Trauma

Renal Trauma

Trauma is the leading cause of death in those aged 1–44, and urologic organs are involved in ~10% of abdominal trauma. Injuries are classed as blunt vs penetrating because management differs. The kidney is the most commonly injured GU organ, and management has shifted decisively from operative exploration to non-operative management in the vast majority of cases.

Pathogenesis

The kidney is fixed only by the renal pelvis and vascular pedicle, making it prone to deceleration injury (falls, motor-vehicle collisions). The pediatric kidney is more susceptible because of an immature, pliable thoracic cage, weaker abdominal musculature, less perirenal fat, and a lower abdominal position.

Diagnosis and Evaluation

• History — the extent of deceleration is the most important information in blunt injury. Trauma anterior to the axillary line is more likely to damage the hilum/pedicle, whereas posterior trauma usually causes parenchymal injury.
• Examination — flank hematoma, abdominal/flank tenderness, rib fractures (an ipsilateral rib fracture triples the risk of significant renal trauma), hematuria, and penetrating injury to the low thorax or flank. The degree of hematuria does not correlate with injury severity and should not be the sole determinant.
• Imaging indications (AUA 2020 — contrast CT with immediate and delayed films, in stable patients): gross hematuria; microscopic hematuria with SBP <90 mmHg; a mechanism concerning for renal injury (rapid deceleration, blow to flank); concerning exam findings (rib fracture, flank ecchymosis); penetrating injury of the abdomen, flank, or lower chest; and a pediatric patient with microscopic hematuria. (Children use the same criteria but often do not become hypotensive; if going straight to the OR, a one-shot IVP — 2 mL/kg, single image at 10–15 min — confirms a functioning contralateral kidney.)
• Modality — CT abdomen/pelvis with IV contrast (immediate + delayed images). Its major limitation is the inability to define a renal venous injury — a medial hematoma suggests one, but no modality diagnoses it reliably.
• CT findings suspicious for significant injury: medial laceration, medial hematoma (vascular pedicle), medial urinary extravasation (renal pelvis/UPJ), hematoma >3.5 cm, lack of parenchymal enhancement (main renal artery injury), and active intravascular contrast extravasation (brisk arterial bleeding). Fluid-collection densities differ: hematoma >30 HU, urinoma 0–20 HU, abscess with rim enhancement.

AAST Grading

Grade	CT criteria
I	Subcapsular hematoma and/or contusion, no laceration
II	Perirenal hematoma confined to Gerota's; laceration ≤1 cm without urinary extravasation
III	Laceration >1 cm without collecting-system rupture; or a vascular injury/active bleeding contained within Gerota's
IV	Laceration into the collecting system with extravasation; renal-pelvis laceration/complete UPJ disruption; segmental vessel injury; or segmental/complete infarction without active bleeding
V	Main renal artery/vein laceration or hilar avulsion; devascularised kidney with active bleeding; or a shattered kidney

Advance one grade for bilateral injury, up to grade III.

Management

• Hemodynamically stable → non-invasive management: close monitoring, bed rest, ICU admission, and transfusion/imaging as needed. Follow-up CT (after 48 h) is indicated only for deep lacerations (grade IV–V) or clinical signs of complications (fever, worsening flank pain, ongoing blood loss, distention) — grade I–III rarely needs it. In grade 3–4 injuries, the risk of bleeding/intervention rises with a medial hematoma, a hematoma >3.5–4 cm, or contrast extravasation; delayed bleeding usually occurs within 21 days.
• Hemodynamically unstable → immediate intervention (surgery or selective angioembolization). Intervene immediately for a large perirenal hematoma (>4 cm) and/or vascular contrast extravasation in a deep/complex (grade 3–5) laceration. Angioembolization controls segmental-vessel bleeding, but a patient unstable despite resuscitation goes to the OR, not angiography. Post-embolization syndrome is self-limiting and occurs in ~10% (fever, pain, ileus). (WSES/AAST 2019: non-operative management is the choice for all stabilised patients; isolated urinary extravasation is not an absolute contraindication.)
• Surgical — the transabdominal approach allows full inspection, with early vascular control before opening Gerota's: the small bowel is mobilised outside the surgical field to expose the mid-peritoneum, an incision above the IMA exposes the renal veins, the renal vein is secured and retracted cephalad to expose the renal artery beneath it, then the artery is secured; for a large hematoma that may obscure vision, the IMV is used as a landmark to incise medially. Once the vessels are secured the kidney is exposed — left kidney exposure via the Mattox maneuver, right kidney via the Cattell maneuver. Principles of renal reconstruction: limited debridement, suture-ligation hemostasis, watertight collecting-system closure, parenchymal reapproximation, coverage with a fascioadipose/omental flap, and liberal drains. For a major renovascular injury with two kidneys, a prompt nephrectomy is advocated (salvage rates are low); damage-control packing (returning at ~24 h) stabilises the cold/acidotic/coagulopathic patient, but an unstable patient with no damage-control option undergoes immediate total nephrectomy.

