Most patients with significant genitourinary injuries require prompt urologic consultation. The majority of these patients will have additional injuries within the chest, abdomen, or pelvis that will also mandate immediate surgical evaluation. It is extremely rare for the genitourinary tract to be injured in isolation. Therefore, the initial management of genitourinary trauma should not be in isolation either. General trauma management, as explained in other chapters in this book, should be implemented upon arrival in order to identify and treat all life-threatening injuries.

In the intensive care unit (ICU), life-threatening injuries, such as traumatic shattered kidney or urosepsis from bladder rupture, are encountered much more frequently than an isolated injury to the external genitalia. Although situations such as a zipper injury or priapism might be considered a genitourinary emergency in the emergency department (ED), it would be extremely rare for someone to be admitted to an ICU solely under those circumstances. However, attention must be paid to the entire genitourinary system in the ICU. For example, it is more common in the ICU to have a patient with an injury to the external genitalia that accompanies a pelvic fracture. Timely recognition and appropriate treatment of all genitourinary emergencies are vital to minimizing associated morbidity, which may include renal insufficiency, sepsis, incontinence, decreased sexual function, impotence, and infertility. In addition, these less frequently encountered injuries are important because they will be relevant in some way, such as when not to place a Foley catheter in a trauma patient or when to complete a rape kit in a patient with pelvic injuries secondary to physical abuse.

Finally, it is always important to remember that even though the human body and medicine are broken down into systems, such as the genitourinary system, there is considerable overlap among them. Many topics pertaining to the genitourinary system are addressed elsewhere in this book, such as the management of renal failure and sepsis.

The upper genitourinary tract consists of the kidneys and the ureters. Owing to the location of the liver, the right kidney extends lower than the left kidney. Substantial force is necessary to injure the kidneys, given their location and the fact that they are shielded by the lower ribs, back musculature, and perinephric fat. The ureters travel from the renal pelvis on the front of the psoas muscles and insert into the back of the bladder at the trigone.¹ Both the kidneys and ureters are located within the retroperitoneal space.

The lower genitourinary tract consists of the bladder, urethra, and the external genitalia. Because it is a hollow organ, the bladder is compact within the lower pelvis and is relatively protected when empty. However, when filled with urine, the bladder may expand up to the level of the umbilicus, where it is more at risk to injury. The male urethra runs through the prostate gland and is divided into anterior and posterior portions. The female urethra is shorter and more mobile than the male urethra. The male external genitalia are made up of the penis, testicles, scrotum, and the ejaculatory system. The female external genitalia are made up of the vagina, vulva, labia majora, labia minora, and the clitoris.¹

The kidney is the most commonly injured organ of the genitourinary system. Renal injury occurs in approximately 1% to 5% of all traumas.² As explained above, significant force is required to harm the kidneys. Therefore, associated intra-abdominal injuries are also likely to occur. Ninety to 95% of renal injuries are the result of blunt trauma, such as motor vehicle accidents (MVAs), falls, direct blows, lower rib fractures, and bicycle accidents. Most severe are those that involve decelerating forces, which may cause avulsion of the renal pedicle or renal artery dissection.¹ The remainder of renal injuries is due to penetrating injuries, which tend to be more severe, have a higher number of associated organ injuries, and usually result in a higher nephrectomy rate.³ It is important to note that preexisting renal disease makes renal injury more likely following trauma.⁴ The Committee on Organ Injury Scaling of the American Association for the Surgery of Trauma (AAST) has developed a system for classifying the severity of renal injuries (Table 33-1).⁵

Injuries to organs that lie within the retroperitoneal space, such as the kidneys, may be difficult to identify since the area may be isolated from traditional physical examination, and these injuries may not present with signs and symptoms of classic peritonitis. Clinical signs of a potential renal injury are nonspecific and may include pain, bruising, abdominal or flank tenderness, posterior rib or spine fractures, hematuria, or other organ injury or shock. It is important to note that hematuria may not correlate with the degree of injury.⁶ For example, injuries such as ureteropelvic junction disruption, renal pedicle damage, or segmental artery thrombosis may occur without hematuria.⁷ On the other end of the spectrum, patients with preexisting renal disease had a higher degree of macroscopic hematuria, a lower rate of associated trauma to other abdominal organs, and their kidneys were more frequently injured by low-velocity impacts.⁸

In those patients who are hemodynamically stable, a CT scan with intravenous contrast is the modality of choice for the identification and staging of traumatic renal injury, both blunt and penetrating. It also gives a picture of the entire area around the kidney, in particular the retroperitoneum and other neighboring organs and can identify any preexisting lesions.⁹ For the most part, CT scan has replaced intravenous pyelography as the definitive study for suspected renal trauma not involving the ureters. Plain radiographs may identify injuries such as rib, spine, or pelvic fractures, which, as mentioned, may be associated with renal injury.

