Lower Urinary Tract Trauma

Includes 2020 AUA Guideline Notes on Urotrauma

See Original 2020 AUA Urotrauma Guidelines

See Upper Urinary Tract Trauma Chapter Notes

Bladder Injury

Background

• Bladder rupture can be classified as intraperitoneal (into the peritoneal cavity) vs. extraperitoneal (outside the peritoneal cavity)

• Bladder injuries are:
  • Extraperitoneal in ≈60%
  • Intraperitoneal in ≈30%
  • Both intraperitoneal and extraperitoneal in ≈10%
• Extraperitoneal bladder injury
  • Usually associated with pelvic fracture
• Intraperitoneal bladder injury
  • Can be associated with pelvic fracture but are more commonly due to penetrating injuries or burst injuries at the dome by direct blow to a full bladder.

Pathogenesis

• Penetrating trauma
  • Bladder is generally protected from external trauma because of its deep location in the bony pelvis
• Blunt trauma
  • Most blunt bladder injuries are the result of rapid-deceleration motor vehicle collisions, but many also occur with falls, crush injuries, assault, and blows to the lower abdomen
  • Bladder injuries that occur with blunt trauma are rarely isolated injuries
    • Most common associated injury is pelvic fracture, but pelvic fracture is not often associated with bladder injury
      • 83-95% of bladder injuries are associated with pelvic fractures
      • 5-10% of pelvic fractures are associated with bladder injury
• Iatrogenic
  • Obstetric and gynecologic complications are the most common causes of bladder injuries during open surgery

Grading

• AAST Bladder Injury Scale:
  • Grade I
    • Contusion, intramural hematoma
    • Partial thickness laceration
  • Grade II
    • Extraperitoneal bladder wall laceration <2 cm
  • Grade III
    • Extraperitoneal (>2cm) or intraperitoneal (<2cm) bladder wall laceration
  • Grade IV
    • Intraperitoneal bladder wall laceration >2cm
  • Grade V
    • Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice (trigone)
  • *Advance one grade for multiple lesions up to grade III

Diagnosis and Evaluation

History and Physical Exam

Physical Exam

• Indicators of potential bladder rupture (12):
  1. Gross hematuria
     • Most common indicator of bladder injury
     • A limited number of pelvic fracture patients with bladder injuries will present with microscopic hematuria
  2. Lower abdominal bruising
  3. Abdominal distention
  4. Suprapubic pain
  5. Muscle guarding and rigidity
  6. Inability to void
  7. Low urine output
  8. Diminished bowel sounds
  9. Pubic symphysis diastasis
  10. Obturator ring fracture displacement >1 cm
  11. Increased creatinine and BUN (secondary to peritoneal absorption of urine)
  12. Intraperitoneal low density free fluid on abdominal imaging (urinary ascites)

Imaging

• Indications for cystography in stable patients
  • 2020 AUA Guidelines
    • Absolute (1):
      1. Gross hematuria and pelvic fracture
    • Relative (2):
      1. Gross hematuria and a mechanism concerning for bladder injury
      2. Pelvic ring fractures and clinical indicators (see above) of bladder rupture
         • The vast majority of bladder injuries are associated with pelvic fractures because the bladder is well protected within the pelvis, however, pelvic fracture alone does not warrant radiologic evaluation of the bladder
  • Campbell's 11th edition
    • Absolute (2):
      1. Gross hematuria with pelvic fracture
      2. Penetrating injuries with any degree of hematuria
    • Relative (2):
      1. Blunt trauma with gross hematuria without pelvic fracture
      2. Microscopic hematuria with pelvic fracture
• Modality: retrograde cystography (CT or plain film)
  • Critical as it can determine the presence of an injury and whether it is intraperitoneal or extraperitoneal.
  • Plain film and CT cystography have similar specificity and sensitivity, and are both highly accurate for the diagnosis of bladder rupture
  • Technique
    • The bladder should be filled in cooperative and conscious patients to a sense of discomfort and otherwise to 300-350 mL
      • False-negative studies have been reported with retrograde instillation of only 250 mL.
      • In CT cystography, dilution of the contrast (1:6) is mandatory because undiluted contrast is so dense that the CT quality is compromised by scatter artifact.
      • Clamping a Foley catheter to allow excreted IV-administered contrast to accumulate in the bladder is not appropriate.
    • With plain film cystography, a minimum of 2 views are required, the first at maximal fill and the second after bladder drainage.
    • Drainage films are not required after CT cystography because the retrovesical space can be well visualized with axial images.
  • Cystography will demonstrate:
    • Extraperitoneal extravasation: dense, flame-shaped collection of contrast material in the pelvis
      • See Figure
      • See Case
    • Intraperitoneal extravasation: contrast material outlines loops of bowel and/or the lower lateral portion of the peritoneal cavity
      • See Figures
    • The amount of extravasation is not always proportional to the extent of bladder injury.

