Lower Genitourinary Trauma

Etiology

Traumatic injuries to the genitourinary tract are more likely to occur with blunt rather than penetrating trauma. Motor vehicle collisions are the most common cause of genitourinary trauma in the Western Hemisphere. Motorcycle and other two-wheeled vehicle crashes are more associated with external male genitalia.[2] Sexual intercourse is almost exclusively the cause of penile fractures.[3] Female genitalia injuries frequently occur in victims of sexual assault.

Epidemiology

Urogenital trauma is present in approximately 10% to 20% of abdominal trauma, with males being 3 times more involved than females.[4] A high energy force is required to injure the bladder; therefore, pelvic fractures are associated with 60%-90% of adult bladder injuries.[5] Due to the high force needed to cause genitourinary trauma, there are frequently other associated injuries. The most commonly injured structures are intra-abdominal, with the liver, spleen, and kidneys occurring more often. Patients presenting with gross hematuria are likely to have associated intra-abdominal injuries in 24% of cases.[6]

Pathophysiology

Bladder

Bladder injuries occur more frequently in blunt trauma, with the most common mechanisms being motor vehicle collisions, falls, crush injuries, and blows to the lower abdomen. As mentioned above, pelvic fractures are associated with up to 90% of adult bladder injuries. Bladder injuries are broken into 2 categories: intraperitoneal injury and extraperitoneal injury. Extraperitoneal bladder injuries account for about two-thirds of bladder injuries and are more likely associated with pelvic fractures. Intraperitoneal bladder ruptures are less associated with pelvic fractures at 25%.[7] Intraperitoneal bladder injuries typically occur when direct pressure or a blow is applied to the lower abdomen when the bladder is distended. This causes a rise in the intraluminal pressure of the bladder and a rupture at the bladder dome.[5]

American Association for the Surgery of Trauma (AAST) Bladder Injury Scale

• I: Contusion, intramural hematoma; partial thickness laceration
• II: Extraperitoneal bladder wall laceration <2 cm
• III: Extraperitoneal bladder wall laceration >2 cm; intra-peritoneal bladder wall laceration <2 cm
• IV: Intraperitoneal bladder wall laceration >2 cm
• V: Intraperitoneal or extraperitoneal bladder laceration extending into the bladder neck or ureteral orifice (trigone)

Urethra

Urethral injuries are rare and are more likely to occur in male patients. Almost all injuries are a result of blunt trauma. Urethral injuries occur in up to 10% of pelvic trauma and are referred to as pelvic fracture urethral injury (PFUI).[8] Specifically, pelvic fractures at the inferomedial pelvic ramus and pubic diastasis increase the risk of urethral injuries. Another common cause of urethral injury is stretch injuries, also known as straddle injuries. This occurs from a direct blow to the perineum which causes compression of the urethra between the external force and the inferior portion on the pubic bone. The injury typically occurs at the bulbous urethra.[9] Urethral injuries are broken into two categories: anterior and posterior urethral injuries. Anterior injuries are injuries to the bulbar and penile urethra, whereas posterior injuries involve the prostatic and membranous urethra.[5] The anterior and posterior urethra are equally affected in penetrating trauma, whereas the posterior urethra is more vulnerable to blunt trauma. The bulbar urethra is more fixed in place, making it more vulnerable to crush injuries.[10] Combined bladder and urethral injuries are found in up to 20% of cases.[11]

AAST Urethral Injury Scale

• I: Contusion with blood at urethral meatus and normal urethrography
• II: Stretch injury with elongation of urethra but without extravasation of urethrography contrast
• III: Partial disruption with extravasation of urethrography contrast at the injury site with visualization of contrast in the bladder
• IV: Complete disruption with <2 cm of urethral separation and extravasation of urethrography contrast at injury site without visualization of the bladder
• V: Complete transection with >2 cm urethral separation or extravasation into the vagina or prostate