Special Scenarios

• Urinary extravasation — persistent extravasation risks urinoma, perinephric infection, and (rarely) renal loss. Stable patients without renal-pelvis/proximal-ureteral injury are observed — parenchymal collecting-system injuries resolve spontaneously in >90%. Intervene (ureteral stent ± Foley, or percutaneous urinoma drain/nephrostomy) for suspected renal-pelvis/proximal-ureteral avulsion, an enlarging/purulent urinoma, or complications (fever, ileus, fistula).
• Hypertension — rare early but can occur later, via renal vascular injury (Goldblatt one-clip kidney), a Page kidney (parenchymal compression by blood/urine), a post-traumatic AV fistula, or ureteral/UPJ obstruction — the first three stimulate the renin-angiotensin axis. Treat with antihypertensives, observation, or (uncommonly) nephrectomy.

Ureteral Trauma

Ureteral injury is rare (~1% of urologic injuries) but frequently iatrogenic and unrecognised at the time. This tab covers its causes, intraoperative detection, grading, and stability-based management.

Pathogenesis and Causes

Acute ureteral injury arises from iatrogenic injury (open, laparoscopic, or endoscopic surgery), external violence (high-speed blunt — massive force should raise suspicion), and penetrating stab/gunshot wounds.

• Iatrogenic — the commonest culprit is hysterectomy (54%), then colorectal surgery (14%), ovarian-tumour removal (8%), and transabdominal urethropexy (8%). Injuries during laparoscopy are less often recognised immediately than in open surgery (where ~1/3 are caught intraoperatively).
• Endoscopic — perform ureteroscopy over a wire in the renal pelvis. Complication risk rises with longer operative times, stone treatment, surgeon inexperience, and prior irradiation; persisting with basketing after a tear is a classic cause. When a perforation is identified, stop and place a stent.
• Other — ureteral manipulation in aortoiliac/aortofemoral bypass (12–20%) can cause hydronephrosis (usually benign; steroids if symptomatic). A gunshot blast contusion can cause delayed stricture or necrosis. Prophylactic preoperative stenting does NOT reduce injury risk in gynaecologic surgery (RCT), though it may aid intraoperative recognition.

Intraoperative Ureteral Assessment

Options to confirm ureteral integrity include direct inspection (opening the retroperitoneum), retrograde pyelography, and IV dye (methylene blue or indigo carmine) with cystoscopy to confirm absence of hematuria and the presence of bilateral ureteral jets (a poor predictor of injury).

• IV methylene blue is safe at <2 mg/kg but is a potent MAO inhibitor — contraindicated in pregnancy (teratogenic), with SSRIs/SNRIs (fatal serotonin toxicity), and in G6PD deficiency (methemoglobinemia, hemolysis). IV indigo carmine is contraindicated in pregnancy and can cause bronchospasm and hypotension.
• Ineffective methods: single-shot IVP, intraoperative hydration/diuretic, digital palpation, and grasping the ureter to evoke peristalsis (never rely on this).

