Genitourinary Trauma: Presentations, Evaluation, and Management Updates

Jason Arthur, MD, MPH (@jarthurEM, Assistant Professor of Emergency Medicine & Emergency Ultrasound Fellow, University of Arkansas for Medical Sciences), Steven Chadwick, DO (@SLC_EMP, EM Resident Physician, University of Florida – Jacksonville), & Christopher Ellington, MD (Diagnostic Radiology Resident Physician, University of Missouri-Kansas City) // Edited by Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Case

A 24-year-old male with no past medical history is brought to the ED by EMS after suffering multiple gunshot wounds. EMS reports normal vital signs on scene but reports multiple apparent gunshot wounds to the legs, flanks, and groin.

Upon arrival, the patient is complaining of pain in the flank, back, pelvis, and testicles as well as a sensation of urinary urgency and inability to void. Vital signs are normal. The exam is remarkable for one wound to the right flank, three wounds to the left flank, two wounds to the right thigh, and a single wound to the scrotum. There is no blood at the urethral meatus.

What are your concerns at this point? What imaging modalities should be ordered?

 

Background

Trauma is the 6thleading cause of death worldwide accounting for 10% of mortalities.1  In the United States, over 2.8 million people are hospitalized as a result of trauma yearly, with estimated costs of $406 billion annually in medical expenditures and lost productivity.2  Approximately 10% of trauma patients sustain injury to the genitourinary (GU) system. Penetrating injuries, most commonly gunshot and stab wounds, account for 15% of all GU injuries.3

Blunt trauma is the leading cause of traumatic renal injury. While penetrating renal injury is responsible for only 16% of renal trauma, its incidence is increasing due to the rise in civilian gunshot wounds (GSWs) in the United States.4  Despite this, renal injury is a relatively uncommon complication of trauma and is seen in only 3.5% of victims of gunshot wounds, 2.2% of motor vehicle collisions (MVCs), 1.9% of bicycle accidents, 1.5% of pedestrian accidents, 0.8% of stab wounds, and 0.5% of falls.5  Ureteral trauma most commonly occurs in penetrating trauma, most frequently due to GSWs.6  Pereira et. al reported a male predominance, with 83.4% of cases occurring in males.  This male predominance may be representative of the strong association of ureteral injuries with penetrating trauma (61–62%).7

Bladder injuries are most commonly caused by blunt trauma, the attributable cause in 51-86% of cases.8  Among penetrating injuries, GSWs account for 88% of injuries despite the fact that bladder injury is noted in only 3.6% of abdominal gunshot wounds.9  Urethral trauma occurs most commonly due to blunt trauma. Straddle injury is frequently implicated in urethral injuries. In a study of over 200 males with pelvic fracture, Koraitim et al. reported that combined straddle fracture (fracture of bilateral superior and inferior pubic rami) and diastasis of the sacroiliac joint confers a 24 times higher risk of urethral injury.10  Injuries to the urethra may be divided into the anterior and/or posterior urethra. Posterior urethral injuries are associated with pelvic fractures and rarely occur in the setting of penetrating injury.  Anterior urethral injuries are 25% more common than posterior urethral injuries, and blunt trauma is by far more common a mechanism usually a straddle type injury.11  Penetrating injuries to the anterior urethra are most commonly from GSWs.12  In a retrospective review of 309 patients sustaining GSWs, 2.9% of civilian GSWs involving the GU system had an injury to the urethra.Blunt trauma to the scrotum is more common than penetrating trauma, accounting for an estimated 85% of scrotal and testicular injuries. While less common, penetrating scrotal trauma is usually more severe and requires surgical exploration. Approximately 40%–60% of penetrating genitourinary injuries involve the external genitalia. A single institution retrospective review of 110 patients with penetrating external genital injuries found that gunshot wounds account for 55% of penetrating scrotal trauma, stab wounds/lacerations account for 42%, and the remaining 3% largely attributed to bites.13  Penile trauma is even more uncommon than scrotal and testicular trauma yet still accounts for 10-16% of all GU injuries.14  Penile injuries are often identified on history and physical exam. Rupture of the tunica albuginea, known as penile fracture, commonly presents with a history of trauma accompanied by an audible snap and then rapid detumescence. Exam may show penile ecchymosis. Concomitant urethral injury occurs in 10-22% of cases. One study found that penetrating penile trauma accounted for 33% of all penetrating genital trauma.13,15  Concomitant urethral injury occurs in 4-29% of cases of penetrating penile trauma.5,8,15

