Continuing Education Activity

Trauma is a major cause of morbidity and mortality around the world. Trauma to the lower genitourinary tract presents unique challenges as there are usually psychological factors that come into play. A thorough understanding of the anatomy, injuries, treatments, and complications is essential to minimize poor outcomes. This activity describes the anatomy of the lower genitourinary tract, epidemiology and pathophysiology of genitourinary injuries, the evaluation, and treatment of lower genitourinary trauma and highlights the role of the interprofessional team in the management of patients with this condition.

Objectives:

• Identify the etiology of lower genitourinary trauma.
• Outline the appropriate evaluation of lower genitourinary trauma.
• Review the management options available for lower genitourinary trauma.
• Describe interprofessional team strategies for improving care coordination and communication to advance the care of patients with lower genitourinary trauma and improve outcomes.

Introduction

Traumatic injuries can range from minor wounds to major, complex injuries causing shock and multi-system organ dysfunction. Trauma is the leading cause of death in patients between the ages of 15 and 24. It accounts for approximately 30% of all ICU admissions annually.[1]

The lower urogenital (GU) tract is composed of the bladder, urethra, vagina, uterus, ovaries, penis, scrotum, and testes. The lower GU tract is typically protected by the bony pelvis. The pelvis is a ring structure composed of the sacrum, the coccyx, and the innominate bones: the pubis, ischium, and ilium. The innominate bones join anteriorly at the pubic symphysis.

Bladder Anatomy

The urinary bladder functions as a reservoir. The size, shape, and spatial relation to surrounding organs differs depending on the volume within the bladder. An empty bladder lies within the protection of the bony pelvis. However, as the bladder fills, it extends superiorly into the abdominal cavity and is more prone to traumatic forces. The base of the bladder is closely related to the vagina in females and the rectum in males. The bladder neck is the most inferior portion and is generally the most fixed portion of the bladder. The pubovesical ligaments fix the bladder neck to the pubic bones in both males and females. It is essentially the internal urethral orifice. The anterior bladder is separated from the transverses fascia by adipose tissue, which is the retropubic space (space of Retzius). Bilateral ureters drain into the bladder at the ureteral orifices located on the trigone. The inferolateral surfaces are not covered by peritoneum. In males, the superior portion of the bladder is covered with peritoneum, which continues posteriorly and over the rectum to form the rectovesical pouch. In females, the superior surface is also mostly covered in peritoneum being reflected at the uterus, forming the vesicouterine pouch. The remainder of the superior bladder is separated from the cervix by areolar tissue. As the bladder fills and becomes distended, the anterior portion, which is not covered by peritoneum, is exposed over the pubic bones.

The blood supply is mainly from the superior and inferior vesical arteries. These arise from the internal iliac artery. The veins that drain the bladder form a plexus on the inferolateral surface of the bladder and then drain into the internal iliac veins. Lymphatic drainage is generally to the external iliac nodal basin. There is both sympathetic (T10-L2) and parasympathetic (S2-S4) innervation to the bladder, which arises from the pelvic plexus.

The bladder consists of 4 layers, the urothelium, lamina propria, muscularis propria, and serosa. The muscularis propria is the detrusor muscle and consists of 3 layers: inner and outer longitudinal and a circular layer. The detrusor is a smooth muscle. It relaxes to allow the bladder to fill and then contracts to empty the bladder. Bladder contraction is via parasympathetic actions.

Urethra Anatomy

The male urethra is about 18 to 20 cm in length. It is a conduit from the inferior bladder to the external urethral meatus. The posterior urethra is about 4 cm in length and is located above the corpus spongiosum. The prostatic urethra is a portion of the posterior urethra. The lowest portion of the prostatic urethra is fixed in place by the puboprostatic ligament rendering it immobile. The anterior urethra is surrounded by corpus spongiosum.

The urethral artery branches from the internal pudendal artery just below the perineal membrane and travels within the spongiosum to the glans penis, giving off branches to the urethra. The dorsal penile artery helps provide blood to the urethra via the circumflex branches. The anterior urethra has venous drainage via the dorsal veins of the penis and the internal pudendal veins. These then drain into the prostatic plexus. The posterior urethra drains into the prostatic and vesicle plexus, which then drains into the internal iliac veins. The posterior urethra generally drains into the internal iliac nodes, whereas the anterior urethra drains into the deep inguinal lymph nodes. The prostatic plexus supplies the prostatic urethra. The internal urethra sphincter receives sympathetic innervation from the pelvic plexus to prevent retrograde ejaculation. Parasympathetic innervation is from S2 to S4.

The female urethra is about 4 cm in total length. It is fixed anteriorly by the suspensory ligament of the clitoris and beneath the pubis by the posterior pubourethral ligaments. Female urethras are primarily supplied by the vaginal artery, with some flow coming from the inferior vesicle artery. The urethral veinous plexus drains into the vestal venous plexus around the bladder and into the internal pudendal veins. The lymphatics drain into both the internal and external iliac nodal basins. Parasympathetic innervation, similar to males, originates from the S2 to S4 nerves.

