A 22-year-old man presents to the emergency room after being involved in a motor vehicle accident in which his car was struck from the side. In the emergency room he is noted to be tachycardic, with a heart rate (HR) of 135, and hypotensive, with blood pressure (BP) 90/60. On physical examination he is noted to be diaphoretic, with right flank pain, costovertebral angle tenderness, and significant flank ecchymosis. His initial laboratory studies are notable for a HCT of 30. Two large-bore IVs and a Foley catheter are placed without difficulty, and the Foley drains bright red blood. His urinalysis shows >100 red blood cells (RBCs)/hpf.
Diagnosis of injuries to the genitourinary system requires a high index of suspicion, and can be missed in the setting of distracting injuries. This chapter includes a systematic discussion of the presentation and management of trauma to all components of the genitourinary system, with an emphasis on radiological recognition to avoid dangerous delays in diagnosis.
Overall, renal trauma accounts for 3% of all trauma admissions, and comprises 67% of cases of genitourinary (GU) trauma.1 Blunt renal trauma is 9 times more common than penetrating trauma, but is far less likely to be clinically significant (5% vs 64%).1 Renal trauma occurs in up to 10% of blunt injuries to the abdomen, and is often associated with concomitant liver or splenic injury.2
Ureteral injuries are commonly missed on initial trauma survey, represent only 1% of all GU injuries, and require a high index of suspicion to diagnose. Risk factors for ureteral injury include prior radiation, retroperitoneal fibrosis, and iatrogenic causes such as intraoperative bleeding leading to rapid application of surgical clips or sutures. While 80% of ureteral injuries are iatrogenic, any penetrating injury to the upper or lower quadrants can inflict ureteral injury.3 Blunt trauma, particularly rapid deceleration injuries, can also lead to a ureteropelvic junction disruption or tear of the ureter.
Bladder injuries make up 22% of GU trauma, but represent less than 2% of all injuries requiring surgery. Roughly two-thirds of all bladder injuries are blunt, and the remaining are penetrating injuries.4 Bladder injuries are more common in children, in whom the bladder is an abdominal organ unprotected by the bony pelvis.
Urethral injuries comprise 3% of all genitourinary trauma, and are most commonly seen in the setting of pelvic fractures. Posterior urethral injuries (prostatic and membranous urethra) are seen in 4% to 14% of pelvic fractures, often with a concurrent bladder injury.5 Anterior urethral injuries (bulbar and pendulous urethra) are less common, comprising 10% of all urethral injuries, and are most commonly seen after straddle injury or gunshot trauma.