Prehospital Care
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.
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Establish an airway if needed and/or administer oxygen.
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Establish 2 large-bore IVs.
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Take cervical spine precautions (eg, hard collar, back-board).
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Leave the scene as soon as possible and quickly transport the patient to the trauma center.
Medical Care
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:
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Trauma surgeon for associated intra-abdominal injuries
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Urologist for lower GU tract injury
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Orthopedic surgeon for management of frequently associated pelvic fractures
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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:
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CT scan not available
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No staff urologist
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Multiple injuries that surpass hospital's resources
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Unavailability of specialized care required by patient's injuries
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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.