Vagina, Uterus, and Ovaries Anatomy

Female external genitalia consists of the mons pubis, labia minora and majora, clitoris, vestibule, and vestibular bulb. The mons pubis is the rounded area of adipose tissue anterior to the pubic symphysis. The labia majora are two folds that run longitudinally from the mons pubis to the perineum. Each is composed of adipose tissue, smooth muscles, and a deep membranous layer called Colles fascia, which is continuous with Scarpa’s fascia. The vestibule is the cavity between the labia minora; it contains the vaginal and external urethral orifices. Blood supply to the external genitalia arises from superficial and deep branches of the external pudendal branches of the femoral artery superior and the internal pudendal artery inferiorly.

The vagina is a tube structure composed of fibromuscular tissue that goes from the vestibule to the uterus. The anterior vaginal wall supports the inferior bladder and the urethra. The upper portion of the posterior vagina is separated from the rectum by Denonvillier’s fascia and peritoneum (rectouterine pouch). The vagina receives its blood supply from the azygos arteries, which are branches of the uterine artery coming from the internal iliac artery. They run along the anterior and posterior vaginal walls. The venous drainage is via the vaginal veins, which empty into the internal iliac veins. The lymphatic vessels drain into the internal iliac, external iliac, and superficial inguinal basins. The pudendal nerve supplies the lower vagina; S2 to S4 nerves supply the upper vagina.

The uterus is a muscular organ that is located between the bladder anteriorly and the rectum posteriorly. The uterus is a mobile organ, so its position can vary depending on the contents of the bladder and rectum. The uterus is very thick and muscular. It is composed of three layers: inner endometrium, middle myometrium, and the outer serosa. The anterior surface is covered in peritoneum that folds back to the bladder (uterovesical fold), whereas the posterior surface’s peritoneum continues onto the rectum (rectouterine pouch, or pouch of Douglas). The cervix communicates with the uterus at the internal os and the vaginal canal at the external os. The uterus receives its blood supply from the uterine artery. The uterine artery branches from the internal iliac and traverses the ureter anteriorly at the broad ligament. It is important to remember this relationship to avoid injury to the ureter while ligating the uterine artery. It then inserts into the uterus around the uterocervical junction. The uterine veins drain into the internal iliac veins. The lymphatic vessels drain into three nodal basins: the internal iliac, external iliac, and obturator. Innervation to the uterus is primarily from the inferior hypogastric plexus.

Fallopian tubes run from the upper body of the uterus, with an opening into the uterus, to the abdominal os where the fimbria extends toward the ovary. The fallopian tube is broken into four sections: intramural, isthmus, ampulla, and infundibulum. The fimbriae are finger-like projections that extend from the infundibulum toward to ovary and aid in capturing oocytes as they are released from the ovary. Blood supply to the fallopian tubes is from branches of the ovarian and uterine arteries. The lateral two-thirds of the Fallopian tube drains into the pampiniform plexus to the ovarian veins. The medial portion drains into the uterine plexus. The lymphatic vessels drain into the para-aortic nodes and the internal iliac nodal basin.

The ovaries lie on each side of the uterus, close to the abdominal wall. The ovaries are suspended in the mesovarium, a double fold of peritoneum. Ovaries consist of an inner medulla and an outer cortex. The ovary is surrounded by a capsule of connective tissue called the tunica albuginea. The suspensory ligament attaches to the superolateral surface of the ovary and contains the ovarian vessels and nerve. The ovarian ligament attaches the inferomedial portion of the ovary to the lateral uterus. The ovaries are supplied by the ovarian arteries, which branch directly from the aorta below the renal arteries. The veins draining the ovary form a plexus known as the pampiniform plexus. These form into the ovarian vein, which drains into the inferior vena cava on the right and the left renal vein on the left. Lymphatics drain into the para-aortic lymph nodes.

Penis, Scrotum, and Testes Anatomy

The penis is composed of four parts: base, shaft, glans, and foreskin (in uncircumcised males). The base is attached to the pubis by two suspensory ligaments, which are continuous with Buck’s fascia. The penis contains 2 columns of erectile tissue: 2 corpus cavernosa anteriorly and the corpus spongiosum posteriorly. The corpus spongiosum enlarges at the distal end and forms the glans of the penis. The glans is covered by foreskin in uncircumcised males. The skin overlying the shaft is mobile due to the lack of connections to the underlying fascia, whereas the skin of the glans is immobile due to its attachment to the underlying tunica albuginea. Under the penile skin lies the dartos fascia of the penis, then the deeper, tougher Buck’s fascia. Buck’s fascia covers both corpus cavernosum and splits to cover the corpus spongiosum.

