TraumaHigh-yieldUpdated Aug 202632 min read

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Renal Trauma

Epidemiology / Pathogenesis

Most commonly injured GU organ in trauma
Prone to deceleration injury (falls, MVC) — kidney fixed only by renal pelvis + vascular pedicle
Pediatric kidney more susceptible — ↓ protective mechanisms: pliable thoracic cage, weaker abdominal muscles, less perirenal fat, lower abdominal position
- Children carry up to a 50% higher risk of renal trauma than adults after blunt abdominal injury, and a 33% higher risk of high-grade injury
- Also: larger kidney relative to body size, non-ossified ribs and less rib coverage; a high catecholamine output that maintains blood pressure until roughly 50% of blood volume is lost; and more congenital abnormalities (severe hydronephrosis, UPJ obstruction) where minor trauma causes significant injury

History / Physical Exam

Primary survey: ABCDE + X-rays (pelvis, chest, C-spine), cross-match and labs. Secondary survey: AMPLE (Allergy, Medications, Past history, Last meal, Events) + Foley catheter
Take the initial urine sample for urinalysis BEFORE fluid resuscitation — resuscitated urine is diluted and gives a false-negative
Events worth asking: seat belt · ejected from the vehicle · speed · driver or passenger · height of fall · size of weapon · loss of consciousness · able to void · able to walk
Extent of deceleration = most important info in blunt injury
Anterior to axillary line → hilum/pedicle injury; posterior → parenchymal injury
Exam findings (5): flank hematoma, abdominal/flank tenderness, rib fractures, hematuria, penetrating injury to low thorax/flank
- Ipsilateral rib fracture → 3× risk of significant renal trauma
- Degree of hematuria does not correlate with injury severity — don't use as sole determinant

Imaging — indications

Gross hematuria
Microscopic hematuria + SBP <90 mmHg
Mechanism concerning for renal injury (rapid deceleration, blow to flank)
Exam findings concerning for renal injury (rib fracture, flank ecchymosis)
Penetrating injury of abdomen/flank/lower chest
Any pediatric patient with more than 5 RBCs/HPF
- Adults with microscopic hematuria, no shock and a non-suggestive mechanism can be observed without imaging — this does NOT extend to children

Imaging — modality

CT abdomen/pelvis with IV contrast + immediate AND delayed images
Children → US may be used, but CT preferred
OR without prior CT → intraop one-shot IVP (2 mL/kg bolus, single image at 10–15 min) to confirm contralateral functioning kidney
Major CT limitation: cannot define renal venous injury → medial hematoma suggests venous injury (no modality reliably diagnoses)
FAST has poor specificity for renal injury in the adult — limited by obesity, subcutaneous air and prior abdominal surgery. It can confirm two kidneys and detect a retroperitoneal collection, but cannot differentiate a hematoma from a urine leak
If CT urography does not visualize the ureter, add cystoscopy and retrograde pyelography

CT findings suspicious for significant injury (6)

Medial laceration
Medial hematoma (vascular pedicle injury)
Medial urinary extravasation (renal pelvis / UPJ injury)
Hematoma >3.5 cm
Lack of parenchymal enhancement (main renal artery injury)
Active intravascular contrast extravasation (brisk arterial bleed)

Fluid collection density: Hematoma >30 HU | Urinoma 0–20 HU | Abscess = rim enhancement (rare post-trauma)

AAST Renal Injury Scale

Grade	CT criteria
I	Subcapsular hematoma and/or parenchymal contusion, no laceration
II	Perirenal hematoma confined to Gerota; laceration ≤1 cm, no urinary extravasation
III	Laceration >1 cm without collecting system rupture/extravasation; OR vascular injury (pseudoaneurysm/AVF) or active bleed contained within Gerota
IV	Laceration into collecting system with urinary extravasation; OR renal pelvis laceration / complete UPJ disruption; OR active bleed beyond Gerota; OR segmental vein/artery injury; OR segmental/complete infarction (thrombosis, no active bleed)
V	Main renal artery/vein laceration or hilar avulsion; OR devascularized kidney with active bleed; OR shattered kidney

Advance one grade for bilateral injury up to grade III

Separating grade IV from grade V on CT: if there is contrast around the kidney it is at least grade IV. Then look at the kidney itself — enhancing and not shattered is IV; shattered or non-enhancing is V.