Vagina, Uterus, and Ovaries

Blunt trauma can result in perineal and vaginal injuries; it is uncommon to cause injury to the cervix or non-gravid uterus. Ovaries, gravid uterus, and fallopian tubes are more often injured in penetrating trauma. Female genitalia injuries are reported in up to 50% of sexual assault victims.[12] These patients have a high degree of morbidity due to the psychological and emotional distress associated with their injuries. Rape comprises 5% to 10% of violent crimes and occurs in 2.8 per 1,000 persons in the United States. It is important to note that up to 30% of patients with female genital injuries have coexisting urologic injuries.[13]

AAST Vagina Injury Scale

• I: Contusion or hematoma
• II: Superficial laceration (mucosa only)
• III: Deep laceration (into fat or muscle)
• IV: Complex laceration (into cervix or peritoneum
• V: Injury to adjacent organs (rectum, anus, urethra, bladder)

AAST Vulva Injury Scale

• I: Contusion or hematoma
• II: Superficial laceration (skin only)
• III: Deep laceration (into fat or muscle)
• IV: Avulsion (skin, fat, or muscle)
• V: Injury to adjacent organs (rectum, anus, urethra, bladder)

AAST Non-gravid Uterus Injury Scale

• I: Contusion or hematoma
• II: Superficial laceration (<1 cm)
• III: Deep laceration (>1 cm)
• IV: Laceration involving uterine artery
• V: Avulsion or devascularization

AAST Gravid Uterus Injury Scale

• I: Contusion or hematoma without placental abruption
• II: Superficial laceration (<1 cm) or partial placental abruption (<25%)
• III: Deep laceration (>1 cm) in the second trimester or placental abruption >25% but <50%; deep laceration in the third trimester
• IV: Laceration involving the uterine artery; deep laceration (>1 cm) with > 50% placental abruption
• V: Uterine rupture in the second or third trimester; complete placental abruption

AAST Fallopian Tube Injury Scale

• I: Contusion or hematoma
• II: Laceration <50% of the circumference
• III: Laceration >50%
• IV: Transection
• V: Vascular injury or devascularized segment

AAST Ovary Injury Scale

• I: Contusion or hematoma
• II: Superficial laceration (depth <0.5 cm)
• III: Deep laceration (depth >0.5 cm)
• IV: Partial disruption of blood supply
• V: Avulsion or complete parenchymal destruction

Penis, Scrotum, and Testes

Trauma to the penis is rare, mostly due to the mobility of it. Injury to a flaccid penis is especially rare and is usually due to machinery accidents or penetrating trauma.[14] Penile fractures occur almost exclusively with coitus. Barros et al. showed fractures were more common with “doggy style” (41%) and “man-on-top” (25.5%). These positions were also more likely to have bilateral corpus cavernosum fractures and urethral injury.[3] Fractures typically occur distal to the suspensory ligament; however, they can occur anywhere along the shaft of the penis. Injuries associated with sexual intercourse most commonly occur lateral or ventral due to the thin tunica albuginea in these locations.[15] Urethral injuries frequently accompany penile fractures.[16]

Testicular trauma is rare due to the position and mobility of the testes. The cremasteric muscle fibers, mobility, and tunica albuginea contribute to the sturdiness of the testes. Testicular rupture is characterized by extrusion of the seminiferous tubules through the ruptured tunica albuginea. Testicular injuries occur most frequently in sporting events. Another common cause is motorcycle accidents when the testes are compressed between the bony pelvis and the fuel tank of the vehicle. Bilateral testicular trauma is uncommon, comprising only 1.5% of testicular injuries. The right testis is more frequently injured. Roughly 80% of testicular trauma has associated injuries of nearby structures, including the thigh, penis, urethra, bladder, perineum, and femoral vessels.[17] 

AAST Scrotum Injury Scale

• I: Contusion
• II: Laceration <25% scrotal diameter
• III: Laceration >25% scrotal diameter
• IV: Avulsion <50%
• V: Avulsion >50%

AAST Testis Injury Scale

• I: Contusion or hematoma
• II: Subclinical laceration of tunica albuginea
• III: Laceration of tunica albuginea with <50% parenchymal loss
• IV: Major laceration of tunica albuginea with >50% parenchymal loss
• V: Total testicular destruction or avulsion