Management

• If blood is noted at the meatus or the catheter does not pass easily, retrograde urethrography should be performed first because urethral injuries occur concomitantly in 10-30% of patients with bladder rupture
• Based on extraperitoneal vs. intraperitoneal
  • Uncomplicated extraperitoneal bladder ruptures: large-bore (22-Fr) Foley catheter left in place 2-3 weeks
    • In the setting of significant concurrent injuries, it is acceptable to leave the catheter in longer.
    • Campbell’s 11th edition: if a pelvic hematoma is present, antimicrobial agents are started on the day of injury and continued for at least 1 week to prevent infection of the hematoma
    • Consideration for open repair may be appropriate in those patients with non-healing bladder injuries who are unresponsive to Foley catheter drainage >4 weeks.
    • Follow-up cystography
      • Should be done to confirm that the injury has healed with catheter drainage
  • Intraperitoneal bladder rupture: prompt surgical repair
    • Failure to repair intraperitoneal bladder injuries can result in peritonitis (from translocation of bacteria from the bladder to the abdominal cavity), sepsis, and other serious complications
    • Repair may need to be delayed in the unstable patient
    • Campbell’s 11th edition: in patients with intraperitoneal rupture, antimicrobial agents are administered for 3 days in the perioperative period only
    • Follow-up cystography
      • Should be done 7-10 days after surgery in complex repairs
      • May not be necessary in more simple repairs
• Indications for immediate surgical repair of bladder
  • 2020 AUA Guidelines(7)§: Immediate Bladder Repair NOVA
    1. Intraperitoneal bladder rupture
    2. Exposed Bone spicules in the bladder lumen
    3. Concurrent Rectal injury; may lead to fistula formation to the ruptured bladder
    4. Bladder Neck injuries; may not heal with catheter drainage alone and repair should be considered
    5. Patient undergoing Open reduction internal fixation; to reduce risk of infection to hardware)
    6. Concurrent Vaginal injury; may lead to fistula formation to the ruptured bladder
    7. Patient undergoing repair of Abdominal injuries, consider performing bladder repair for extraperitoneal bladder injury given that the typical bladder repair can be performed quickly and with little morbidity.
  • Additional indications for immediate repair of bladder injury (Campbell’s 11th edition):
    1. Penetrating or iatrogenic non-urologic injury
    2. Inadequate bladder drainage or clots in urine
    3. Open pelvic fracture
• Surgical management
  • Step by step to repair the bladder
    • Enter the anterior bladder wall
    • Confirm the integrity of the bladder neck and ureteral orifices and consider repair if injured
    • Close the tear intravesically with absorbable suture
    • Note that the perivesical pelvic hematoma should not be disturbed
  • Following surgical repair for bladder injuries, urethral catheter drainage alone without suprapubic (SP) cystostomy is recommended
    • Studies have shown no advantage of combined SP and urethral catheterization
    • Exceptions in which combined SP and urethral catheterization may be considered (3):
      1. Patients requiring long-term catheterization, such as those with severe neurological injuries (i.e., head and spinal cord), those immobilized due to orthopedic injuries
      2. Complex bladder repairs with tenuous closures
      3. Significant hematuria

Urethral injury

Background

• Urethral injuries may be partial or complete disruption of the urethra
• Male urethral injuries are classified as posterior (at or above the membranous urethra) vs. anterior urethra (penile or bulbar urethra)

Pathogenesis

• Posterior injuries
  • Almost exclusively associated with pelvic fractures
    • Urethral injury occurs in ≈10% of males and up to 6% of females with pelvic fractures
      • In females, urethral injuries occur almost exclusively as a result of pelvic fracture
    • The bulbomembranous junction is more vulnerable to injury during pelvic fracture than the prostatomembranous junction because the posterior urethra is densely adherent to the pubis via the urogenital diaphragm and the puboprostatic ligaments
• Anterior injuries
  • May be blunt (e.g., straddle injuries, where the urethra is crushed between the pubic bones and a fixed object) or penetrating, and the urethra may be lacerated, crushed, or disrupted.
  • Most commonly involves bulbar urethra since it is most susceptible to compressive injury due to its fixed location beneath the pubis