Diagnosis and Evaluation

Hematuria is non-specific and significant injury can occur without it. Missed injury presents postoperatively with flank pain, fever, leukocytosis, ileus, abdominal distention, or a urinary fistula. In stable patients not going straight to laparotomy, obtain a contrast CT with 10-minute delayed films; findings suggesting injury are contrast extravasation, absent contrast distal to the injury, an ipsilateral delayed pyelogram, and ipsilateral hydronephrosis. Otherwise, inspect directly at laparotomy.

AAST Grading

• I — contusion or hematoma without devascularisation.
• II — laceration with <50% transection.
• III — laceration with ≥50% transection.
• IV — complete transection with <2 cm devascularisation.
• V — avulsion with >2 cm devascularisation.

Management

Management depends on hemodynamic stability:

• Stable — repair lacerations immediately, converting a longitudinal laceration into a transverse closure (Heineke-Mikulicz) to avoid narrowing. Definitive choice also follows a time window — early (<7 days) vs late (>7 days) recognition:
  • Early (<7 days): URS perforation → stent 4–6 weeks (avulsion → immediate repair); thermal/high-velocity contusion → debridement and ureteroureterostomy; small contusion → stent 4–6 weeks; major pelvic injury → reimplant ± psoas hitch (6–10 cm) or Boari flap (12–15 cm); major abdominal injury → reimplant, ureteroureterostomy (2–3 cm), or TUU; UPJ → pyeloplasty; loss of the entire ureter → ileal ureter, nephrectomy, or autotransplant.
  • Late (>7 days): retrograde stent → if failed, antegrade stent → if failed, PCN, then wait 6 weeks for final management.
• Unstable — temporary urinary drainage with delayed definitive repair: a ureteral stent alone, a short period of observation with reoperation at ~24 h, exteriorising the ureter, or tying off the ureter (with long silk for identification) plus percutaneous nephrostomy.

General principles of ureteral repair: mobilise widely while sparing the adventitia, debride minimally until the edges bleed (especially after gunshot), and create a spatulated, tension-free, stented, watertight anastomosis with fine absorbable monofilament (e.g. 5-0 PDS) and retroperitoneal drainage; retroperitonealise the repair, do not tunnel ureteroneocystostomies, and use omental interposition for complex/blast injuries. Post-operative sequence: keep the Foley 24–48 h, remove the Foley before the drain, then remove the drain 1 day after the Foley if there is no high output. Repair choice follows the defect's level (see the Ureteric Stricture Disease topic):

• Above the iliac vessels — ureteroureterostomy, ureterocalicostomy, transureteroureterostomy, or interposition/autotransplant (not acutely); rarely acute nephrectomy.
• Below the iliac vessels — ureteroneocystostomy, psoas hitch, or Boari flap.

Special scenarios: a ureteral contusion is stented unless severe, large, or gunshot-related (then resect devitalised tissue plus an adjacent segment of normal ureter for the blast effect, and spatulate ~5–6 mm at 180° apart). A delayed diagnosis is managed with a stent, escalating to nephrostomy if stenting fails or is impossible — but immediate repair is indicated if detected within 72 h, if the injury is near a closed viscus (bowel/vagina), or if re-exploring anyway. An endoscopic injury is managed with a stent ± nephrostomy. A ureterovaginal fistula is first managed by stent (64–100% success); failures → reimplant ± Boari/psoas hitch or TUU. A ligation is managed by removing the ligature and observing viability; if viability is uncertain, perform a ureteroureterostomy or reimplant. A ureteroarterial fistula is catastrophic (life-threatening hematuria) and must be diagnosed and treated immediately. Follow-up after repair: remove the stent at 6 weeks (with a retrograde ureterogram), a Lasix renogram at 10 weeks, and renal US at 4 months.

Bladder Trauma

Bladder rupture is classified as extraperitoneal (~60%), intraperitoneal (~30%), or both (~10%). The distinction drives management: extraperitoneal ruptures usually accompany a pelvic fracture and are managed by catheter drainage, whereas intraperitoneal ruptures need surgical repair.