Management

Shift from operative exploration → non-operative management in vast majority
Non-op of blunt injury firmly established; penetrating + high-grade remains debatable

Hemodynamically stable → non-invasive management

Close hemodynamic monitoring, bed rest, ICU admission, blood transfusion (when indicated), imaging (when indicated)
Follow-up CT (after 48 h) indicated for (2): clinical signs of complications (fever, worsening flank pain, ongoing blood loss, distention); deep lacerations (Grade IV–V)
- Grade I–III → low complication risk, routine follow-up CT not advised
Risk factors for bleeding / need for intervention in grade III–IV (3): medial hematoma; hematoma >3.5–4 cm; vascular contrast extravasation
Delayed bleeding can occur up to weeks later, usually within 21 days

Renal artery thrombosis / devascularized kidney

Salvageability window is 8 hours
First line — observation. For unilateral arterial thrombosis, revascularization rarely produces a salvaged or viable kidney; as long as the contralateral kidney is normal, observation is often best
Second — thrombectomy and endovascular stent (disadvantage: coagulopathy and bleeding risk)
Third — surgical exploration (invasive, low salvageability, high risk of nephrectomy)
Reconstruction of the main renal artery is only a primary consideration in a stable patient with a solitary kidney, or with bilateral renal arterial injuries

Hemodynamically unstable → immediate intervention (surgery OR angioembolization)

Immediate intervention if large perirenal hematoma (>4 cm) and/or vascular extravasation with deep/complex laceration (AAST III–V)
Segmental vessel bleeding → angioembolization (effective, minimally invasive)
Unstable despite resuscitation → OR, not angiography
WSES/AAST 2019: non-op for all stable/stabilized; isolated urinary extravasation is NOT an absolute contraindication to non-op

Post-embolization syndrome — self-limiting; in 10% presents with fever, pain, ileus

Conservative management rarely fails within the first 24 hours — about 2.7%. Risk factors for failure: injury grade, non-renal abdominal injuries, penetrating mechanism. Most failures need only a ureteral stent or angioembolization
Monitor blood pressure periodically for up to a year after injury, for the rare instance of acute or delayed renovascular hypertension
Percutaneous nephrostomy is NOT contraindicated
Retrograde stent placement is sometimes impossible — pelvic fracture urethral distraction defect, severe genital trauma preventing urethral access, complete ureteral transection, or fractures preventing lithotomy. Percutaneous nephrostomy with consideration of an antegrade stent is the alternative

Delayed hematuria and flank pain after discharge — AV fistula vs pseudoaneurysm. A venous phase is required to tell them apart.

	Radiological appearance
Pseudoaneurysm	An enhancing mass that flushes out after the arterial phase
Arteriovenous fistula	Communication with the venous system, visible in the arterial phase

Treat with angioembolization

Surgical management

Absolute indications for exploration (distinct from the CT signs of significant injury)

Hemodynamic instability with no or only transient response to resuscitation
Expanding or pulsatile renal hematoma — usually indicates renal artery laceration
Suspected renal vascular pedicle avulsion
Ureteropelvic junction avulsion

Relative indications

Urinary extravasation with significant parenchymal devascularization
Renal injury together with colon or pancreatic injury — higher complication rate if not repaired at the same time, though it may be closely observed after the enteric repair
Arterial thrombosis
Urinary extravasation from a parenchymal injury