 

Evaluation and Management

Upon presentation to the ED, patients undergo the classic primary and secondary exams, with a focus on resuscitation if needed. Unstable patients presenting with lacerated or shattered kidney, renal vascular injuries, or other life-threatening injuries commonly proceed directly to the operating room without imaging of the Genitourinary (GU) system. If possible, obtain a thorough history including mechanism of injury, as well as previous GU injuries and/or procedures.

In stable patients with suspected genitourinary injury, the secondary survey should include a thorough GU exam. By convention, the GU system is examined from caudal to cephalad, with external genitalia examined first. A thorough secondary survey must be performed of the skin, pelvis, external genitalia, and rectum to identify signs of GU trauma. The clinical presentation of GU trauma is classically taught as pain with voiding, inability to void, blood at the urethral meatus, perineal hematoma, and a high riding prostate. These classic signs and symptoms are suggestive of urethral disruption, though the absence of these signs does not exclude injury to the urethra. One retrospective review of 405 patients with pelvic fracture identified 21 patients with urethral injury. Of these 21 patients, only 12 demonstrated blood at the urethral meatus, high-riding prostate, or perineal hematoma.16  For this reason, in circumstances where GU trauma is suspected, imaging plays a critical role.17

Kidney

Renal imaging is indicated in patients suffering from blunt trauma who have gross hematuria or microscopic hematuria and hemodynamic instability. Among those with penetrating trauma, the role of renal imaging is to assess the severity and extent of injury, assess the injured kidney for underlying parenchymal abnormalities, the condition of the opposite kidney, and if there is significant trauma to surrounding structures.16  Contrast-enhanced multidetector computed tomography (CT) is the imaging technique of choice to evaluate the proximal urinary tract, including the renal vasculature, renal parenchyma, and the collecting system.18  CT imaging is 100% sensitive and 100% specific in characterizing renal trauma.19  Use of intravenous contrast is routine, while enteric contrast is usually not required. Enteric contrast has not been shown to change the accuracy of CT in trauma and may make conventional angiography more challenging.20 The delay between injection of intravenous contrast and initiation of the scan determines the location of opacification and/or enhancement by contrast material. Depending on the delay, contrast may enhance or opacify the arteries, veins, parenchyma, collecting duct, or bladder. Some facilities may employ automatic bolus tracking rather than a fixed delay in order to compensate for variability in cardiac output.21  Assessment of the arterial-phase may be desired in select cases and can be obtained by a 25-30 second delay between contrast injection and image acquisition. Arterial-phase imaging provides information about active hemorrhage, but it is only indicated in patients with severe trauma, with known displaced pelvic fracture, and/or a suspicion for active hemorrhage.20  Most commonly CT is performed with contrast in the portal venous phase, 45-60 seconds after contrast injection. This corresponds to the early nephrographic phase of renal parenchymal enhancement, which is suited for picking up the parenchymal lacerations and de-vascularized segments. If a renal laceration is detected, an additional scan should be obtained at a 10-minute delay to assess the collecting system for urinary extravasation.22

Ultrasound may detect parenchymal injury and perirenal and subcapsular hematomas, but it is unable to demonstrate or exclude active extravasation of blood or urine. For this reason, ultrasound is limited to identifying gross abnormalities of the kidneys. Intravenous pyelography (IVP) has a poor sensitivity for detecting renal and ureteral injuries. In one series, IVP had a 75% false negative rate.23  In another series, 82% of IVPs were indeterminant.24  For this reason, intravenous pyelography has been relegated to situations where CT is not readily available or intraoperatively.25  MRI is considered equivalent to CT for blunt renal trauma and is more able to distinguish peri-renal from intra-renal hematoma. In cases where CT is equivocal, among pregnant patients, or among those with severe contrast allergy, MRI may be considered if available.26

