Urotrauma

Page updated Winter 2021.
DisclaimerMedicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Renal Trauma

Hemodynamically Unstable

Immediate intervention is needed.

Surgery 

Angioembolization - in selected situations.

Hemodynamically Stable

Non-invasive management: 

Observation

Ureteral stent

Percutaneous nephrostomy

Percutaneous urinoma drain

Follow-up CT:

- Deep lacerations (Grade IV-V) 

- Fever, worsening flank pain, ongoing blood loss, abdominal distention.

Ureteral Trauma

Unstable Patients

Temporary urinary drainage

Stable Patients

Injury above iliac vessels: 

Primary repair over a ureteral stent. 

Injury below iliac vessels: 

Primary repair over a ureteral stent

Reimplantation. Psoas hitch or Boari flap might be needed.

Contusions:

Resection and primary repair

Delayed Diagnosis

Incomplete ureteral injuries

Ureteral stent

Percutaneous nephrostomy: if not able to place a stent.

Endoscopic Injuries

Ureteral stent and/or percutaneous nephrostomy tube.

Open repair if above measures fail.

Ureterovaginal Fistula

Stent

Additional surgical intervention: If stent doesn't help.

Bladder Trauma

Intraperitoneal Bladder Rupture

Surgical repair

Extraperitoneal Bladder Injuries

Uncomplicated:  

Catheter Drainage for two to three weeks.

Consider open repair if bladder injuries don't heal after four weeks.

Complicated: 

Surgical repair.

Complicated cases include:

- Bladder neck injuries

- Pelvic fractures that result in exposed bone spicules in the bladder lumen 

-Concurrent rectal or vaginal lacerations

- Having open reduction internal fixation of pelvis

- Repair of abdominal injuries

Urethral Trauma

Pelvic Fracture Urethral Injury

Percutaneous or Open Suprapubic Tube

Suprapubic cystostomy can be used safely even if anterior
pubic hardware is placed.

Primary Realignment

An option in hemodynamically stable patients.

Should not perform prolonged attempts.

Urethral catheter is removed after 4 o 6 weeks.

Suprapubic catheter should be kept. 

Straddle Injury to the Anterior Urethra

Percutaneous or Open Suprapubic Tube

Primary Realignment: 

In less severe cases.

Uncomplicated Penetrating Trauma of the Anterior Urethra

Prompt surgical repair

Primary repair should not be undertaken if

- Patient is unstable

- If there is extensive tissue destruction or loss
Penile Fracture

Prompt surgical exploration and repair is needed.

Evaluate for concomitant urethral injury.

Ventral vertical penoscrotal incision is usually preferred.

Close the tunical defect.

Interrupted 2-0 or 3-0 absorbable sutures is advised.

Penetrating Scrotal Injuries

Prompt surgical exploration with repair is needed.

Perform Orchiectomy if non-salvageable.

Testicular Rupture

Perform scrotal exploration and debridement with tunical closure.

Perform orchiectomy if non-salvagable.

Extensive Genital Skin Loss or Injury

From infection, shearing injuries, or burns.

Fournier Gangrene

Limited debridement of non-viable tissue should be done.

Tissues with marginal viability may survive due to collateral blood flow.

Multiple procedures in the operating room are needed.

Wound management options are: 

Gauze dressings

Silver sulfadiazine or topical antibiotic and occlusive dressing 

Wound vac

Early suprapubic urinary diversion

Genital Burns 

Early resection of burn eschar and coverage with split-thickness skin grafts when possible. 

Partial-thickness skin loss may be treated with silver sulfadiazine cream.

Deep Penile Electrical Burns

Conservative approach.

Autopenectomy and/or death as a result of extensive concurrent injuries may happen.

Traumatic Penile Amputation

Prompt penile replantation