The genitourinary tract, or simply the urinary tract, consists of the kidneys, ureters, bladder, and the urethra. The kidney is the most frequently injured.{{Cite book, title=Smith & Tanagho's General Urology, last=McAnich, first=Jack, last2=Lue, first2=Tom, publisher=Lange, year=2013, isbn=, location=, pages=Chapter 18 Injuries to the kidney commonly occur after automobile or sports-related accidents. A blunt force is involved in 80-85% of injuries. Major decelerations can result in vascular injuries near the kidney's hilum. Gunshots and knife wounds and fractured ribs can result in penetrating injuries to the kidney. Pelvic fractures can damage the urethra and bladder.

Presentation

Comorbidity

In 90% of bladder injuries there is a concurrent pelvic fractures. Pelvic bone fragments penetrate and perforate the bladder. Perforations can be either extraperitoneal or

intraperitoneal The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...

. Intraperitoneal perforations allow for urine to enter the peritoneal cavity. Symptoms typically develop immediately if the urine is infected. Otherwise sterile urine may take days to cause symptoms.

Diagnosis

Hematuria Hematuria or haematuria is defined as the presence of blood or red blood cells in the urine. “Gross hematuria” occurs when urine appears red, brown, or tea-colored due to the presence of blood. Hematuria may also be subtle and only detectable ...
in Patients Presenting After Trauma

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

Foley Catheter

The urethral meatus should be examined after trauma. Blood at the urethral meatus precludes insertion of a

foley catheter In urology, a Foley catheter (named for Frederic Foley, who produced the original design in 1929) is a flexible tube that a clinician passes through the urethra and into the bladder to drain urine. It is the most common type of indwelling urina ...

into the bladder. Erroneously placing a foley in this situation can result in infections of periprostatic and perivesical

hematoma A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is ...

s or conversion of a partial transection to a complete urethral transections. Blood at the urethral meatus suggests an injury to the urethra. Otherwise a foley catheter can be placed into the bladder and hematuria can be assessed for.

Abdominal Imaging

Hemodynamically stable individuals should undergo further

radiographic Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...

assessment. Abdominal computed tomography (CT) with contrast can detect retroperitoneal hematomas, renal lacerations, urinary extravasation, and renal arterial and venous injuries. A repeat scan ten minutes after the first is recommended.

Retrograde Urethrography (RUG)

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

Retrograde
Cystography In radiology and urology, a cystography (also known as cystogram) is a procedure used to visualise the urinary bladder. Using a urinary catheter, radiocontrast is instilled in the bladder, and X-ray imaging is performed. Cystography can be use ...

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

Angiography Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. Modern angiography is perform ...

Helpful in identifying injuries to the kidney's

parenchyma Parenchyma () is the bulk of functional substance in an animal organ or structure such as a tumour. In zoology it is the name for the tissue that fills the interior of flatworms. Etymology The term ''parenchyma'' is New Latin from the word π ...

and vasculature.

Management

Genitourinary Trauma

Urethral Injuries

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

= Posterior Urethra Injuries

= The membranous urethra can be separated from the

prostate The prostate is both an accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found only in some mammals. It differs between species anatomically, chemically, and physio ...

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

References

Genitourinary system Injuries