Ureter

Despite advances in imaging, ureteral injury is difficult to diagnose on initial presentation. Multi-Detector CT is thought to be the most sensitive imaging modality for ureteral injury. CT findings suggestive of ureteral injury include extravasation of contrast from the ureter or partial or complete ureteral obstruction. As mentioned previously, the delay between injection of contrast and obtaining MDCT images dictates the site of opacification and/or enhancement. One small series of patients ultimately diagnosed with ureteral injuries included 3 patients who underwent CT with both oral and IV contrast. In that series, a 50 second delay between IV contrast administration and obtaining the imaging failed to demonstrate the ureteral injury and resulted in delay in diagnosis of the injury.27  A later series of patients diagnosed with ureteral injury underwent initial CT with a 60 second IV contrast delay which showed subtle findings suggestive of ureteral injury such as perinephric stranding, fluid surrounding the kidney and/or ureter, and perinephric hematoma. These findings prompted 7 out of 8 cases to obtain delayed/excretory phase imaging which immediately confirmed the ureteral injury by visualizing extravasation of contrast from the ureter.28  In circumstances where ureteral injury is of high clinical suspicion, a 10-minute delay between injection of contrast and obtaining images allows contrast to enter the renal excretory phase. Due to the rarity of ureteral injury, the sensitivity and specificity of CT for ureteral injury in trauma is not known. For this reason, in circumstances where there is a high index of suspicion a repeat, CT scan hours to days later may be beneficial as it may demonstrate a fluid collection where urine has accumulated.28  IVP has little use in diagnosing ureteral trauma due to a high (33%) false-negative rate.26

Bladder

There is debate over the indications for bladder imaging. The Eastern Association for the Surgery of Trauma (EAST) recommends cystography for patients with gross hematuria, pelvic fractures other than acetabular fracture, and/or among patients with fluid in the pelvis.26  Others have suggested that gross hematuria in absence of pelvic fracture, microhematuria with pelvic fracture, and isolated microhematuria be considered relative indications for evaluation of the bladder, with imaging recommended in patients with clinical symptoms such as suprapubic pain or voiding difficulties.29  Due to the high probability of bladder injury, bladder imaging is indicated in trauma patients with both pelvic fracture and gross hematuria.30  If there is blood at the meatus or if a urethral injury is suspected, a retrograde urethrogram to assess the integrity of the urethra must be conducted prior to evaluation of the bladder.

MDCT of the abdomen without cystography, even with a clamped foley and distended bladder, is insufficient to detect bladder injury.31  Cystography is the testing modality of choice to detect bladder injury. Conventional cystography involves obtaining either a minimum of three x-rays or use under fluoroscopy. An initial x-ray of the bladder is performed for comparison. 300-350ml of contrast material is then instilled retrograde into the bladder via a catheter and clamped. A second x-ray is obtained at that point. The catheter is then unclamped, and the patient is asked to void, at which point a third x-ray is obtained. Injury is confirmed by the extravasation of contrast material. Approximately 10% of bladder injuries may identified on the post drainage alone.32  Conventional cystography has an accuracy of 95-100% in diagnosing bladder rupture compared with conventional CT accuracy of 50-60%.33  CT Cystography involves a similar protocol, wherein an initial CT of the abdomen and pelvis is obtained. Thereafter 300-350ml of contrast material is instilled into the bladder retrograde through a catheter and clamped. A repeat CT of the pelvis is then obtained. The catheter is then removed or unclamped, and a third CT of the pelvis is obtained post-void.34  Like conventional cystography, CT cystography demonstrates injury to the bladder via extravasation of contrast. One study compared CT cystography and conventional cystography and found identical sensitivity (95%) and specificity (100%) in detecting and characterizing bladder injuries.35,36  The Eastern Association for the Surgery of Trauma considers CT and conventional cystography to be equivalent.26  In patients whom the cystography is deemed necessary, factors such as availability and radiation dosage will likely drive whether conventional or CT cystography is obtained.

