About 10% of all injuries seen in the emergency room involve the genitourinary system to some extent. Many of them are subtle and difficult to define and require great diagnostic expertise. Early diagnosis is essential to prevent serious complications.
Initial assessment should include control of hemorrhage and shock along with resuscitation as required. Resuscitation may require intravenous lines and a urethral catheter in seriously injured patients. In men, before the catheter is inserted, the urethral meatus should be examined carefully for the presence of blood.
The history should include a detailed description of the accident. In cases involving gunshot wounds, the type and caliber of the weapon should be determined, since high-velocity projectiles cause much more extensive damage.
The abdomen and genitalia should be examined for evidence of contusions or subcutaneous hematomas, which might indicate deeper injuries to the retroperitoneum and pelvic structures. Fractures of the lower ribs are often associated with renal injuries, and pelvic fractures often accompany bladder and urethral injuries. Diffuse abdominal tenderness is consistent with perforated bowel, free intraperitoneal blood or urine, or retroperitoneal hematoma. Patients who do not have life-threatening injuries and whose blood pressure is stable can undergo more deliberate radiographic studies. This provides more definitive staging of the injury.
When genitourinary tract injury is suspected on the basis of the history and physical examination, additional studies are required to establish its extent.
Algorithm for staging blunt trauma in adults.
Algorithm for staging penetrating trauma in adults.
Algorithm for staging blunt trauma in children
Catheterization and Assessment of Injury
Assessment of the injury should be done in an orderly fashion so that accurate and complete information is obtained. This process of defining the extent of injury is termed staging. The algorithms (Figures 18–1, 18–2, and 18–3) outline the staging process for urogenital trauma.
Blood at the urethral meatus in men indicates urethral injury; catheterization should not be attempted if blood is present, but retrograde urethrography should be done immediately. If no blood is present at the meatus, a urethral catheter can be carefully passed to the bladder to recover urine; microscopic or gross hematuria indicates urinary system injury. If catheterization is traumatic despite the greatest care, the significance of hematuria cannot be determined, and other studies must be done to investigate the possibility of urinary system injury.
Abdominal computed tomography (CT) ...