AAST Penis Injury Scale

• I: Cutaneous laceration or contusion
• II: Laceration of Buck fascia without tissue loss
• III: Cutaneous avulsion, laceration through glans or meatus, or cavernosal or urethral defect <2 cm
• IV: Partial penectomy or cavernosal or urethral defect >2 cm
• V: Total penectomy

History and Physical

The initial approach to any trauma patient is described in the Advanced Trauma Life Support (ATLS) course; it is a structured and standardized approach. The approach is meant to recognize and stabilize life-threatening injuries first. It is important to note an initial detailed history is not essential to begin evaluating a patient with acute injuries. The emergency medical services personnel bringing the patient to the trauma bay will provide a brief history of present illness. After the initial evaluation and stabilization of the patient, a detailed history can be obtained. Some useful information includes the mechanism of injury, whether ambulatory at the scene, bowel or bladder incontinence, and any numbness or weakness. Gross hematuria or blood at the urethral meatus can be a tip-off of genitourinary injury.[18]

Patients with urethral injuries often present with blood at the urethral meatus, perineal laceration or ecchymosis, scrotal hematoma, urinary retention, superiorly displaced prostate on digital rectal exam, or an inability to pass foley catheter.[10][18]

Evaluation

The initial evaluation of the trauma patient is the primary survey. The mnemonic ABCDE is a helpful way to remember the order of the evaluation.

• A: Airway and cervical spine protection. An easy way to assess the airway is to have the patient speak. Ask them their name.
• B: Breathing. Listen for bilateral breath sounds and look at the chest wall motion during the respiratory cycle.
• C: Circulation. This helps determine whether the patient is in shock.
• D: Disability. This is the Glasgow coma scale (GCS)
• E: Exposure and environmental control. Undress the patient and cover them with a warm blanket.

The secondary survey follows the primary survey.[19] This is a head-to-toe complete exam. Examining for blood at the urethral meatus can indicate a urethral injury. A digital rectal exam should also be performed during the secondary survey. Gross blood indicates a gastrointestinal injury, and a high riding prostate could be another indication of a urethral injury.[20] The pelvis is assessed with anteroposterior compression. Perineal hematoma should also raise suspicion for pelvic content injuries, including the genitourinary system. Any instability indicates a pelvic fracture. Any compressive force causing movement of the pelvis can disrupt any hemostasis that has occurred, so this force is generally limited to a single attempt.[19][21]

Laboratory markers are often useful in traumatic settings. Sensitive markers for hemorrhage include elevated serum lactate and a base deficit, which can both be obtained from an arterial blood gas. It is important to remember that initial hemoglobin and hematocrit are not sensitive for traumatic hemorrhage.[20][22] Other useful laboratory markers are coagulation panels. Patients that have undergone a traumatic injury are susceptible to coagulopathy, increasing their mortality risk.[20] Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) can be useful tools to allow targeted resuscitation with blood products.[23]

Multiple imaging modalities can be useful in evaluating pelvic trauma. An ultrasound can be used to perform a Focused Assessment with Sonography in Trauma (FAST) exam while in the trauma bay. A FAST exam is used to identify free fluid. It cannot differentiate bowel contents from blood.[24] Pelvic X-rays in a hemodynamically unstable patient may help identify potentially life-threatening causes of injury. If the patient is unstable, a quick X-ray can direct care. It is still important to remember there are likely additional injuries, so a pelvic fracture may not be the sole cause of instability. A pelvic X-ray is also useful to evaluate for hip pathology, such as a fracture or dislocation that needs quick reduction.[25]

X-ray, while useful for quick evaluation in an unstable patient, is overall inferior to a computed tomography (CT) scan, which provides greater detail of injuries. The ability to add contrast increases the ability to find injuries. A triple-phase contrast-enhanced CT consists of an arterial phase, a portal phase, and a delayed phase.[20][26] A blush on the arterial phase indicates active arterial bleedings; it can be seen as a hyperdensity within a hematoma. A delayed phase will show injuries to urologic structures.