Point of Care Ultrasound (POCUS) has been gaining favor over the past several years, with multiple case reports and small studies showing success in diagnosing bladder rupture at bedside. A retrospective study of 103 patients with polytrauma used ultrasound with retrograde saline instillation to successfully diagnose 20 patients with bladder rupture of 22 patients with features suggestive of bladder rupture, a reported sensitivity of 90%.37

Urethra

There is insufficient evidence to utilize CT to exclude urethral injury. However, CT may be obtained before a retrograde urethrogram is performed and may demonstrate findings suggestive of urethral injury. These common findings include obscuration of the urogenital diaphragmatic fat plane (88% of cases), hematoma of the ischiocavernosus and/or obturator internus muscles (88% of cases), obscuration of the prostatic contour (59% of cases), and obscuration of the bulbocavernosus muscle (47% of cases).22,38

Imaging of the urethra is indicated in all trauma patients presenting with blood at the urethral meatus, inability to void, or in whom there is concern for urethral injury. The absence of blood at the urethral meatus, gross hematuria, and pelvic fractures cannot exclude urethral injury. Additionally, female urethral injuries may present atypically as vaginal bleeding or incontinence and therefore may be easily overlooked.26  Imaging of the urethra is obtained by performing a retrograde urethrogram (RUG). A RUG should be obtained before attempting to catheterize the patient due to the risk of converting a partial urethral tear into a complete tear.30 A RUG is performed either as a series of 3 to 4 x-rays or under fluoroscopy. To perform a RUG the patient is positioned supine with the fluoroscopic C arm or x-ray collimator positioned in the vertical plan at 45 degrees above pelvis with the center just below the symphysis pubis. A 16- or 18-French Foley catheter (some utilize 6- to 10-French catheters) is flushed with radiopaque contrast to remove any air bubbles. The penile glans and urethral meatus should be cleaned with antiseptic. The catheter is then placed with sterile technique just inside the urethral meatus so that the catheter balloon rests in the fossa navicularis. The catheter balloon in filled with 1-2 ml of radiopaque contrast, saline, or water. The balloon should not be overfilled, as this can cause distal urethral rupture. The operator then pulls the penis laterally to straighten the urethra, grasping the penis as distally as possible, and distal to the inflated balloon. A scout film is then obtained before 20-30 ml of radiopaque contrast is gently infused with a catheter tip syringe through the catheter and into the urethra while additional films are obtained. A normal study demonstrates retrograde flow of contrast from the catheter through the anterior and posterior urethra and into the bladder.32,39  Extravasation of contrast or failure of contrast to reflux into the bladder signifies injury. Incomplete urethral tears will show extravasation along with reflux of contrast into the bladder as contrast flows past the defect in the urethra. Complete urethral tears will prevent reflux of contrast past the defect. Injuries are often described as involving the anterior urethra (consisting of the penile and bulbar urethra) or the posterior urethra (consisting of the membranous and prostatic urethra). Typically, if a RUG is indicated, the physician will perform a RUG, and if no abnormalities are found, advance the catheter and perform a conventional cystogram to exclude bladder injury.

POCUS alone is not adequate for diagnosing urethral trauma. Several studies have evaluated penile fracture and penile stricture with sonourethrography (SUR) that suggest POCUS may have a role in evaluating the extent of urethral injury from trauma in the future.40,41  One prospective study compared the ability of sonourethrography and retrograde urethrography to detect male anterior urethra abnormalities, using operative findings as the gold standard. In determining the length and diameter of the stricture, SUR sensitivity and specificity were comparable to, if not outperforming RUG.42  Sonography may also demonstrate hematoma size and the extent of fluid extravasation better than retrograde urethrogram.43