Grading

• See AAST Urethra Injury Scale

Diagnosis and Evaluation

History and Physical Exam

Physical Exam

• Indicators of urethral trauma (5):
  1. Blood at the urethral meatus
     • Most common finding
  2. Inability to urinate
  3. Perineal/genital ecchymosis
  4. In males, high-riding prostate on physical exam
  5. In females, labial edema and/or blood in the vaginal vault
• If Buck’s fascia disrupted, blood and urinary extravasation into the scrotum may occur
  • Recall, Colle’s, Scarpa’s and Dartos are continuous.
  • If Buck’s fascia (deep to Dartos) is disrupted, urine will travel outside Buck’s but below Dartos in penis, up into scrotum below dartos layer and up abdominal wall below Scarpa’s. The posterior limit is Colle’s fascia. This pattern describes the “butterfly” urinoma/hematoma
    • See Figure

Imaging

• Modality: retrograde urethrogram (RUG)
  • See figure of retrograde urethrogram of traumatic proximal urethral injury
  • Should be performed immediately when urethral injury is suspected
    • May demonstrate partial or complete urethral disruption, providing guidance for how to best manage bladder drainage in the acute setting
    • Blind catheter passage prior to RUG should be avoided, unless exceptional circumstances indicate an attempt at emergent catheter drainage for monitoring
      • Patients with pelvic fracture urethral injury (PFUI) are often unable to urinate due to their injuries. Trauma resuscitations typically involve aggressive hydration and a critical need to closely monitor patient volume status
      • In the acute setting of a partial urethral disruption, a single attempt with a well-lubricated catheter may be attempted by an experienced team member.
  • Technique
    1. Position the patient obliquely with the bottom leg flexed at the knee and the top leg kept straight
       • If severe pelvic or spine fractures are present, leaving the patient supine and placing the penis on stretch to acquire the image is appropriate.
    2. Introduce a catheter tipped syringe or a 12Fr Foley catheter into the fossa navicularis
    3. Place the penis on gentle traction
    4. Inject 20-25 mL undiluted water-soluble contrast material and capture images
  • Occasionally a Foley catheter has been placed before evaluating the urethra
    • If no meatal blood is present and suspicion of injury is low, further imaging is not warranted.
    • If blood is present, a pericatheter RUG should be performed to identify potential missed urethral injury.
      • A pericatheter RUG can be done by injecting contrast material through a 3Fr catheter or angiocatheter held in the fossa navicularis to distend the urethra and prevent contrast leak per meatus.

Other

• Endoscopy
  • In female patients with suspected urethral injury, direct inspection by urethroscopy is suggested in lieu of RUG

Management

• Regardless of the type of injury, securing catheter drainage of the bladder is the immediate goal of treatment.
• Blind catheter passage prior to retrograde urethrogram should be avoided, unless exceptional circumstances indicate an attempt at emergent catheter drainage for monitoring.§
  • If retrograde urethrogram demonstrates partial urethral disruption (contrast passes proximal to site of injury), then a a single attempt with a well-lubricated catheter may be attempted by an experienced team member