The only absolute INTRA-OPERATIVE indication is a pulsatile, expanding retroperitoneal hematoma, suggesting a life-threatening renal artery laceration
By transabdominal approach
- Small bowel mobilized outside surgical field to expose mid-peritoneum
- Incision above the IMA to expose renal veins
- Secure renal vein & retract cephalad to expose renal artery beneath it
- Then secure renal artery
- For large hematoma that may obscure vision → use IMV as a landmark to incise medially
- After securing the renal vessels, the kidney is exposed
- Left kidney exposure → Mattox maneuver
- Right kidney exposure → Cattell maneuver
Limited debridement; suture ligation of bleeders; watertight collecting-system closure; reapproximate parenchyma; omental/Gerota flap coverage; liberal drains
Major renovascular injury + 2 kidneys → speedy nephrectomy (vascular repair salvage rates poor) — if repaired, salvageability is only about 33%; repair with 5-0 non-absorbable suture
Where parenchyma is left open, cover with a pedicled omental flap where possible — its vascular and lymphatic supply promotes healing and lowers delayed bleeding and urinary extravasation; absorbable mesh, peritoneal graft or retroperitoneal fat also work
Hemostatic agents (thrombin-plus-gelatin preparations) have an increasing role in genitourinary trauma
Damage control: pack kidney, return in ~24 h after ICU stabilization (cold/acidotic/coagulopathic)
Unstable + no damage control option → immediate total nephrectomy

Urinary extravasation

Persistent extravasation → urinoma, perinephric infection, renal loss (rare)
Stable + no renal pelvis/proximal ureteral injury suspected → observe (grade IV parenchymal/forniceal extravasation resolves spontaneously >90%)
Intervention indications (4): suspected renal pelvis / proximal ureteral avulsion (large medial urinoma, contrast extravasation without distal ureteral contrast); enlarging/purulent/complex urinoma; complications (fever, infection, pain, ileus, fistula); continued extravasation
Options: ureteral stent (preferred) ± Foley; percutaneous urinoma drain / nephrostomy

Hypertension post-trauma

Rare early, can occur later. Mechanisms (4): renovascular stenosis/occlusion; Page kidney (parenchymal compression by blood/urine); post-trauma AVF; ureteral/UPJ obstruction
RAAS stimulated by partial ischemia. Treat: antihypertensives, observation, rarely nephrectomy

Ureteral Trauma

Epidemiology / Pathogenesis

Rare — 1% of urologic injuries
Causes (3): iatrogenic; external violence (high-speed blunt); penetrating (stab/GSW)
Iatrogenic procedures: hysterectomy 54%, colorectal 14%, ovarian tumor 8%
Ligation is the commonest ureteral injury in gynecologic surgery
External violence causes ureteral damage in <4% of penetrating and <1% of blunt trauma; associated visceral injury is common — small bowel 39–65%, large bowel 28–33%; 10–28% also have a renal injury, ~5% a bladder injury
Injuries during gynecologic laparoscopy cluster around electrosurgical or laser lysis of endometriosis — endometrioma can involve the ureter, adhesions obscure it, and the disease deviates it medially out of position

Mechanisms

Intra-operative: suture ligature · thermal injury · freezing (cryoablation) · sharp cut · crush · devascularization · avulsion
Extra-operative: gunshot · blunt external trauma

Intravenous methylene blue — safety

Dose <2 mg/kg
Avoid in pregnancy, in G6PD deficiency, and in patients taking SSRIs, SNRIs or MAOIs — methylene blue is a potent monoamine oxidase inhibitor and can precipitate serotonin toxicity, and rarely serotonin syndrome and death

Intraoperative ureter assessment

Cystoscopy with retrograde pyelography — most accurate for location and degree
Cystoscopy checking ureteric efflux — efflux can persist with a partial transection, so it does not exclude injury
Ureteroscopy · stenting or catheterization (no resistance suggests no significant injury) · IVP · indigo carmine or methylene blue (IV, into the renal pelvis, or down a stent)
Surgical exploration — direct dissection is the most accurate method; direct inspection especially for high-velocity or thermal injury

Factors that decide the repair: location · mechanism · degree · patient characteristics · the operating surgeon's experience

Endoscopic / iatrogenic

Ureteroscopy over a wire into renal pelvis
Perforation recognized → stop procedure, place stent
Aortoiliac/aortofemoral bypass manipulation → hydronephrosis in 12–20% (benign; steroids if symptomatic)
Prophylactic preop stenting does NOT reduce injury risk (RCT, gyn surgery)

