Genitourinary Trauma

Definition/Etiology:

• 65% blunt trauma vs 35% penetrating trauma
• Most common in males <30 years old
• Frequently not lethal, but commonly assoc w pelvic fracture or similar which can be lethal
  • Genitourinary trauma includes bladder, urethra, and external genitalia of both males and females.
  • Frequent mechanisms can include motorcycle crash, GSWs, sexual trauma and bicycles. Can also occur with harness injury (rock climbers, skydivers, linemen, etc).
  • If a bladder injury communicates with the peritoneum, it requires surgical repair.

Pathophysiology:

Possible undesirable sequelae:

• urinary incontinence
• difficulty voiding
• sexual dysfunction
• secondary psychosocial stressors
• fistula formation

Possible mechanisms:

• Motor vehicle crash
• Motorcycle crash
• Fall from height
• Straddle injury (mountain biking, etc)
• Sexual assault
• Consensual intercourse

Possible injuries:

• Laceration of external genitalia
• Abrasions
• Penile fracture
• Testicular torsion (twisting)
• Testicular displacement (out of scrotum, usually into peritoneum)
• Testicular rupture
• Bladder rupture (most likely if bladder is full when injured)
• Urethral injury (more common in males since urethra is longer)
• Concomitant rectal or vaginal injury

Clinical Presentation:

• suprapubic tenderness
• hematuria
• blood at the urethral meatus (if present, do not catheterize)
• difficulty voiding
• ecchymosis 
• hematoma
• possible unstable pelvis (mortality from internal bleeding)
• Pain
• Patient may be hyperfocused on this injury in spite of other injuries also present
• Immediate loss of erection if penile fracture.  Also, hematoma, rapid swelling, ecchymosis.  Patient often reports hearing/feeling a pop.

Collaborative Management:

• Evaluate for possible upper GU trauma also (kidneys, ureters). Kidney injury can be fatal.
• Utilize SANE (sexual assault nurse examiner) if appropriate
• If suspected assault, and SANE is available, let them handle all undressing of patient to get in a gown so that evidence is preserved.
• Social worker if appropriate
• Urethral catheterization or suprapubic is usually performed by urology

Testing: 

• Urinalysis
• CT abdomen/pelvis
• Ultrasound
• Pyelogram/Cystogram/Urethrogram
• KUB radiograph

Evaluation | Patient Monitoring | Education:

• Frequent monitoring of vitals 
• Pain management with medication, ice packs
• Full trauma assessment
• Be aware of possible sexual assault
• Emotional support
• Social worker consult

Linchpins (Key Points)

• Genitourinary tract is seldom injured in isolation.  
• Look for other life-threatening injuries.  Don’t just focus on distracting one.
• Kidney injury and/or pelvic fracture can be lethal.
• Keep in mind possible sexual assault for all patients, not just women.