Male

Posterior injuries

• Pelvic fracture urethral injury: immediate suprapubic tube (percutaneous or open) with delayed repair
  • Immediate
    • Suprapubic tube
      • Remains the gold standard for urinary drainage
      • Technique
        • If the bladder is displaced due to pelvic hematoma, bladder localization techniques such as aspiration with an 18 G spinal needle or imaging with ultrasound or fluoroscopy may facilitate percutaneous SPT insertion.
        • 14 Fr or larger Foley catheter is preferred
      • May be placed in patients undergoing open reduction internal fixation (ORIF) for pelvic fracture
        • No evidence to indicate that SPT insertion increases the risk of orthopedic hardware infection.
    • Primary realignment
      • Refers to advancing a urinary catheter across the ruptured urethra
      • May require two urologists to navigate the urethra simultaneously from above and below with multiple flexible or rigid cystoscopes, video monitors, and fluoroscopy.
      • May be associated with less severe urethral strictures compared to patients undergoing suprapubic tube alone; however, has been associated with a longer clinical course due to multiple procedures required for recurrent obstruction over an extended timeline.
      • Even if primary alignment successful, patients with pelvic fracture associated urethral injury are at high risk for developing urethral stricture, and suprapubic tube drainage should be maintained while awaiting resolution of PFUI.
    • Primary realignment vs. suprapubic tube
      • The Emergency Department setting is inappropriate for primary realignment of most PFUI.
      • Prolonged attempts at endoscopic realignment in patients with PFUI should be avoided.
    • Immediate sutured repair of posterior urethral injury
      • Associated with unacceptably high rates of erectile dysfunction and urinary incontinence
  • Delayed reconstruction
    • Most PFUI patients will develop obliterative strictures which are amenable to open posterior urethroplasty
    • Posterior urethroplasty can be undertaken safely at 3 months, provided that the patient is ambulatory and associated injuries are stabilized
      • In posterior urethral disruption, the rupture defect between the two severed ends fills with scar tissue, resulting in a complete lack of urethral continuity.
        • This separation is not a stricture; it is a true urethral rupture defect filled with fibrosis.
      • The scar tissue at the urethral disruption site is stable enough at 3 months to allow repair
    • Prior to repair, a cystogram and retrograde urethrogram should be obtained to delineate the characteristics of the urethral rupture defect
    • Surgical management
      • Approach
        • Open perineal anastomotic posterior urethroplasty
          • Posterior urethral reconstruction including excision of the fibrotic segment with distal urethral mobilization and primary anastomosis is associated with the best long-term outcomes after urethral disruption
            • Preferred treatment for most urethral distraction injuries because it definitively cures the patient without the need for multiple procedures.
          • It is important to limit the lithotomy time to ≤5 hours to prevent lower extremity complications when any complex urethral reconstruction is undertaken
        • Endoscopic (e.g. direct-vision internal urethrotomy)
          • Best reserved for selected short urethral stenoses, such as partial distraction injuries for which early catheterization achieved urethral continuity.
            • AUA urethral stricture guidelines recommend urethroplasty over endoscopic management of strictures related to PFUI.
      • Complications of posterior urethral injury and it's repair (3):
        1. Urethral stricture
        2. Erectile dysfunction
        3. Incontinence
        • Patients should be followed for at least 1 year following urethral injury to monitor for development of complications
          • Surveillance strategies for stricture recommended for the first year after injury include uroflowmetry, retrograde urethrogram, cystoscopy, or some combination of methods.
          • Stricture can be treated with urethroplasty or direct vision internal urethrotomy
        • After posterior urethroplasty, 5-15% of patients have recurrent stenosis at the anastomosis
        • Impotence and incontinence are generally considered to be caused by the pelvic fracture itself rather than contemporary interventions for PFUI.
        • Incontinence rates after reconstruction are low (<4%)

Anterior injuries

• Contusions and incomplete injuries: urethral catheter diversion alone
• Straddle injury to the anterior urethra: suprapubic tube (or primary realignment, in less severe cases) with delayed repair
  • With straddle injury, immediate operative intervention with to repair or debride the injured urethra is contraindicated due to the indistinct nature of the injury border.
  • Stricture formation after straddle injury is very high and thus all patients require follow-up surveillance using uroflowmetry, retrograde urethrogram and/or cystoscopy.
  • Delayed anastomotic urethroplasty is the procedure of choice in the totally obliterated bulbar urethra after a straddle injury
• Penetrating trauma: prompt surgical repairs should be performed in patients with uncomplicated penetrating trauma of the anterior urethra
  • Spatulated primary repair of uncomplicated injuries in the acute setting offers superior outcomes to delayed reconstruction.
    • This is in contrast to PFUI or straddle urethral injuries where delayed reconstruction is recommended.
  • Surgical repair should not be undertaken if the patient is unstable, the surgeon lacks expertise in urethral surgery or in the setting of extensive tissue destruction or loss

Female

• Urethral disruption related to pelvic fracture: immediate primary repair, or at least urethral realignment over a catheter
  • Avoids subsequent urethrovaginal fistulae or urethral obliteration
  • Delayed reconstruction is problematic in females because the urethra is too short (≈4 cm) to be amenable for mobilization during an anastomotic repair when it becomes embedded in scar

External Genitalia Injury

Background

• Traumatic injuries to the genitalia are uncommon, in part because of the mobility of the penis and scrotum
• Ancillary psychological, interpersonal, and/or reproductive counseling and therapy should be considered for patients with genital trauma when loss of sexual, urinary, and/or reproductive function is anticipated.

Penile trauma

Penile fracture

Definition

• Penile fracture: disruption of the tunica albuginea with rupture of the corpus cavernosum

Pathogenesis

• Most commonly occurs during vigorous sexual intercourse, when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury.
  • Campbell's 11th edition: In the Middle East, self-inflicted fractures predominate owing to the practice of taqaandan, in which the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence.
  • Review article
    • 21 studies from Middle East and Central Asia published 2003-2014
    • Results:
      • Etiologies of penile fracture
        • Vigorous sexual intercourse (41%)
        • Manual bending of erect penis (29%)
        • Vigorous masturbation (10%)
        • Rolling over in bed (14%)
        • Blunt trauma (6%)
    • Majzoub, Ahmad A., and Talib A. Raidh Onder Canguven. "Alteration in the etiology of penile fracture in the Middle East and Central Asia regions in the last decade; a literature review." Urology annals 7.3 (2015): 284.
• When the erect penis bends abnormally, a laceration can occur and it is usually
  1. On proximal shaft, distal to the suspensory ligament
  2. Transverse
  3. Unilateral
     • Tears in both corporeal bodies occur in 10% of injuries.
  4. Ventral or lateral
     • Tunica albuginea is the thinnest between the 5 o’clock and 7 o’clock positions
     • Recall that Peyronie's Disease usually occurs dorsally
     • Laceration location in manual bending will depend on direction of bend
  5. 1-2 cm in length

