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

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

Laboratory Studies

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]


Imaging Studies

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 urethrogram showing an irregularity of Retrograde urethrogram showing an irregularity of the urethra indicating injury secondary to a shotgun wound.

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.)

Ruptured dome of urinary bladder detected by retro Ruptured dome of urinary bladder detected by retrograde cystogram.

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.)

Normal bladder on CT scan. Normal bladder on CT scan.
Ruptured urinary bladder detected by CT scan. Ruptured urinary bladder detected by CT scan.

CT cystography is an emerging imaging modality for use in the diagnosis of bladder injuries.


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 ImagingUrethral Trauma Imaging and Testicular Trauma Imaging.