Genitourinary tract injury

In 90% of bladder injuries there is a concurrent pelvic fractures.[1] Pelvic bone fragments penetrate and perforate the bladder.[1] Perforations can be either extraperitoneal or intraperitoneal.[1] Intraperitoneal perforations allow for urine to enter the peritoneal cavity. Symptoms typically develop immediately if the urine is infected.[1] Otherwise sterile urine may take days to cause symptoms.[1]

Blood in the urine after abdominal trauma suggests a urinary tract injury.[2] Renal injuries are suggested by lower rib fractures.[2] Bladder and urethral injuries are suggested by pelvic fractures.[2]

The urethral meatus should be examined after trauma.[2] Blood at the urethral meatus precludes insertion of a foley catheter into the bladder.[2] Erroneously placing a foley in this situation can result in infections of periprostatic and perivesical hematomas or conversion of a partial transection to a complete urethral transections.[2] Blood at the urethral meatus suggests an injury to the urethra.[2] Otherwise a foley catheter can be placed into the bladder and hematuria can be assessed for.[2]

Hemodynamically-stable individuals should undergo further radiographic assessment.[2] Abdominal computed tomography (CT) with contrast can detect retroperitoneal hematomas, renal lacerations, urinary extravasation, and renal arterial and venous injuries.[2] A repeat scan ten minutes after the first is recommended.[2]

The purpose of this study is to identify and characterize injuries to the urethra.[2] The tip of a small (12F) foley catheter is placed in the urethral meatus.[2] The catheter remains fixed after 3 mL of water are instilled into the foley catheter's balloon.[2] Radiographic films are taken as 20 mL of water-soluble contrast material are injected[2] This outlines the urethra from the urethral meatus to the bladder neck.[2] If injuries exist, the location can be determined.[2]

The purpose of this study is to identify bladder perforations.[2] The bladder needs to be adequately distended with contrast medium.[2] 300 mL or more are generally recommended.[2] The study has two films. One film is taken when the bladder is adequately distended and filled with contrast.[2] The next film is taken after the bladder is emptied without the assistance of a foley catheter.[2]

Helpful in identifying injuries to the kidney's parenchyma and vasculature.[2]

Management depends on what part of the urethra was injured and to what extent.[3] The two broad anatomical separations are the posterior and anterior urethra.[3] The posterior urethra includes the prostatic and membranous urethra.[3] The anterior urethra includes the bulbous and pendulous portion.[3]

The membranous urethra can be separated from the prostate's apex after blunt trauma.[3] The urethra should not be catheterized.[3] Initial management should be the creation of a suprapubic cystostomy for urine drainage.[3] The bladder should be opened in the midline so to facilitate inspection of bladder lacerations.[3] Perforations can be closed with absorbable sutures.[3] The suprapubic cystostomy remains in place for three months.[3] Incomplete urethral disruptions heal spontaneously and the suprapubic cystostomy can be removed after three weeks for these injuries.[3] Before removing a cystostomy, a voiding cystourethrography should demonstrate no urine extravasation.[3] Delayed urethral reconstruction may be performed within 3 months.[3] This typically entails a direct excision of the now strictured area and anastomosis of the bulbous urethra to the prostate's apex.[3] A urethral catheter and suprapubic cystostomy should be left in place.[3] These are removed within a month.[3]