Diagnosis and Evaluation

• Diagnosis of penile fracture can me made reliably by history and physical exam

History and Physical Exam

• History
  • Indicators of penile fracture
    1. Penile ecchymosis or swelling
    2. Cracking, popping, or snapping sound during intercourse or manipulation and immediate detumescence.
• Physical exam
  • Penis
    • Swollen
    • Ecchymotic
      • If Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical “eggplant deformity.”
      • If Buck fascia is disrupted, the hematoma can extend to the scrotum, perineum, and suprapubic regions (see above “butterfly hematoma”).
    • Fracture line in the tunica albuginea may be palpable
    • Deviates to the side opposite the tunical tear because of hematoma and mass effect

Imaging

• Indication (1)
  • History and physical examination are equivocal for penile fracture
    • Usually unnecessary as diagnosis can often be made based on history and physical exam
• Options (2):
  1. Ultrasound (preferred)
     • Preferred over MRI because it is rapid, readily available, noninvasive, inexpensive, and accurate
     • Most useful for ruling out fracture in patients with low clinical suspicion or to identify the location of the tear, potentially guiding the choice of incision
  2. Penile-perineal MRI
     • Most accurate test
     • Can be considered if ultrasound equivocal to prevent unnecessary surgical exploration.
  • Both penile Doppler and cavernosography have very high false negative rates and are not recommended in the evaluation of suspected penile fracture. [SASP 2016]
• If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed

Other

• Urethral evaluation (urethroscopy or retrograde urethrogram)
  • Urethral injury occurs in 10-22% of cases of penile fracture
    • Bilateral corporeal injuries are more commonly associated with urethral injury
  • Indications
    • Penile fracture or penetrating trauma with
      1. Blood at the urethral meatus
      2. Gross hematuria
      3. Inability to void

Management

• Suspected penile fractures should be promptly explored and surgically repaired
• Surgical reconstruction results in (7):
  1. Faster recovery
  2. Decreased morbidity
  3. Lower complication rates
  4. Lower risk of erectile dysfunction
  5. Lower incidence of long-term penile curvature
  6. Reduced risk of cavernosal diverticulum (may be pulsatile)
  7. Reduced risk of chronic penile pain
• Surgical delay of up to 7 days after the time of injury does not adversely affect the results of repair

Technique

• Approach (2)
  1. Ventral vertical penoscrotal incision
     • Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.
  2. Distal circumcising incision
     • May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.
• See Video
• Equipment
  • Sutures
    • 2-0 or 3-0 PDS
    • 3-0 Vicryl
    • 4-0 Chromic
  • Penrose to use as tourniquet
  • Injectable saline with methylene blue
  • 25 Gauge butterfly needle
  • Local anesthetic
• Step by step with distal circumcising incision
  • Place holding stitch on dorsal aspect of glans, close to coronal sulcus.
  • Hold penis on stretch
  • Use marking pen to denote a circumferential incision approximately 2cm proximal to the coronal sulcus
    • Skin will need to be very dry for ink to be applied properly
  • Use a scalpel to cut down on incision.
    • Cut down to level of Buck's fascia
    • Be careful near urethra
  • Place holding stich at 12 o'clock on cut penile skin edge.
  • Deglove penis
    • Use Metzenbaum scissors to dissect skin off of tunica albuginea. Use closed scissors and then spread. Then cut attachments.
      • Be careful near urethra
    • Use gauze for blunt dissection
    • Continue to deglove penis until area of fracture is exposed
  • Evacuate hematoma
    • Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated
  • Identify defect
    • Proximal corpora is the most common site of rupture
      • Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration♦
    • Laceration usually transverse in direction
    • Obtain adequate exposure of defect
  • Repair defect
    • Repair defect in tunica albuginea with interrupted 2-0 or 3-0 PDS sutures.
  • If urethral injury
    • Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter
    • Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter
  • Test repair
    • Apply tourniquet proximal to repaired defect
    • Use a 25 Gauge butterfly needle to inject saline mixed with methylene blue into the corporal body distal to the defect
    • If leak noted, place additional interrupted sutures.
  • Repair Buck's fascia overlying defect
  • Obtain hemostasis
  • Reduce foreskin and reapproximate cut edges of skin with 4-0 chromic
    • Start by placing stitches in 4 corners and leave tails long to use as handle
      • Place box/U stitch in area of frenulum
    • Position penis using stay stitches to align skin edges and perform interrupted stitches
  • Penile block
    • Dorsal penile nerve block
    • Ring block
  • Apply dressing
• Post-operative management
  • Therapy with broad-spectrum antibiotics
  • 1 month of sexual abstinence