Gross hematuria in the setting of a pelvic fracture, blunt trauma, or low-density free-fluid in the pelvis are absolute indications for lower urogenital evaluation. Cystography, either conventional or CT, is the imaging study of choice for bladder injury. For a CT cystogram, the bladder is filled with 40 mL of water and 350 mL of contrast agent. Images are then taken when the bladder is completely filled and again when it is drained. The identification of contrast outside the bladder confirms the diagnosis. The contrast will remain in the pelvis in extraperitoneal bladder ruptures. Intraperitoneal injuries show contrast lining the bowel loops and diffusing through the mesenteric folds.[5] 

Urethral injuries typically present with blood at the urethral meatus, urinary retention, or suprapubic fullness. Straddle injuries can present as perineal ecchymosis or hematoma.[9] A high index of suspicion is needed to prevent a missed injury. A retrograde urethrogram should be performed in all suspected urethral injuries. As urethral injuries alone are not life-threatening, any vascular or visceral injury should be managed before undergoing urethrogram. In the trauma setting, a urethrogram should be performed in a fluoroscopic suite by a trained radiologist. In an ascending study, a 6 to 8 French Foley catheter is inserted into the fossa navicularis, which is just beyond the meatus. The foley balloon is filled with 2 to 3 mL of water. A C-arm is brought over the bed and is rotated to either the left or right 30 degrees to an anterior oblique position. The patient then elevates his left side to the same degree. 30 mL of iodinated contrast is slowly injected into the foley catheter until the contrast is visualized within the bladder. A descending study fills the bladder with 400 mL of contrast. The patient is then asked to micturate into a bottle in a standing oblique position. An injury is visualized as contrast extravasation. A complete urethral transection typically requires both an ascending and descending urethrogram to estimate the length of transection.[9][27][28]

Female genital trauma, as mentioned above, can have psychological stressors for the patient if caused by sexual abuse or assault. If an abusive history is given, the appropriate police and support services should be notified. Assessment includes a detailed history and thorough physical exam. If necessary, a “rape kit” should be available for evidence collection. The exam starts by examining the external genitalia, looking for ecchymosis, edema, or lacerations. An internal speculum exam should then be completed looking for lacerations or impaling injuries from pelvic bone fractures.

Penile fracture is typically a straightforward diagnosis based on the history and physical exam. It is not uncommon for these patients to present in a delayed fashion due to patient embarrassment over the situation. Patients will usually describe an acute bending of the penis, followed by a snap or pop, acute pain, and immediate detumescence. Buck’s fascia usually limits swelling to the penis, creating the “eggplant deformity.” However, swelling can spread to the perineum and scrotum if Buck’s fascia is disrupted. The penis is often swollen and ecchymotic. It tends to deviate to the side opposite the tunic tear because of the hematoma at the fracture site. If the history and physical are consistent with penile fracture, then no imaging is necessary. Ultrasonography is the imaging modality of choice for penile fractures if imaging is necessary. It can also help identify the location of the tear.[29] If the findings are equivocal, then magnetic resonance imaging (MRI) should be performed.[30]

A ruptured testis should be considered in all blunt scrotal trauma. The most common symptom is extreme pain, rapid swelling, and nausea. Ecchymosis can be variable, and hematoma size does not correlate with the degree of injury. Pain and scrotal hematocele (blood and fluid within the tunica vaginalis compartment) often limit the physical exam. The first imaging tool of choice is a testicular ultrasound. Ultrasonography has a reported specificity of 93.5% and a sensitivity of 100% for testicular rupture.[31] The main goal of sonography is to determine blood flow and testicular integrity. Acute bleeding is identified as a hyperechoic area, and old blood is generally hypoechoic.[32] Signs of testicular rupture on ultrasound include a heterogeneous pattern of the testicular parenchyma and disruption of the tunica albuginea. Fracture lines through the testis, decreased blood flow, and hematocele can also be identified with ultrasound. The doppler capabilities of ultrasound are invaluable as disruption in blood supply can determine treatment.[31] If an ultrasound is equivocal, then an MRI can be useful if the patient is otherwise stable.[33]