Outside of a shattered kidney, a major renal vascular laceration, or a massive decelerating mechanism, genitourinary trauma is seldom life threatening. As with all trauma situations, the initial screening of a trauma patient is to identify and manage any potential life-threatening injuries, as addressed in other chapters of this book. Injuries to the kidneys that result in shock, hemodynamic instability, or evidence of continued bleeding are indications for urgent surgical exploration.¹⁰ Delaying surgery in these situations to obtain imaging studies in these patients may be deleterious. Special attention should be paid to penetrating renal injuries, particularly stabs and gunshot wounds. In these patients, if renal injury is clinically suspected or if hematuria is present, surgery should be strongly considered.¹¹ In renovascular injuries, nephrectomy is the treatment of choice unless there is a solitary kidney or the patient has sustained bilateral injuries.¹² The majority of patients with grade IV or grade V renal injury present with major associated injuries, with a resultant higher rate of renal exploration.¹³ Interventional radiology arteriography with selective renal embolization for hemorrhage control is a reasonable alternative to surgery in selected hemodynamically stable patients.¹⁴

Early complications consist of bleeding, infection, abscess, sepsis, urinary fistula, hypertension, urinary extravasation, and urinoma. After approximately 4 weeks, delayed complications include bleeding, hydronephrosis, renal calculi, pyelonephritis, hypertension, arteriovenous fistula, and pseudoaneurysms. If any of these complications are life-threatening, such as bleeding or sepsis, they should be handled immediately as explained elsewhere in the other chapters. Stable bleeding and pseudoaneurysms may be amenable to interventional radiology selective embolization.¹⁵ Perinephric abscess may be drained percutaneously. Any of these complications may warrant reoperation. Acute renal failure may also occur, most commonly in those patients who experience hemodynamic instability.

In hemodynamically stable patients, supportive care with bed rest and hydration is the preferred initial nonsurgical approach and is associated with a lower rate of nephrectomy, without any increase in morbidity.¹⁶ In most cases, grade I and grade II renal injuries can be managed this way. Some studies advocate this treatment for grade III injuries as well.¹⁷

The ureters are small in size, mobile, and in a protected location, which makes injury rare. The majority (75%) of ureteral injuries are iatrogenic, with most occurring during urologic, general surgical, or gynecologic procedures. Blunt injury (18%) is the next most common mechanism; most commonly from a significant deceleration force with avulsion at the ureteropelvic junction resulting from a MVA or fall. The remainder of ureteral injuries are due to penetrating trauma (7%).¹ The AAST has also developed a system for classifying the severity of ureteral injuries (Table 33-2).¹⁸

Ureteral injury should be suspected in all penetrating abdominal injuries and in blunt injuries with a deceleration mechanism. Major intra-abdominal injuries are often associated with ureteral injury. It is important to note that as with renal injury, hematuria is not a consistent finding. Urinalysis is normal approximately 25% of the time.¹⁹ Also, similar to renal injury, signs and symptoms of ureteral injury can be vague. Often, ureteral injury is not discovered until the late findings of fever, flank pain, and a palpable flank mass have set in.

Initial diagnosis of a ureteral injury may be difficult. When a CT scan is used to identify renal injury, it may also be used to identify ureteral injury. It is important to note that time must be allowed in order for the kidneys to excrete the intravenous contrast. When these delayed images are not diagnostic, intravenous pyelography may be used, although sensitivity ranges can vary greatly. Under surgical conditions, the ureters may be directly inspected. Retrograde pyelography may also be useful when the diagnosis is elusive.¹⁹

Partial tears can be managed via ureteral stenting or via a nephrostomy tube for urinary diversion. Injuries above grade III are surgically repaired with debridement, stenting, and reconstruction. The specific type of reconstructive repair depends on the nature and site of the injury.²⁰

Urinary bladder injury may result from either blunt (67%-86%) or penetrating (14%-33%) injury.²¹ Ruptures of the urinary bladder are most frequently seen in multitrauma patients with blunt injuries, particularly following MVAs. The majority of patients with bladder rupture from blunt trauma are linked with pelvic fractures.²² The propensity for bladder injury is related to the degree of distension at the time of impact.²³ When empty, the bladder is relatively protected unless the force of injury fractures the bony pelvis. When distended by urine, the bladder may extend up to the level of the umbilicus, where it is vulnerable to blunt trauma inflicted upon the lower abdomen. In an interesting combination, driving under the influence of alcohol predisposes to both accidents and a distended bladder.²⁴ The AAST has also developed a system for classifying the severity of bladder injuries (Table 33-3).¹⁸