Gunshot wounds

• Treatment principles include immediate exploration, copious irrigation, excision of foreign matter, antibiotic prophylaxis, and surgical closure.
• Urethral injuries resulting from
  • Low-velocity penetrating trauma should be closed primarily by use of standard urethroplasty principles.
  • High-velocity penetrating trauma or close-range shotgun blasts associated with extensive tissue damage from may require staged repair and suprapubic urinary diversion

Bites

• Dog bites
  • Initial management includes copious irrigation, debridement, and immediate primary closure (with a drain) along with prophylactic use of a broad-spectrum antibiotic (amoxicillin/clavulin, cefoxitin, cefotan, or clindamycin with ciprofloxacin).
    • Tetanus and rabies immunizations should be used as appropriate.
• Human bites
  • Human bites produce contaminated wounds that often should not be closed primarily, unlike animal bites.

Amputation

• A rare injury that is usually self-inflicted and associated with extreme mental illness.
• Every attempt should be made to locate, clean, and preserve the severed portion in a “double bag” technique.
  • The distal penis should be rinsed in saline solution, wrapped in saline-soaked gauze, and sealed in a sterile plastic bag, and the bag should be placed into an outer bag with ice or slush.
• Patients should be transferred to a facility with microsurgical capabilities
  • Reconstruction of the urethra and reanastomosis of the corporeal bodies with microsurgical repair of dorsal penile vessels and nerves achieves remarkably good results. Reanastomosis of the corporeal arteries is not recommended.
    • Macrovascular reconstruction alone can preserve erectile function, glans vascularity, and urethral continuity.
    • Microvascular re­ anastomosis is required for preservation of skin (dorsal artery and vein re-anastomosis) and sensation (dorsal nerve re-anastomosis).
    • Macrovascular or microscopic reconstruction of the penile shaft provides equivalent outcomes for erectile function.
  • If such a facility is unavailable, macroscopic anastomosis of the urethra and corporeal bodies can be performed with good erectile results, albeit with potential compromise of sensation and skin loss.
• Successful reimplantation is possible
  • < 16 hours of cold ischemia time OR
  • < 6 hours of warm ischemia

Zipper injuries

• Risk factors
  • Usually occur in impatient boys or intoxicated men.
• Management
  • After a penile block, the zipper slider and adjacent skin can be lubricated with mineral oil, followed by a single attempt to unzip and untangle the skin. If this fails, a bone cutter or similar tool can be used

Testicular trauma

• Testicular rupture must be considered in all cases of blunt scrotal trauma
  • Blunt scrotal trauma may lead to rupture of the tunica albuginea of the testicle.

Diagnosis and Evaluation

History and Physical Exam

• History
  • Most patients complain of exquisite scrotal pain and nausea.
    • ≈5% of spermatic cord torsions are believed to be precipitated by trauma; torsion should be considered in all cases of significant scrotal pain without signs or symptoms of major scrotal trauma
• Physical exam
  • Clinical examination of the scrotum following trauma can be limited due to significant scrotal swelling and patient discomfort
  • Swelling and ecchymosis are variable, and the degree of hematoma may not correlate with the severity of testicular injury; absence does not entirely rule out testicular rupture, and contusion without fracture can manifest as significant bleeding.
  • Scrotal hemorrhage and hematocele along with tenderness to palpation often limit a complete physical examination.
  • A nonpalpable testis in a trauma patient should raise the possibility of dislocation outside the scrotum. Manual or surgical reduction of the displaced testis is indicated.

Imaging

• Modality: ultrasound
  • Can reliably diagnose testicular rupture with a high level of accuracy in the setting of blunt scrotal trauma.
    • The utility of scrotal ultrasound for the evaluation of testicular rupture in the setting of penetrating scrotal trauma is limited.
  • Ultrasound findings suggestive of testicular fracture include (2):
    1. Heterogeneous pattern of the testicular parenchyma
    2. Disruption of the testicular contour/tunica albuginea
  • A normal or equivocal ultrasound study should not delay surgical exploration when physical examination findings suggest testicular damage; definitive diagnosis is often made in the operating room.