Treatment / Management

Bladder

Bladder contusions can be observed clinically.[4] Simple extraperitoneal bladder injuries are treated non-operatively with catheter drainage for 10 to 14 days. A large-bore Foley should be used to ensure adequate drainage. Prior to catheter removal, a CT or plain-film cystography is performed to assess healing. If the imaging fails to show contrast extravasation, the catheter can be removed unless needed for other reasons. If extravasation persists, the catheter is left in place, and imaging is performed at 7-day intervals. Operative repair is indicated if extravasation is still present 4 weeks later. Antibiotics are typically continued for 7 days after injury. Contraindications to nonoperative management include pelvic fracture requiring internal fixation, bony fragments within the bladder, or associated rectal or vaginal injury. Vaginal or rectal injury can lead to an infected hematoma, urinoma, or cause a vesicovaginal fistula. Therefore these should be repaired.[34]

Patients undergoing exploratory laparotomy for other injuries should have the extraperitoneal bladder injury repaired at the same time. The bladder is entered via an anterior cystotomy. It is very important to avoid entering a retropubic hematoma. The laceration can be repaired intravesically with absorbable suture. A large-bore Foley catheter is used to drain the bladder, and a cystography is performed 7 days post-repair to ensure the bladder is healing well.[34]

Intra-peritoneal injuries require operative repair.[34][35] The dome of the bladder can be repaired through either a midline laparotomy or laparoscopically. Once the bladder injury is located, the interior of the bladder is inspected for other injuries. It is important to examine the ureteral orifices and bladder neck for injury and ensure efflux from both orifices. Any injury involving the orifice requires primary repair of the defect and ureter reimplantation over a stent. Intraperitoneal bladder injuries may require wound edge debridement to clean out devascularized tissue. The injury is then repaired in 2 layers using absorbable suture. The bladder is decompressed with a large-bore catheter for 7 to 10 days. Antibiotics are typically continued for 3 days. Cystography is performed before catheter removal.[34][36]

Urethra

Grade one urethral injuries do not require treatment. Grades 2 and 3 are typically treated non-operatively with catheterization.

Urethral injuries associated with pelvic fractures are best treated with suprapubic cystotomy or primary urethral realignment. Traditionally suprapubic drainage was the standard approach. This can be performed percutaneously quite easily as the bladder is already distended. Alternatively, the catheter can be placed via an open approach at the same time as laparotomy. Suprapubic drainage is followed by 3 to 6 months of observation while the anatomy stabilizes and the pelvic hematoma resolves. Repeat antegrade and retrograde urethrograms are obtained, and definitive reconstruction is performed. Suprapubic catheters do not increase hardware infection when pelvic fractures are treated with internal fixation. Primary realignment is an option if the patient is hemodynamically stable, and an experienced urologist is available. This involves passing instruments in an antegrade and retrograde fashion through the urethra. Ultimately it results in a wire from the urethra meatus to the bladder. A Council-tip catheter is then advanced over the wire. Primary realignment does significantly decrease stricture rate and, thus, may be beneficial if situationally appropriate.[10][34]

Surgical reconstruction is recommended for penetrating injuries to the anterior urethra. It is also recommended for urethral injury associated with penile fracture. Local exploration is typically sufficient. Limited debridement may be necessary. The urethra is then primarily anastomosed with a spatulate technique. If the patient cannot undergo immediate repair due to other injuries, urinary diversion with a suprapubic catheter is indicated. Extensive urethral damage with associated tissue loss may require a staged repair.[34][37](B2)

Blunt trauma causing complete anterior urethral division is best managed with suprapubic diversion with delayed repair 3 to 6 months later. This gives perineal hematomas a chance to resolve and allows an end-to-end urethroplasty. Straddle injuries should be treated with a suprapubic catheter for urinary diversion. After a recovery period, anastomotic urethroplasty is the treatment of choice for obliterated bulbar urethra after a straddle injury.[38](A1)

Female urethral injuries in the proximal or mid urethra should be repaired. Repair over a catheter is the treatment of choice. If a vaginal injury coexists, it should be repaired at the same time to help prevent urethrovaginal fistulas. Suprapubic catheters are generally reserved for hemodynamically unstable female patients.