Blood supply to the corporal bodies rises from the penile artery, a branch of the internal pudendal artery. The penile artery has 3 main branches that supply the penis: cavernous artery, bulbourethral artery, and the dorsal penile artery. It is important to note these branches are highly variable. Three venous systems drain the penis: superficial, intermediate, and deep. The superficial system is within the dartos fascia; it forms a single superficial dorsal vein. The superficial dorsal vein is located just below the dartos fascia and ultimately drains into the great saphenous vein. The intermediate drainage occurs through the circumflex and deep dorsal veins. These are located within and deep to Buck’s fascia. They drain into the prostatic plexus. The deep system drains the proximal third of the penis via the deep and crural cavernous veins, ultimately draining into the internal dental vein. Lymphatic vessels drain into the superficial and deep inguinal nodal basins and the internal iliac nodes. The glans penis has the most sensation and is provided by the dorsal nerve. The dorsal nerve runs deep to Buck’s fascia on either side of the deep dorsal vein. Parasympathetic and sympathetic innervation to the corpus cavernosa is provided by the cavernous nerve, coming from the pelvic plexus.

The scrotum is a dual-chambered sac composed of multiple tissue layers and contains the testicles, the vas deferens, and the epididymis. The scrotal layers include skin, dartos muscle, spermatic fascia, cremasteric fascia, and the internal spermatic fascia. Dartos is continuous with Colle’s fascia of the perineum and the dartos fascia of the penis. The gubernaculum fixes the testis in place within the scrotum. Arterial supply is from the external pudendal artery (from the femoral artery), scrotal branches of the internal pudendal artery, and cremasteric branches from the inferior epigastric artery. Venous drainage follows the arterial supply. Lymphatic drainage is to the ipsilateral superficial inguinal nodal basins. Innervation is provided by the ilioinguinal nerve (L1), genitofemoral nerve (L1, L2), posterior scrotal branches of the perineal nerve (S2-S4), and the perineal branch of the posterior femoral cutaneous nerve (S1-S3).

The testes are suspended in the scrotum by the spermatic cord with the left testis lying lower than the right. Within the testis are the seminiferous tubules. Spermatogenesis occurs within the tubules. The testis is enclosed in a capsule that is composed of 3 layers: tunica vasculosa (innermost), tunica albuginea (middle), and the outer tunica vaginalis. The tunica vasculosa contains a plexus of blood vessels. The tunica albuginea is a dense layer composed mainly of collagen fibers. Posteriorly, it injects inward to form an incomplete fibrous septum within the testis. The tunica vaginalis is an extension of the peritoneal processus vaginalis; failure to obliterate the processus vaginalis results in direct communication between the peritoneal cavity and the scrotum. The testis receives its blood supply from multiple arteries. The testicular artery supplies about two-thirds of the testis. The remaining one-third comes from a combination of small arteries, including the vasal artery and the cremasteric arteries. The testicular artery arises from the aorta. The vasal artery arises from the superior vesicle artery, and the cremasteric artery is a branch of the inferior epigastric artery. The testis drains into the pampiniform plexus, which ultimately forms a single vein that drains into the inferior vena cava on the right and the left renal vein on the left. The lymphatic vessels drain predominantly into the inter-aortocaval and para-caval nodes. Sympathetic innervation is by the T10 nerve; sensory innervation is via T10 and the genitofemoral nerve (L1 and L2).

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]

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]

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]

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.

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]

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.

Consultations

• Urology
• Gynecology
• Orthopedic surgery
• Psychology

Deterrence and Patient Education

Cell phone use while driving causes an estimated 1.6 million car crashes annually. About 1 in 4 crashes are related to texting while driving. Drivers should always obey the speed limit, avoid driving under the influence, and should not be distracted while driving. Pedestrians should always be aware of the traffic around them. It should not be assumed a car will see them or give the pedestrian the right of way.

It is important to set patients’ expectations. Patients may need extended rehabilitation and physical therapy, especially with pelvic fractures. They should be educated on the possibility of chronic pain and should receive information on pain management options, as well as options for the possible depression and anxiety that may follow. Patients with suprapubic or indwelling catheters should receive catheter training. The possibility of sexual dysfunction should be addressed with appropriate referrals to gynecologists or urology.

Enhancing Healthcare Team Outcomes

Managing traumatic genitourinary injuries requires an interprofessional team approach. The emergency department and trauma surgery teams should recognize the risk factors for genitourinary injuries and involve the urology and gynecology teams early when injuries are identified. It is important to have open communication with all consulting services, including urology, gynecology, and orthopedics. Potential complications should be common knowledge for the teams involved for early detection. Physical and occupational therapy should be involved early in care. Psychologists should be employed early in the care of patients with genital injuries. Patients with genitourinary injuries truly do require an interprofessional team to achieve the best results.