Management

• Minor scrotal injuries without testicular damage may be managed with ice, elevation, analgesics, and irrigation and closure.
• Indications for scrotal exploration (6):
  1. Imaging findings of testicular rupture
  2. Equivocal imaging but suspected testicular rupture
  3. Large hematoma
     • Should be explored and drained even in the absence of testicular rupture to prevent progressive pressure necrosis and atrophy, delayed exploration, and orchiectomy.
  4. Clear physical findings of testicular rupture
  5. Penetrating scrotal injuries
     • Inspect for testicular, vascular and vasal injury; >50% will have testicular rupture
       • The injured vas should be ligated with nonabsorbable suture, and delayed reconstruction should be performed if necessary
     • ≈30% of gunshot wounds injure both testes, and exploration of the contralateral testis should be considered, depending on the findings of physical examination and the path of the projectile
  6. Significant hematoceles (not in 2020 AUA guidelines)
     • Up to 80% are caused by testicular rupture
• Early exploration and repair of testicular injury is associated with (6):
  1. Increased testicular salvage rates
     • Salvage rates with exploration and repair within 72 hours of injury: >90%
       • Orchiectomy rates 3-8x higher with conservative management and delayed surgery
       • Recall
         • Penile fracture: repair within 7 days does not adversely affect outcomes
         • Ischemic priapism: shunting procedure is considered within 72 hours of onset
  2. Reduced ischemic atrophy
  3. Reduced risk of infection
  4. Preservation of fertility and hormonal function
  5. Reduced convalescence and disability
  6. Faster return to normal activities
• Technique
  • Incision: transverse scrotal incision is preferable in most cases.
  • The tunica albuginea should be closed with small absorbable sutures after removal of necrotic and extruded seminiferous tubules.
  • Every attempt to salvage the testis should be performed; loss of capsule tissue may require removal of additional parenchyma to allow closure of the remaining tunica albuginea.
    • A flap or graft of tunica vaginalis may be used to cover a large defect in the tunica albuginea in an otherwise salvageable testis
    • Orchiectomy is performed when the testicle non-salvagable
• Males with a solitary testis
  • Testicular injuries are exceedingly rare in boys involved in individual or team contact sports and recreational activities.
  • Parents of boys with a solitary testis should be appropriately counseled, and a protective cup device should be recommended.

Genital skin loss

• Most common cause of extensive genital skin loss: necrotizing gangrene secondary to polymicrobial infection in the genital area, or Fournier gangrene
• In patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical), perform exploration and limited debridement of non-viable tissue
  • Genital skin is well vascularized and tissues with marginal viability may survive due to collateral blood flow.
  • Typically, these injuries require multiple procedures in the operating room prior to definitive reconstructive procedures.
  • Wound management can include a variety of methods including gauze dressings with frequent changes, silver sulfadiazine or topical antibiotic and occlusive dressing, or negative pressure dressings.
  • If a urethral catheter is used in a genitalia burn, it should be removed after 72 hours to prevent urethral slough and fistula formation
  • Reconstructive techniques for definitive repair include primary closure and advancement flaps, placement of skin grafts, free tissue flaps, and pedicle based skin flaps

Penile reconstruction

• Thick (0.012- to 0.015-inch), non-meshed, split-thickness skin grafts are preferred for penile reconstruction.
  • Meshed grafts can be used but have a tendency to contract and are cosmetically inferior to unmeshed grafts.
• If grafts are to be used, care must be taken to remove any subcoronal skin remaining after debridement. Lymphatic obstruction of this distal foreskin, if it is not excised, results in circumferential lymphedema
• A foreskin flap is the best option for coverage of acute penile skin loss for small distal lesions
• Skin grafts placed on the penile shaft never regain normal sensation, although sexual function is often preserved because of intact sensation in the glans

Scrotal reconstruction

• Scrotal skin loss defects of up to 50% can often be closed directly.
• Meshed, split-thickness skin grafts are preferred for scrotal reconstruction
• For extensive injuries, the testes may be placed in thigh pouches treated with wet dressings, or placed under vacuum pressure dressings until reconstruction.
  • In cases of infection, thigh pouches are not recommended initially, until the infection is stabilized, because transmission of the infectious process into uninvolved tissues may occur.