Background and Pathogenesis

• Extraperitoneal injury is usually associated with a pelvic fracture.
• Intraperitoneal injury can occur with a pelvic fracture but more often follows penetrating trauma or a burst at the dome from a blow to a full bladder.
• The bladder is protected within the bony pelvis, so blunt injury (deceleration MVC, falls, crush) is rarely isolated — 83–95% of bladder injuries have a pelvic fracture, but only 5–10% of pelvic fractures involve the bladder. Obstetric/gynaecologic procedures are the most common cause of iatrogenic open-surgical injury.

AAST Grading

• I — contusion/intramural hematoma or partial-thickness laceration.
• II — extraperitoneal laceration <2 cm.
• III — extraperitoneal >2 cm or intraperitoneal <2 cm laceration.
• IV — intraperitoneal laceration >2 cm.
• V — laceration extending into the bladder neck or ureteral orifice (trigone).

Diagnosis and Evaluation

• Indicators of rupture — gross hematuria is the most common (a few present with microscopic hematuria), plus lower-abdominal bruising, distention, suprapubic pain, guarding, inability to void, low urine output, diminished bowel sounds, pubic-symphysis diastasis, obturator-ring displacement >1 cm, raised creatinine/BUN (peritoneal urine absorption), and urinary ascites.
• Cystography indications (AUA 2020) — absolute: gross hematuria with a pelvic fracture; relative: gross hematuria with a concerning mechanism, or pelvic ring fracture with clinical indicators. Pelvic fracture alone does not warrant cystography. (Campbell's adds penetrating injury with any hematuria as absolute.)
• Modality: retrograde cystography (CT or plain film) — both are highly accurate and distinguish intra- from extraperitoneal rupture. Fill to 300–350 mL (false negatives occur at 250 mL); in CT cystography dilute the contrast 1:6. Plain film needs a fill view and a drainage view (not required for CT). Extraperitoneal rupture shows a flame-shaped pelvic collection; intraperitoneal rupture outlines bowel loops. The amount of extravasation does not reflect injury size.

Management

If blood is at the meatus or the catheter will not pass, perform a retrograde urethrogram first — urethral injury coexists in 10–30% of bladder ruptures.

• Extraperitoneal (uncomplicated) — a large-bore (22-Fr) Foley for 2–3 weeks, with follow-up cystography to confirm healing; consider open repair if it fails to heal after >4 weeks of drainage (start antibiotics if a pelvic hematoma is present).
• Intraperitoneal — prompt surgical repair (failure risks peritonitis and sepsis). Repair the tear intravesically with absorbable suture after confirming the bladder neck and ureteral orifices, and do not disturb the perivesical hematoma. Follow-up cystography at 7–10 days for complex repairs.
• Indications for immediate repair (AUA 2020): intraperitoneal rupture, exposed bone spicules in the lumen, concurrent rectal injury, bladder-neck injury, open reduction–internal fixation of the pelvis, concurrent vaginal injury, when repairing other abdominal injuries, a penetrating or iatrogenic non-urologic injury, and inadequate drainage or clots.
• Bladder perforation from a cystoscopic procedure — obtain a cystogram first: an extraperitoneal perforation is managed by bladder drainage, and a small intraperitoneal perforation is also managed by bladder drainage. Repair if it is large, there is a suspected intra-abdominal injury, tissue is protruding into the bladder, or there is ileus, peritonitis, significant bleeding, or urethral-catheter clogging.
• After repair, urethral catheter drainage alone is sufficient (no advantage to adding a suprapubic tube), except with long-term catheterisation needs, a tenuous closure, or significant hematuria.

Urethral Trauma

Urethral injuries may be partial or complete. In males they are classified as posterior (at or above the membranous urethra) or anterior (penile/bulbar) — a distinction that determines management: posterior injuries are drained and repaired late, whereas penetrating anterior injuries are repaired early.

Background and Pathogenesis

• Posterior injuries are almost exclusively associated with pelvic fractures (urethral injury occurs in ~10% of males and up to 6% of females with pelvic fractures). The bulbomembranous junction is most vulnerable because the posterior urethra is densely anchored to the pubis by the urogenital diaphragm and puboprostatic ligaments.
• Anterior injuries are blunt (straddle injury, crushing the urethra against the pubis) or penetrating, most commonly involving the bulbar urethra (its fixed position beneath the pubis).

