Falls, assaults, motor vehicle crashes, and sports injuries are
the most common mechanisms for blunt GU injuries, whereas gunshot
wounds and stab wounds are the most common causes for penetrating
injuries.1 The majority of ureteral injuries are
caused by penetrating trauma.1–3 Bladder
injuries are typically caused by pelvic fracture, with urethral
injuries seen in 5% to 10% of pelvic fractures.4 Children
are more susceptible to GU injury than the general population. Children
lack periadipose tissue, and kidney size is large relative to overall
body size.5 Appropriate management will minimize
or prevent complications such as renal function impairment, urinary
incontinence, and sexual dysfunction.6
Perform an ordered and systematic clinical evaluation to allow
for the timely identification and management of GU injuries. To
avoid missing GU injury, perform a thorough GU evaluation in all
patients with multiple trauma. Consider the mechanism of injury,
perform a focused physical examination, and obtain appropriate diagnostic
imaging and laboratory testing.
A detailed history is important to determine the time and mechanism
of injury and the magnitude of forces involved. Seat location in
motor vehicle crashes, use of restraints, speed of the vehicle,
and manner in which the crash occurred provide vital information
about forces applied to the victim. Any injury caused by rapid deceleration
can cause major vascular and parenchymal damage to the kidneys and
bladder, even in the absence of symptoms and physical findings.
In penetrating trauma, information regarding the caliber of weapon
or type of knife involved can help identify the extent of damage.
The length of the weapon, any contamination of it, and whether or
not it was found or removed intact are key historical components.
An inability to urinate may be due to an empty bladder, or inability
to void because of pain, but can also result from bladder perforation,
urethral injury, or spinal cord injury.
Inspect the perineum during the secondary survey. Blood on the
underwear or pants is an important finding and may be an indication
of genital trauma. Inspect the folds of the buttocks for signs of
perineal injury, which may be related to an open pelvic fracture.
Do not deeply probe perineal injuries because such examination could
result in disruption of a clot. One study reported that 25% of
patients sustaining injury to the external genitalia required red
blood cell transfusion due to blood loss from genital injury alone.7 Rectal
examination identifies sphincter tone, position of the prostate
gland, and presence of blood. If the prostate is “missing” or
riding high or feels boggy, assume disruption of the membranous
urethra until proven otherwise.
In males, examine the scrotum for ecchymoses, laceration, and
testicular disruption. Palpate and inspect the penis for ecchymoses,
deformity, and blood at the meatus. In females, examine the vaginal
introitus for lacerations and hematomas. Lacerations and hematoma
can accompany pelvic ...