Female Organs

Perineal lacerations can be treated in the emergency department if there is no associated urinary or rectal injury. Lacerations to the vulva should be irrigated and debrided of devascularized tissue. It can then be repaired primarily with interrupted absorbable suture. Large perineal hematomas may require incision and drainage with ligation of the bleeding vessel. The area can then be packed or closed loosely with a drain.[35]

Vaginal and cervical lacerations have the potential for significant bleeding from the pudendal vessels. If bleeding is minimal, a speculum exam with laceration repair can be done under local anesthesia in the emergency department. Exam under anesthesia is indicated for large hematomas or significant bleeding obstructing a thorough exam. Simple lacerations can be repaired with absorbable suture in either a running or interrupted fashion. Vaginal or cervical lacerations associated with pelvic fractures are more complex and require a team of multiple specialty surgeons. These are repaired in the operating room. The urinary system and rectum should be examined for injury and diversion performed as indicated. Vaginal lacerations are still repaired with absorbable suture, incorporating both the mucosa and muscular layer in the repair. Vaginal packing should be placed for 24 hours after repair. Sexual assault victims require extensive psychological support, prophylactic antibiotics, and if desired, emergency contraceptive options.

As mentioned above, injury to a non-gravid uterus is exceedingly rare. Most occur due to penetrating trauma, and thus generally necessitate laparotomy for other injuries. Blunt trauma can cause uterine injury. The uterus should be repaired with a two-layer closure using absorbable suture. Blast injury to the uterus may require a hysterectomy. Hysterectomy may also be required if the uterine artery is damaged. Uterine artery damage has also been treated with oxytocin. Fallopian tube or ovarian lacerations are repaired primarily with absorbable suture. If the damage is too extensive, then salpingo-oophorectomy should be performed.[39](B3)

Male Organs

Penile trauma is most often managed surgically as early operative repair provides the best results.[34] Blunt penile injuries are usually accessed through a ventral penoscrotal or a circumferential subcoronal incision.[40] The tunica albuginea is closed with an absorbable 3-0 suture. Debridement is generally not required prior to repair. The skin is then closed with interrupted chromic sutures as this allows drainage from the wound and provides the best cosmetic effect. If a penile fracture is associated with a urethral injury, catheter drainage is necessary. Coitus is contraindicated for 1 month following penile fracture repair. Penetrating injuries to the penis are also explored in this fashion with repair of the corpus cavernosum and urethra. Penetrating injuries are more likely to injure neuromuscular bundles; therefore, microsurgical repair of these structures should be performed when possible.(B2)

Traumatic penile amputation is very rare. Reimplantation is possible up to 6 hours of warm ischemic time and 16 hours of cold ischemic time. The amputated penis should be irrigated, wrapped in saline-soaked gauze, put in a bag, then placed in another bag with cold slush. Direct contact with ice should be avoided, as this can cause hypothermic injury to the penis. Reconstruction involves anastomosis of the urethra, corporeal bodies, and neuromuscular bundles. Therefore, the patient should be transferred to a facility with microsurgery capabilities. If the amputated penis is unavailable, the stump should be irrigated, the corpus closed, and a neomeatus should be created.[34] 

Early testis exploration is associated with higher rates of salvage. A vertical scrotal incision is typically used for exploration. Clots are removed, and any extruding seminiferous tubules are debrided to allow the tunica albuginea to close. The tunica albuginea, even small defects, should be closed with slowly absorbing suture. If it is not closed, any swelling over time will cause further extrusion of seminiferous tubules. If there is extensive capsular loss, more parenchyma can be removed, or the tunica vaginalis can be used to create a tunica albuginea flap.[34] Large testicular hematomas should be explored and drained to prevent ischemia pressure necrosis. Significant hematoceles should also be explored surgically. Up to 80% are caused by testicular rupture even if imaging is negative for tunica albuginea disruption.[41] Penetrating testicular injuries should also be explored surgically. Repair principles are the same as blunt. Vas deferens injuries occur in up to 10% of penetrating trauma injuries and should be treated with suture ligation. Delayed reconstruction is an option if desired. Depending on the trajectory of the penetrating trauma, the contralateral testicle should be explored as well.[42](B2)

Scrotal lacerations should be explored to ensure the testicle is not injured. In the absence of testicular injury, the wound can generally be closed primarily. The tunica dartos and skin should be closed in two separate layers. Skin avulsion can occur without damage to underlying structures; however, the wound should be explored to ensure surrounding structures are uninjured. Scrotal tissue loss can be treated with debridement of devascularized tissue followed by repair or split-thickness skin grafting.