Scrotum & Testicles

Trauma may result in intra- and/or extra-testicular hematomas, hematoceles, testicular torsion, testicular contusion, fracture, or rupture among other injuries.44,45  Due to favorable test characteristics, cost, and availability, ultrasound is the test of choice to detect testicular or scrotal injury. A high-frequency linear transducer using grayscale as well as color and spectral doppler modalities is used to detect injury.45  Sonography has a reported sensitivity of 100% and a specificity of 93.5% for the diagnosis of testicular rupture.46  Ultrasonography is performed with the patient lying supine with the scrotum supported by a towel between the thighs. In patients being evaluated for scrotal trauma, the asymptomatic side is scanned first to establish gray-scale and doppler baseline settings for comparison with the affected side. The entire testis and epididymis are examined in at least two planes (longitudinal and transverse). Transverse images with portions of each testis in the same image should be acquired in gray-scale and color doppler modes to allow comparison of the testes.47  Color and spectral doppler parameters should be optimized to low velocity settings to display blood flow within the testes and the surrounding structures. Spectral doppler tracings should be obtained and recorded in each testis. Power doppler may be used to evaluate patients with acute scrotal pain when minimal flow is detected with color doppler. In addition to static images, cine clips of the scrotum can be obtained for careful scrutiny of the area after the examination.46  Ultrasound affords the operator the ability to locate the defect in the tunica albuginea in real time. The presence of a heterogeneous echotexture and a loss of normal contour (without direct depiction of discontinuity of the tunica albuginea) are sufficient to diagnose testicular rupture with 100% sensitivity and 65.0%–93.5% specificity.48, 49

In patients with inconclusive ultrasound findings, Magnetic Resonance Imaging (MRI) may be considered if it is available. Due to the testicles high soft-tissue contrast and the multiplanar capability of MRI, Kim et al proposed MRI as a potential alternative diagnostic modality for blunt scrotal trauma. In 7 patients with blunt scrotal trauma, the diagnostic accuracy of MRI was 100%. Three cases with testicular rupture were diagnosed accurately, with interruption of the dark signal intensity line of the tunica albuginea being pathognomonic for the diagnosis of testicular rupture. In 2 cases in which there was an inconclusive diagnosis by ultrasonography, diagnoses of epididymal hematomas were correctly made by MRI. The remaining 2 cases showed concordant results with the surgical findings.50  However, testicular rupture is typically managed with surgical exploration and repair, and early operative intervention is associated with improved salvage rates.15  In the setting of an abnormal or equivocal ultrasound, Urology should be consulted before obtaining MRI.

Penis

Penile injury is often diagnosed by history and physical exam. However, dorsal vein thrombosis or rupture or intracavernosal hematoma may mimic penile fracture.51  Because penile injury is associated with urethral injury, exclusion of urethral injury is critical in the evaluation of penile trauma and is mentioned above. Imaging modalities for penile trauma include MRI, ultrasound, and cavernosonography.52  Cavernosonography it is not routinely used to evaluate penile trauma.51  Cost, availability, and time constraints make ultrasound the most pragmatic imaging modality for penile injury.

Ultrasound of the penis is performed with the patient in the supine or lithotomy (frog-leg) position and the penis in the anatomic position, lying on the anterior abdominal wall. Longitudinal and transverse gray-scale and doppler images of the entire length of the penis are obtained with a high-frequency linear transducer. A transperineal approach with elevation of the testes is used to assess the base of the penis.53  A defect in the tunica albuginea and/or an adjacent hematoma is suggestive of penile fracture.51,54

In addition to ultrasound, MRI can demonstrate soft-tissue delineation in evaluation of the integrity of the tunica albuginea, which is hypointense on images obtained with all pulse sequences whether or not a hematoma is present.55  However, surgical repair of blunt trauma to the penis is associated with a lower risk of erectile dysfunction and significant penetrating penile injuries should be explored intraoperatively. To minimize delay and unnecessary costs Urology consultation should be considered prior to obtaining MRI of the penis.15  Many EDs do not have access to MRI, and this test is often not feasible in the ED.

 

Key points

-GU trauma is common, occurring in 10% of traumas.

-The classic teaching of high riding prostate, perineal hematoma, and pain with or inability to urinate is not sensitive for GU trauma.

Gross hematuria should prompt consideration of GU trauma.

Timing of contrast is critical to assessing the GU system for injury.

-Conventional cystography is equally as sensitive as CT cystography.

-A RUG should be performed prior to catheterization among patients with gross hematuria, inability to void, or a high index of suspicion for urethral injury.

Ultrasound is the primary imaging modality for the penis and scrotum.

