This document provides an overview of genitourinary trauma, including injuries to the penis, testicles, urethra, bladder, ureters and kidneys. It discusses the causes, signs, investigations and management for each type of injury. Penile fractures require surgical repair to prevent long-term complications. Testicular injuries may require ultrasound or surgical exploration. Urethral injuries are classified using the Goldman system and managed conservatively or surgically depending on severity. Bladder injuries often require retrograde cystography and may be managed conservatively or surgically. Renal injuries are graded based on CT or IVP findings and most grade I-II injuries can be managed conservatively while grade III or higher often require

1. Amy McAllister
April 2014

2. Contents
 Anatomical approach
 Causes
 Symptoms & Signs
 Investigations
 Management
 Learning points

3. Introduction
 GUT injury in ~10% of all trauma
patients
 Long term morbidity
-incontinence
-impotence
-psychological
 Usually not life threatening; need to rule
out other injuries

4. Aetiology
 Penetrating
- Knife, bullet
 Blunt
- MVA
- fall from height
- direct blow/ sports
- straddle injury
- Constriction, Instrumentation
 Also – avulsion, burns, radiation, iatrogenic

5. Penile injuries
Penile “fracture”
 Rupture of the tunica albuginea of one
or both of the corpora cavernosa.

6. Penile fracture
 Aetiolgy
- Frequently a sexually related accident but can also be
from a direct blow
- May be associated with urethral injury
 Investigations
- Usually history is enough
- Diagnostic cavernosography or MRI
 Management
- Previous conservative treatment – high complication
rates
- Surgery

7. Penile fracture
“Eggplant” deformityFascial layers of the penis

8. Penile amputation
 Accidental or deliberate
 “Double Bag” preservation
 Management
 Reimplantation - success has been
reported after 16 hours of cold
ischaemia

9. Penile soft tissue injuries
 Penetrating injuries
 Dog bites
 Constriction
 Degloving
Management
 Sutures
 Removal of constricting devices
 Surgery

10. Testicular injuries
•Haematocele
•Haematoma
•Testicular rupture
•Testicular
dislocation/ torsion

11. Testicular injuries
Signs
 Bruising, swelling, tenderness,
haematuria
Investigation
 USS
 Surgical exploration

12. Testicular rupture
Normal testis Testicular rupture(6)

13. Urethral injuries
Prostatic
Membranous
Bulbous
Pendulous
Anterior urethra
Posterior urethra
(most common)

14. Posterior urethral injury
 Commonly associated with pelvic #
 Violent mechanism

15. Posterior urethral injury
 Signs
 Blood at meatus
 Gross haematuria
 Inability to void
 Ecchymoses, swelling of penis
 Pelvic/suprapubic tenderness
 “High riding”/absent prostate on DRE

16. Anterior urethral injury
 Direct trauma history
 Straddle injury
 Usually no pelvic #
 Similar signs to
posterior
Investigations
 Urinalysis
 Retrograde
urethrogram

17. Urinalysis
*False positives*
 Rhabdomyolysis
 Food – berries/beets
 Drugs – Rifampicin, Alphamethyldopa
etc
 If more than a trace on dipstick – send
for urinalysis

18. Retrograde urethrogram
 Patient tilted at 45 degrees
 Initial KUB film taken
 Penis sretched obliquely
over thigh to promote
visualization of the entire
urethra
 Inject 25mls of water-
soluble contrast using
specialised adaptor or
Foley catheter
 Re-xray

19. Goldman classification of
urethral trauma

20. Retrograde urethrogram
Normal Goldman type III urethral injury

21. Urethral injuries
 Management
 Posterior
 Partial tear - Foley catheter
 Complete tear – Suprapubic catheter, surgery
 Anterior - surgery
 NB. If Foley already in place and suspect tear,
do not remove

22. Bladder injuries
Degree of injury
•Contusion (most common)
•Extraperitoneal rupture
•Intraperitoneal rupture
•Combined intraperitoneal/extraperitoneal
rupture

23. Bladder injuries
 Aetiology
- pelvic # in up to 70% of cases
- blunt abdominal trauma with full bladder

24. Bladder rupture

25. Bladder injuries
Signs
 Gross haematuria
 Microscopic haematuria with pelvic #
 Bruising, suprapubic tenderness, peritonism
 Must rule out urethral injury before placing Foley
Investigations
 Retrograde CT cystography
Management
 Contusions/extraperitoneal – conservative
 Intraperitoneal - surgery

26. Ureteral injuries
 Ureter injury is rare except a
complication of surgery/ penetrating
trauma
 No haematuria in 25% of ureter injuries
 Have high index of suspicion

27. Renal injuries
 Usually blunt trauma
 Sudden deceleration
 MVA / bicycle accidents
Lumbar transverse process #

28. Renal injuries
Signs
•Eccyhmosis to back / flank / lower thorax / upper
abdomen
•Haematuria
•Shock
Delayed findings
•Fever
•Palpable flank mass (urinoma)

29. Renal injuries
Investigations
 CT with contrast
 IVP

30. Classification of renal injuries

31. Renal injuries
 Management
 ABCs
 Grade I and II – conservative
 Grade III and up – operative including
nephrectomy

32. Learning points
 Rule out life threatening injuries first
 Identification prevents long term
problems
 No Foley if urethral trauma suspected –
wait for u/a and pelvic x-ray
 If Foley is in – do not remove if urethral
trauma suspected afterwards
 Gross haematuria or microscopic
haematuria plus shock = GUT trauma

33. References
 (1) Urol Clin North Am. 2013 Aug;40(3):323-34. doi:
10.1016/j.ucl.2013.04.001. Epub 2013 Jun 12.Current epidemiology of
genitourinary trauma. McGeady JB1, Breyer BN
 (2) Bhatt S, Kocakoc E, Rubens DJ, Seftel AD, Dogra VS
(2005)Sonographic evaluation of penile trauma. J Ultrasound Med
24:993–1000, quiz 1001
 (3) Kozacioglu Z., Degirmenci T., Arslan M., et al
 : Long-term significance of the number of hours until surgical repair of
penile fractures. Urol Int 2011; 87: 75-79 CrossRef
 (4) J Urol. 2004 Aug;172(2):576-9.
 Long-term experience with surgical and conservative treatment of
penile fracture.
 Muentener M1, Suter S, Hauri D, Sulser T.
 (5) Wei F.C., McKee N.H., Huerta F.J., et al
 : Microsurgical replantation of a completely amputated penis. Ann Plast
Surg 1983; 20: 317-321 CrossRef

34. References
 (6) Bhandary P, Abbitt PL, Watson L (1992) Ultrasound
diagnosis of traumatic testicular rupture. J Clin Ultrasound
20:346–348
 (7) Lower male genitourinary trauma: a pictorial review Bruce
E. Lehnert & Claudia Sadro & Eric Monroe &Mariam Moshiri
 (8)Gomez RG, Ceballos L, CoburnMet al (2004) Consensus
statement
 on bladder injuries. BJU Int 94:27–32(2)Ramchandani P,
Buckler PM (2009) Imaging of genitourinary trauma. AJR Am
J Roentgenol 192:1514–1523
 (9) Straddle injuries to the bulbar urethra: management and
outcome in 53 patients Elgammal MA.Int Braz J Urol. 2009
Jul-Aug;35(4):450-8. .