Diagnosis and Evaluation

• Indicators — blood at the urethral meatus is the most common finding, plus inability to urinate, perineal/genital ecchymosis, a high-riding prostate (males), and labial edema/vaginal blood (females). If Buck's fascia is disrupted, blood and urine track into the scrotum and up the abdominal wall (deep to Scarpa's, limited posteriorly by Colles' fascia) — the classic butterfly pattern.
• Imaging — retrograde urethrogram (RUG) is performed immediately when injury is suspected; avoid blind catheter passage before the RUG. Position the patient obliquely, place a 12-Fr Foley or catheter-tipped syringe in the fossa navicularis with the penis on traction, and inject 20–25 mL of undiluted contrast. If a Foley is already in place and there is meatal blood, perform a pericatheter RUG (3-Fr feeding tube/angiocath in the fossa navicularis). In female patients, urethroscopy is suggested instead of RUG (the urethra is short).

Management

The immediate goal is securing bladder drainage. With a partial disruption (contrast passes proximally on RUG), an experienced clinician may make a single gentle catheter attempt.

Male — Posterior

Pelvic fracture urethral injury (PFUI): immediate suprapubic tube with delayed repair. The suprapubic tube is the gold standard (placed at 14-Fr or larger; US, fluoroscopy, or 18-G needle aspiration is used to localise a displaced bladder; it can be placed even with ORIF, without raising hardware-infection risk). Primary realignment (advancing a catheter across the rupture) may yield less severe strictures than an SPT alone but over a longer course — the ED is an inappropriate setting for it, and prolonged endoscopic attempts should be avoided. Immediate sutured repair causes unacceptable rates of ED and incontinence. Most patients develop an obliterative rupture defect filled with scar (not a stricture), amenable to open perineal anastomotic posterior urethroplasty — performed at ~3 months once ambulatory and stable (obtain a cystogram + RUG before repair; limit lithotomy time to ≤5 hours), and preferred by the AUA over endoscopic treatment. After urethroplasty, 5–15% develop recurrent stenosis and incontinence rates are low (<4%); follow for at least 1 year.

Male — Anterior

• Contusions/incomplete injuries — urethral catheter diversion alone.
• Straddle injury — suprapubic tube (or primary realignment in milder cases) with delayed repair; immediate operative intervention is contraindicated (indistinct injury borders), and obliterated bulbar segments are later treated by delayed anastomotic urethroplasty.
• Penetrating trauma — prompt spatulated primary repair gives superior outcomes (unlike PFUI/straddle, where delayed repair is preferred), unless the patient is unstable or there is extensive tissue loss.

Female

Pelvic-fracture urethral disruption is treated by immediate primary repair or realignment over a catheter, to avoid urethrovaginal fistula or obliteration — delayed reconstruction is problematic because the female urethra (~4 cm) is too short to mobilise once embedded in scar.

Genital Trauma

External genital injuries are uncommon thanks to the mobility of the penis and scrotum. This tab covers penile fracture and other penile injuries, testicular trauma, and reconstruction of genital skin loss. Two timing rules anchor management: a penile fracture can be repaired up to 7 days out, but testicular rupture should be explored within 72 hours.

Penile Fracture

A penile fracture is disruption of the tunica albuginea with rupture of the corpus cavernosum, most often during vigorous intercourse when the rigid penis buckles against the perineum or pubic bone (in the Middle East, forcible bending — taqaandan — predominates). The tear is usually on the proximal shaft distal to the suspensory ligament, transverse, unilateral (both corpora in 10%), and ventral or lateral (the tunica is thinnest at 5–7 o'clock — contrast Peyronie's, which is dorsal).