 

References/Further Reading

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  4. Najibi S, Tannast M, Latini JM. Civilian gunshot wounds to the genitourinary tract: incidence, anatomic distribution, associated injuries, and outcomes. Urology. 2010;76(4):977–81.
  5. Wessells H, Suh D, Porter JR. Renal injury and operative management in the United States: results of a population-based study. J Trauma. 2003; 54(3):423–30.
  6. Best CD, Petrone P, Buscarini M, et al. Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale. J Urol 2005; 173:1202 –1205
  7. Pereira BM, Ogilvie MP, Gomez-Rodriguez JC. A review of ureteral injuries after external trauma. Scand J Trauma Resusc Emerg Med. 2010; 18:6.
  8. Pereira, B.M.T., de Campos, C.C.C., Calderan, T.R.A. et al. Bladder injuries after external trauma: 20 years experience report in a population-based cross-sectional view. World J Urol (2013) 31: 913-917
  9. Bayne D, Zaid U, Alwaal A, Harris C, McAninch J, Breyer B. Lower genitourinary tract trauma. Trauma [serial online]. January 2016;18(1):12-20. Available from: Academic Search Premier, Ipswich, MA. Accessed July 8, 2018.
  10. Koraitim MM, Marzouk ME, Atta MA. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol. 1996; 77(6):876–80.
  11. Chapple C, Barbagli G, Jordan G. Consensus statement on urethral trauma. BJU Int. 2004; 93(9):1195–202.
  12. Lynch TH, Martinez-Pineiro L, Plas E. EAU guidelines on urological trauma. Eur Urol. 2005;47(1):1–15.
  13. Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: a 30-year single institution experience. J Urol. 2008; 180(1):192–5. discussion 195–6.
  14. Cerwinka WH, Block NL. Civilian gunshot injuries of the penis: the Miami experience. Urology. 2009; 73(4):877–80.
  15. American Urologic Associationhttp://www.auanet.org/guidelines/urotrauma-(2014-amended-2017). Published 2014. Updated 2017. Accessed August 17, 2018
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  18. Kawashima A, Sandler CM, Corl FM, et al. Imaging of renal trauma: a comprehensive review. RadioGraphics 2001; 21:557–574
  19. Bretan PN Jr, McAninch JW, Federle MP, Jeffrey RB Jr. Computerized tomographic staging of renal trauma: 85 consecutive cases. J Urol. 1986;136:561-565.
  20. Webb WR, Brant WE, Major NM. Fundamentals of Body CT. Philadelphia, PA: Elsevier Saunders; 2015
  21. Park SJ, Kim JK, Kim KW, et al. MDCT Findings of Renal Trauma. American Journal of Radiology. 2006; 182(2): 541-547
  22. Dayal, Madhukar, Shivanand Gamanagatti, and Atin Kumar. Imaging in Renal Trauma. World Journal of Radiology 5.8 (2013): 275–284. PMC. Web. 7 July 2018.
  23. Bergren CT. Intravenous pyelogram results in association with renal pathology and therapy in trauma patients. The Journal of Trauma. 1987-05;27:515-518.
  24. A.S. Cass, J. Vieira, Comparison of IVP and CT findings in patients with suspected severe renal injury. Urology. 29 (5) (1987) 484-487
  25. Titton RL, Gervais DA, Boland GW, Mueller PR. Renal trauma: radiologic evaluation and percutaneous treatment of nonvascular injuries. AJR 2002; 178:1507 –1511.
  26. EAST Guidelines: Genitourinary Trauma, Diagnostic Evaluation of. https://www.east.org/education/practice-management-guidelines/genitourinary-trauma-diagnostic-evaluation-of. Published 2003. Accessed August 17, 218
  27. Mulligan JM, Cagiannos I, Collins JP et al: Ureteropelvic junction disruption secondary to blunt trauma: excretory phase imaging (delayed films) should help prevent a missed diagnosis. J Urol 1998; 159: 67.
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  4. Sandler CM, Francis IR, Baumgarten DA, et al. Suspected lower urinary tract trauma. In: ACR appropriateness criteria. Reston, VA: American College of Radiology,2007
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