Diagnosis

Imaging: contrast CT with 10-min delayed films (stable, not going directly to laparotomy)
Findings (4): contrast extravasation; lack of distal ureteral contrast; ipsilateral delayed pyelogram; ipsilateral hydronephrosis
No preop imaging → direct inspection at laparotomy

AAST Ureter Injury Scale

Grade	Criteria
I	Contusion/hematoma, no devascularization
II	Laceration <50% transection
III	Laceration ≥50% transection
IV	Complete transection, <2 cm devascularization
V	Avulsion, >2 cm devascularization

Advance one grade for bilateral injury up to grade III

Management

Stable → look for the time window [less than 7 days or more than 7 days]

Early recognition (<7 days):
- URS: perforation → stent 4–6 wks / avulsion → immediate repair
- Thermal / high-velocity contusion → debridement UU
- Small contusion → stent 4–6 wks
- Major pelvic → reimplant ± psoas hitch (6–10 cm) / (4–5 cm) / Boari flap (12–15 cm)
- Major abdominal → reimplant / UU 2–3 cm / TUU
- UPJ → UP (pyeloplasty)
- Loss of entire ureter → ileal ureter / nephrectomy / autotransplant
Late recognition (>7 days):
- Retrograde stent; if failed → antegrade stent; if failed → PCN → then wait 6 wks for final management

By grade and location

Grades I–II — stent or nephrostomy; a JJ stent is better, with a lower stricture risk. With ligation, remove the offending clip or suture first, then stent for 2–6 weeks; follow-up imaging after removal to exclude stricture
- An intact contused ureter found at laparotomy is primarily managed by stenting; a missed contusion presenting later as a leak is managed first by retrograde imaging with stent placement
- A high-velocity gunshot causing distal ureteral contusion is best managed by re-implantation even with no leak, to avoid later necrosis and stenosis. On a second look, a minor intact contusion needs only a stent; a large or severe one means re-implant
Grades III–V, distal — ureteroneocystostomy. No clear advantage to a non-refluxing anastomosis in an adult. Psoas hitch, then Boari flap if short. Stent 6 weeks · urethral catheter 1–2 weeks (some obtain a cystogram before removal) · drain · ultrasound at 4–6 weeks
Grades III–V, mid and proximal — above the iliacs, primary repair over a stent wherever possible. Ureteroureterostomy is best for small ligation and crush injuries when stenting alone is not possible
Grade V — temporize and defer. Ureterocalicostomy · transureteroureterostomy · ileal ureter · autotransplantation · nephrectomy · buccal graft
- Contraindications to transureteroureterostomy: retroperitoneal fibrosis, urothelial malignancy, nephrolithiasis, and abdominal aortic aneurysm
Ureteroscopic avulsion — proximal and mid: immediate ureteroureterostomy, as for a grade IV laceration. Distal: re-implant — do NOT do a ureteroureterostomy in the distal ureter, the ischemic stricture risk is too high

Unstable → temporary urinary drainage, delayed definitive repair (4 options)

Ureteral stent (internal double-J or exteriorized single-J)
Short observation, reoperate when stable (~24 h)
Exteriorize the ureter
Tie off ureter (long silk for ID) + percutaneous nephrostomy

Special scenarios

Contusion → stent; resection + primary repair if severe/large contusion or GSW-related (excise devitalized tissue + adjacent normal ureter for blast effect; spatulate ~5–6 mm at 180° apart)
Delayed diagnosis → stent; if fails/impossible → percutaneous nephrostomy + delayed repair
- Immediate repair if: injury near closed viscus (bowel/vagina); patient re-explored for other reasons
Endoscopic injury → stent ± nephrostomy
Ureterovaginal fistula → stent (success 64–100%); failures → reimplant ± Boari/psoas hitch or TUU
Ligation → remove ligature, observe viability; uncertain → ureteroureterostomy or reimplant
Ureteroarterial fistula → catastrophic, diagnose + treat immediately (life-threatening hematuria)

Principles of repair

Mobilize sparing adventitia; debride minimally until edges bleed (esp. GSW)
Spatulated, tension-free, stented, watertight anastomosis — absorbable suture + retroperitoneal drainage
Retroperitonealize repair; omental interposition for complex/blast/vascular cases
Non-tunneled widely spatulated ureteroneocystostomy