Questions

1. What percentage of traumatic bladder injuries are extraperitoneal? Intraperitoneal? Which is more likely with pelvic fracture?
2. What are the indications for imaging in a stable patient with suspected bladder trauma?
3. What are clinical indicators of bladder rupture?
4. In an unconscious patient, what is the minimum volume that should be instilled into the bladder on CT cystography to rule out injury?
5. What proportion of patients with bladder injury also have urethral injury?
6. What is the management of bladder injury?
7. When is cystography needed following management of bladder injury?
8. As per the AUA Guidelines on Urotrauma, what are the indications for immediate surgical treatment of an extraperitoneal bladder injury?
9. What clinical findings are suggestive of urethral trauma?
10. What is the next step in management of a patient with suspected urethral injury?
11. Describe how a retrograde urethrogram is performed in a patient with suspected urethral trauma.
12. Retrograde imaging demonstrates posterior urethral disruption in the context of a pelvic fracture. What is the recommended management?
13. What are potential complications of urethral injury?
14. Retrograde imaging demonstrates anterior urethral disruption in the context of penetrating trauma. What is the preferred management?
15. Retrograde imaging demonstrates anterior urethral disruption in the context of straddle trauma. What is the preferred management?
16. What is the earliest timing that urethral reconstruction should take place after PFUI?
17. Which part of the urethra is most likely to be injured in a straddle injury?
18. What are the benefits to surgical repair of suspected penile fracture? Up to how many days after fracture should surgical repair still be considered?
19. What are the benefits of early exploration and repair of testicular injury

Answers

1. What percentage of traumatic bladder injuries are extraperitoneal? Intraperitoneal? Which is more likely with pelvic fracture?
   • 60% extraperitoneal, 30% intraperitoneal, 10% both
   • Extraperitoneal
2. What are the indications for imaging in a stable patient with suspected bladder trauma?
   • MUST: gross hematuria with pelvic fracture
   • Should: gross hematuria with mechanism concerning for bladder injury OR pelvic fracture and clinical indicators of bladder rupture
3. What are clinical indicators of bladder rupture?
   1. Gross hematuria
   2. Abdominal distention
   3. Lower abdominal bruising
   4. Suprapubic pain
   5. Muscle guarding and rigidity
   6. Inability to void
   7. Low urine output
   8. Diminished bowel sounds
   9. Increased BUN and creatinine secondary to peritoneal absorption of urine
   10. Low density free intraperitoneal fluid on abdominal imaging (urinary ascites)
4. In an unconscious patient, what is the minimum volume that should be instilled into the bladder on CT cystography to rule out injury?
   • 300mL
5. What proportion of patients with bladder injury also have urethral injury?
   • 10-30%
6. What is the management of bladder injury?
   • Intraperitoneal bladder rupture: surgical repair
   • Extraperitoneal bladder rupture: foley catheter drainage x2-3 weeks, may need for longer
7. When is cystography needed following management of bladder injury?
   • Extraperitoneal: should be done in complex repairs but may not be needed in simple repairs
   • Intraperitoneal: should be done
8. As per the AUA Guidelines on Urotrauma, what are the indications for immediate surgical treatment of an extraperitoneal bladder injury?
   1. Exposed bone spicules in the bladder lumen
   2. Concurrent rectal or vaginal lacerations
   3. Bladder neck injuries
   4. Patient is undergoing open reduction internal fixation
   5. Patient is undergoing repair of abdominal injuries
9. What clinical findings are suggestive of urethral trauma?
   1. Blood at the meatus
   2. Inability to urinate
   3. Perineal/genital ecchymosis
   4. High-riding prostate on physical exam
10. What is the next step in management of a patient with suspected urethral injury?
    • Retrograde urethrogram
11. Describe how a retrograde urethrogram is performed in a patient with suspected urethral trauma.
    • Patient is positioned obliquely with bottom leg flexed at the knee and the top leg kept straight
    • 12Fr catheter or catheter tip syringe is placed in the fossa navicularis
    • 20mL of undiluted water soluble contrast is injected
    • Image is acquired
12. Retrograde imaging demonstrates posterior urethral disruption in the context of a pelvic fracture. What is the recommended management?
    • Suprapubic tube with delayed repair
13. What are potential complications of urethral injury?
    • Urethral stenosis, incontinence, erectile dysfunction
14. Retrograde imaging demonstrates anterior urethral disruption in the context of penetrating trauma. What is the preferred management?
    • Prompt surgical repair
15. Retrograde imaging demonstrates anterior urethral disruption in the context of straddle trauma. What is the preferred management?
    • Prompt urinary drainage
16. What is the earliest timing that urethral reconstruction should take place after PFUI?
17. Which part of the urethra is most likely to be injured in a straddle injury?
18. What are the benefits to surgical repair of suspected penile fracture? Up to how many days after fracture should surgical repair still be considered?
19. What are the benefits of early exploration and repair of testicular injury

References

• Morey, Allen F., et al. "Urotrauma guideline 2020: AUA guideline." The Journal of urology 205.1 (2021): 30-35.
• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 2, chap 101