• Diagnosis is usually clinical — a cracking/popping sound with immediate detumescence, then swelling and ecchymosis. With Buck's fascia intact, an "eggplant deformity" results; if disrupted, the hematoma spreads as a butterfly pattern; there may be a palpable fracture line, and the penis deviates away from the tear. Imaging is usually unnecessary but, when H&P is equivocal, ultrasound is preferred (MRI is the most accurate); Doppler and cavernosography have high false-negative rates. Evaluate the urethra (urethroscopy or RUG) — urethral injury occurs in 10–22% (more with bilateral corporeal injury) and is suggested by blood at the meatus, gross hematuria, or inability to void.
• Management is prompt surgical exploration and repair, which gives faster recovery and lower rates of ED, curvature, cavernosal diverticulum, and chronic pain; delay up to 7 days does not worsen outcomes. Incision options: a distal circumcising/degloving incision (when the location is uncertain — it exposes all three compartments), an incision at the site of injury, or a ventral midline incision; an artificial erection (saline + methylene blue) locates and tests the defect. The tunica is closed with interrupted 2-0/3-0 PDS, with any partial urethral injury oversewn and a complete injury repaired tension-free over a catheter. Postoperatively: antibiotics and 1 month of sexual abstinence. For the full operative technique, see the Penile Fracture Repair procedure page.

Other Penile Injuries

• Gunshot wounds — immediate exploration, irrigation, debridement, antibiotics, and closure; low-velocity urethral injuries are closed primarily, while high-velocity/shotgun blasts may need staged repair with suprapubic diversion.
• Bites — dog bites are irrigated, debrided, and closed primarily over a drain with broad-spectrum antibiotics (amoxicillin-clavulanate, cefoxitin/cefotetan, or clindamycin + ciprofloxacin) plus tetanus/rabies cover; human bites are contaminated and usually not closed primarily.
• Amputation — preserve the severed part by the double-bag technique (saline-wrapped in a sterile bag, then a bag on ice) and transfer to a microsurgical centre. Macrovascular repair preserves erectile function, glans vascularity, and urethral continuity; microvascular repair is needed for skin (dorsal artery/vein) and sensation (dorsal nerve). Reimplantation is possible within <16 h cold or <6 h warm ischemia.
• Zipper injuries — after a penile block, lubricate with mineral oil and attempt a single unzip; if it fails, cut the slider with a bone cutter.

Testicular Trauma

Testicular rupture must be considered in all blunt scrotal trauma (rupture of the tunica albuginea). Patients have exquisite pain and nausea — and since ~5% of cord torsions are trauma-precipitated, consider torsion with significant pain but minimal injury signs. A non-palpable testis suggests dislocation (needs reduction).

• Ultrasound reliably diagnoses rupture in blunt trauma; suggestive findings are a heterogeneous parenchyma and disruption of the tunica/contour. The degree of hematoma does not correlate with the degree of injury. A normal or equivocal US should not delay exploration when the exam suggests injury.
• Indications for scrotal exploration: imaging or clear physical findings of rupture, equivocal imaging with suspicion, a large hematoma (explore and drain even without rupture, to prevent pressure necrosis), penetrating injury (>50% have rupture; ligate the injured vas, and explore the contralateral side in gunshot wounds since ~30% injure both testes), and significant hematoceles (up to 80% are from rupture).
• Early exploration within 72 h achieves >90% salvage (orchiectomy rates are 3–8× higher with delay). Repair via a transverse scrotal incision — debride extruded tubules, close the tunica albuginea (a tunica vaginalis flap can cover a large defect), and reserve orchiectomy for a non-salvageable testis.

Genital Skin Loss and Reconstruction

The most common cause of extensive genital skin loss is Fournier gangrene. Manage with exploration and limited debridement (genital skin is well vascularised, so marginally viable tissue may survive), often over multiple procedures. A urethral catheter in a genital burn should be removed after 72 h to prevent urethral slough and fistula.

• Penile reconstruction — thick, non-meshed split-thickness skin grafts are preferred (meshed grafts contract); a foreskin flap is best for small distal loss, and residual subcoronal skin is excised to avoid lymphedema. Shaft grafts never regain normal sensation, though sexual function is preserved via glans sensation.
• Scrotal reconstruction — defects up to 50% can be closed directly; otherwise meshed split-thickness grafts are preferred, and the testes can be placed in thigh pouches (or managed with a vacuum dressing) temporarily (avoided initially if infected).