Differential Diagnosis

• Renal injury
• Ureter injury
• Pelvic fracture
• Rectal injury
• Vaginal laceration
• Abdominal injury
• Retroperitoneal hemorrhage
• Urethral stenosis
• Urinary calculi
• Fournier gangrene
• Domestic abuse

Prognosis

The prognosis of patients that suffer from lower genitourinary trauma varies greatly depending on the injury, as well as based on their other associated injuries. Patients that experience lower GU injuries are typically polytrauma patients. Injuries to the GU tract are seldom life-limiting but more frequently are associated with significant morbidity. Ultimately, the prognosis is dependent on injuries sustained in combination with the patient’s comorbidities.

Complications

The recognition and management of urogenital complications are essential as failure to do so leads to significant morbidity and potential mortality. Complications can be divided into early and late complications. Early complications include bleeding, infection, and sepsis, or evidence of missed injury, such as azotemia, peritonitis, urinary ascites, or ileus. Functional abnormalities generally constitute delayed complications and include urinary retention or incontinence, urethral strictures, sexual dysfunction, and reproductive dysfunction.

Urethral strictures are reported in up to 69% of complete urethral transections.[27] Urethral strictures are initially treated conservatively with early referral to urology and serial dilations. If dilation fails, then posterior urethroplasty may be required. Urethroplasty has a success rate of over 90%.[28] 

Urinary incontinence and retention are also treated conservatively initially. Pelvic floor strengthening exercises and biofeedback can be very effective. Duloxetine can be used in combination with physiotherapy and has been successful in multiple patients.[43] A sacral nerve stimulator can be placed in the subcutaneous tissue of the upper buttock and has been used to treat urinary and fecal incontinence.[44] If other methods fail, an artificial urinary sphincter can be implanted and has shown success.[45]

Sexual and reproductive dysfunction is possible with genital trauma. Microvascular repair of the penis’s neurovascular bundle results in regaining of penile sensation in over 80% of cases. The native penile skin can become necrotic, even after microvascular repair. This is because superficial structures supply the skin. If this occurs, split-thickness skin grafts can be applied after several weeks of serial debridements. Hyperbaric oxygen therapy can also be used to promote healing.[46] Sexual dysfunction can be treated with medications, penile pumps, or surgically implanted devices.

Vaginal injuries that extend to the rectum can cause fecal incontinence. Similarly, fecal incontinence starts with nonoperative management. Dietary changes and fiber supplements can optimize stool consistency and limit urgency. Medications can be used to slow the bowels. Examples include the antidiarrheals loperamide and atropine/diphenoxylate, the bile acid binder cholestyramine, and medications the reduce the reflexive relaxation of the sphincter, such as amitriptyline. Physical therapy and biofeedback have been used successfully to strengthen the pelvic floor. If conservative treatments fail, a sphincteroplasty can be performed. Other options include implanting artificial anal sphincters or magnetic anal sphincters. Sacral nerve stimulators can also be successful.[47] 

Rectovaginal fistulas are another potential complication. They have high morbidity, as they negatively affect the social and sexual quality of life. Multiple surgical options exist for rectovaginal fistulas. Endorectal advancement flaps are typically used for low rectovaginal fistulas and have a success rate of up to 71%. Other options include ligation of intersphincteric fistula tract (LIFT) procedure, interposition flaps, mesh repair, or the use of fibrin glue.[48]

Psychologic complications are an important consideration. They can stem from the residual scars, the embarrassment of sexual dysfunction, or from sexual abuse that resulted in the genital trauma. Psychologists should be employed early in the care of these patients.