Genitourinary Tract Injuries

Signs and Symptoms

About 10 percent of all injuries seen in the emergency room involve the genitourinary tract, including the kidneys, bladder, genitals, ureters and urethra. Symptoms of genitourinary injury differ depending on the location of the trauma. However, some common symptoms may include:

• Hematuria, a condition in which blood is present in the urine
• Inability to urinate
• Lower rib fractures
• Fractures to the pelvic bone
• Pain and/or bruising involving a person's side, groin or scrotum

Diagnosis

Many injuries to the genitourinary tract are subtle and difficult to diagnose. Therefore, an early diagnosis and great diagnostic expertise are essential to prevent serious complications. Your doctor will first start by performing a detailed medical history to determine whether you experienced any events, such as an accident, fall, etc. that may have injured your genitourinary tract. A physical examination will then be performed to check for any symptoms associated with injuries to the genitourinary tract.

If injuries are suspected, the following tests may be recommended to make a definite diagnosis:

• Catheterization -- Urinary catheters are tubes placed into the bladder to drain the urine. Catheterization will not be performed if there is blood at the opening of the urethra, a sign of injury to the urethra.

• Abdominal Computed Tomography (CT) -- A computed tomography (CT) uses X-rays to produce detailed pictures of the body's internal structures, such as the abdomen. An abdominal CT scan is used to help identify injuries to the kidneys.

• Retrograde Cystography -- During this test, contrast dye is injected into the bladder through the urethra. X-rays are then taken of the bladder, which helps to identify injuries to the bladder.

• Urethrography -- This test involves X-rays of the urethra to identify any injuries or obstructions in this area.

• Arteriography -- An arteriography involves taking an X-ray of blood vessels. Before X-rays are taken, a dye is injected into surrounding arteries so that the blood vessels are visible on the X-ray. In cases of suspected genitourinary injuries, arteriographies are useful in examining the blood vessels of the kidneys to check for injuries in that area.

• Intravenous Urography -- This test involves taking an X-ray of the urinary tract. Before X-rays are taken, a dye is injected to make urine visible on the X-ray, which shows any blockages in the urinary tract or problems with the kidneys.

Treatment

Management and treatment of genitourinary injuries can be complex and depends on a number of factors, including the severity, location and type of injury, patient's health and whether any other injuries are present. Injuries are either classified as blunt or penetrating. Blunt trauma includes car accidents, straddle-injuries, serious falls, industrial accidents, etc. Penetrating trauma are those from a gunshot wound.

Once your doctor has diagnosed and assessed your injury, short-term management may be performed before a definitive treatment plan is developed. Short-term management may include:

• Urethral Catheter -- A tube is placed into the bladder through the urethra to drain urine.

• Suprapubic Catheter -- A tube is placed through the abdominal wall into the bladder to drain urine.

• Nephrostomy Tube -- A tube is placed through the patient's flank (side) to drain urine directly from the kidney.

• Ureteral Stent -- A temporary tube is placed through the ureter to connect the kidney to the bladder.

Kidney Injuries

Treatment for kidney injuries depends on the type and severity of the injury, and whether a patient has any other injuries.

• Blunt Injuries -- In 85 percent of the cases, injuries to the kidneys are minor and caused by a blunt trauma and do not require surgery. Blunt trauma includes car accidents, straddle-injuries, serious falls, industrial accidents, etc. Treatment aims to stop any bleeding from the kidney. Hospital admission, bed rest and hydration are required until bleeding from the kidney stops and urine is clear.

• Penetrating Injuries -- Surgery is more likely for penetrating injuries, such as those from a gunshot wound, which can cause serious bleeding from the kidney. Patients also may have serious injuries to other parts of the abdomen, such as the bowel and liver. In these instances, surgical exploration and repair of the kidneys may be performed at the same time as surgery for other injured parts. Surgery aims to repair and preserve the injured kidneys. However, if the kidney is severely injured and beyond repair, surgical removal may be required.

Ureteral Injuries

Injuries to the ureters -- the tubes that connect each kidney to the bladder -- are rare and usually occur during a difficult pelvic surgical procedure or from a gunshot wound. Treatment depends on the type and severity of injury.

• Complete Disruption -- Ureteral injuries that cause complete disruption, meaning that the ureter is torn into two pieces, require emergency surgical repair. The best outcome for surgical repair is prompt treatment at the time of injury.

• Partial Injuries -- Partial ureteral injuries, such as those that occur during a pelvic operation, often can be managed by a ureteral stent. Ureteral stents are thin tubes, called catheters, which are inserted into parts of the ureter that carry urine, produced by the kidney, either down into the bladder, or to an external collection system. Ureteral stenting may be placed on a long-term basis, ranging from months to years, to bypass ureteral obstruction. Short-term stenting, ranging from weeks to months, may be placed during an open surgical procedure of the urinary tract to provide a mold around which healing can occur, or to divert the urinary flow away from areas of leakage.

Bladder Injuries

Bladder injuries are most often caused by an accident, such as a car accident, serious fall or heavy object falling on the lower abdomen. Treatment depends on the type of injury.

• Contusion Injury -- In these types of injuries, the bladder wall is only bruised and does not rupture. They can be managed with a urethral catheter, which is a tube inserted into the bladder through the urethra, so that blood clots pass. Once the urine is clear and the patient stable, the catheter can be removed.

• Extraperitoneal Rupture -- These types of injuries can be managed with a urethral catheter, which is a tube inserted into the bladder through the urethra, to keep the bladder empty and allow the urine and blood to drain out into a collection bag. In most instances, a patient will heal within 10 days. However, large blood clots in the bladder or injuries involving the bladder neck require surgical repair.

• Intraperitoneal Rupture -- These ruptures require surgical repair to prevent urine from leaking into the abdomen. The repair is performed by making an incision in the abdomen and then sewing the tear closed. A catheter is left in the bladder for a few days to rest the bladder after surgery.

• Penetrating Injuries -- Penetrating injuries usually require surgical repair of any holes made in the bladder. In most instances, surrounding organs are injured and also require repair. A catheter is left in the bladder to drain the urine and blood as described above.

• Urethral Injuries -- Management and treatment of urethral injuries can be complex and depends on the severity and location of injury, patient's health and whether any other injuries are present. In some cases, emergency surgical repair is recommended, but should be limited to select cases. As a general rule, initial suprapubic cystostomy, which involves placing a catheter in the bladder through the lower abdomen, is the safest and simplest option. For more information, please see the complete section on Urethral Injuries.

• Penile Injuries -- Penile injuries can occur in various instances. For instance, penile factures may occur during sexual intercourse and are usually surgically repaired. In other instances, placing obstructing rings around the base of the penis may lead to gangrene and urethral injuries. The obstructing objects can be removed without further damage. In addition, machinery accidents may cause damage to penile skin, which can be repaired by skin grafting. It also is important to note that penile injuries often occur with urethral injuries. Therefore, when making a diagnosis of penile injuries, an urethrography -- a test involving X-rays of the urethra -- will be performed to identify any injuries or obstructions in this area.

• Testicular Injuries -- Testicular injuries often occur due to a traumatic blow to the groin or scrotum, which can cause severe pain, nausea, vomiting and in some instances, lower abdominal tenderness. In these cases, a testicular ultrasound -- a non-invasive test involving the use of high-frequency sound waves to create images of the testicular -- is usually performed to evaluate possible damage to the testicle. If a testicular fracture is diagnosed, surgical exploration and repair is required.