are immediate pain with loss of erection followed by edema. Urethral injury is reported in 23% of patients. Management is conservative, with spontaneous resolution rates of 90%. The remaining 10% of patients require surgical intervention with evacuation of the hematoma and repair of Buck fascia with absorbable sutures Give preference to treating penile mutilation (self-inflicted or otherwise) by replantation, if the warm ischemia time does not exceed 4 hours.

For penal injuries, conduct microvascular repair of the dorsal vein and both arteries with repair of the urethra, Buck fascia, and skin. Place the amputated segment in cold, lactated Ringer solution containing heparin and antibiotics to prolong ischemia time. If replantation is not possible, debridement is followed with skin closure constructed with a spatulated urethra-to-skin anastomosis. Dirty wounds may have to be left open after debridement. Manage penile strangulation by removal of the strangulating object, administration of antibiotics, and debridement of all necrotic skin. Skin grafting is required if primary repair of the skin is not possible.

Blunt trauma

Radionuclide scan or ultrasonography can help assess the condition of the testes.

Surgical exploration and repair of ruptured testis reduces pain and duration of recovery.

If scrotal skin loss is significant, the testes can be moved to an alternate location (ie, to the perineum or subcutaneously). The skin is debrided and closed. Over time, the scrotum dilates and the testes can be returned.

Consultation

Consultations include the following:

• Trauma surgeon for associated intra-abdominal injuries

• Urologist for lower GU tract injury

• Orthopedic surgeon for management of frequently associated pelvic fractures

• Other specialists as injuries require

Transfer

Assess capabilities of the ED to handle the patient with multiple injuries that include lower GU trauma; the decision to transfer is based on that assessment.

Treat all life-threatening injuries prior to transfer; stabilize and resuscitate the patient.

The responsibility of the transfer, choice of transfer modality, and selection of accepting facility lies with the transferring physician.

The receiving physician confirms the ability of the receiving institution to handle the patient's condition.

An institutional transfer protocol facilitates the transfer process.

Lower GU trauma patients benefit from transfer when the following conditions exist at the transferring center:

• CT scan not available

• No staff urologist

• Multiple injuries that surpass hospital's resources

• Unavailability of specialized care required by patient's injuries

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]

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)

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

Cefotetan (Cefotan)

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)

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)

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.