Post-op principles:

Remove Foley before drain
Foley 24–48 hr post-op
Remove drain 1 day after Foley if no high output
Remove the stent at 6 weeks, with a retrograde ureterogram
Lasix renogram at 10 weeks
Renal ultrasound at 4 months — look for the ureteric jet
For an injury found post-operatively on the ward: repair within 7 days, or after 6 weeks — if 7 days have passed, place a nephrostomy and repair at 6 weeks

Bladder Injury

Background / Pathogenesis

Usually pelvic fracture
Burst injury at dome from blow to full bladder; penetrating
Bladder protected by bony pelvis; blunt injury rarely isolated
83–95% of bladder injuries have pelvic fracture; only 5–10% of pelvic fractures have bladder injury
Iatrogenic → obstetric/gyn most common in open surgery

AAST Bladder Injury Scale

Grade	Criteria
I	Contusion / intramural hematoma; partial-thickness laceration
II	Extraperitoneal laceration <2 cm
III	Extraperitoneal >2 cm OR intraperitoneal <2 cm
IV	Intraperitoneal >2 cm
V	Intra- or extraperitoneal laceration into bladder neck or ureteral orifice (trigone)

Clinical indicators (12)

Classic triad: lower abdominal pain · inability to void · frank hematuria
Gross hematuria = most common indicator
Lower abdominal bruising, abdominal distention, suprapubic pain, guarding/rigidity, inability to void, low urine output, diminished bowel sounds
Pubic symphysis diastasis; obturator ring fracture displacement >1 cm
↑ Creatinine + BUN (peritoneal urine absorption); urinary ascites (intraperitoneal low-density free fluid)

Two presentations that mislead

Alcohol intoxication means a full bladder — blunt trauma in this setting usually produces an intraperitoneal injury
A patient with spinal cord injury or spina bifida presents differently — non-specific illness or sepsis, most often from ischemic necrosis of the suture line. In any neurogenic bladder patient presenting with sepsis, think spontaneous bladder rupture — or suture-line breakdown if recently operated

Imaging — indications

Absolute: gross hematuria + pelvic fracture / also penetrating injury with any hematuria (absolute)
Relative: gross hematuria + concerning mechanism; pelvic ring fracture + clinical indicators
Pelvic fracture alone does not warrant bladder imaging

Imaging — modality

Retrograde cystography (CT or plain film — similar sensitivity/specificity); determines presence + intra- vs. extraperitoneal
Fill to 300–350 mL (or discomfort); false-negatives reported at only 250 mL
CT cystography → dilute contrast 1:6 (mandatory, avoid scatter)
Plain film → 2 views (max fill + post-drainage); drainage film not needed for CT
Extraperitoneal = flame-shaped contrast collection in pelvis
Intraperitoneal = contrast outlines bowel loops / peritoneal cavity
Amount of extravasation ≠ extent of injury
CT urography is a LOW-PRESSURE study and is not sufficient to assess bladder integrity — intravesical pressure must be raised by adequate distension (at least 350 mL in an adult) or the injury is easily missed. Retrograde cystography remains the gold standard
Post-operative suspicion of a bladder injury: send creatinine from the drain (raised confirms urine) · cystogram · CT urography to assess the ureters — and if the creatinine is high, retrograde pyelography

Management

Blood at meatus / catheter won't pass → RUG first (urethral injury coexists in 10–30% of bladder ruptures)

Extraperitoneal (uncomplicated) → catheter drainage

Large-bore (22-Fr) Foley × 2–3 weeks
Open repair if:
- Bone spicules exposed in lumen
- Rectal injury (concurrent)
- Bladder neck injury
- ORIF of pelvic fracture (reduce hardware infection)
- Vaginal injury (concurrent)
- Abdominal injury repair (do bladder at same time)
- penetrating/iatrogenic non-urologic injury
- inadequate drainage/clots

Intraperitoneal → prompt surgical repair

Lower midline laparotomy incision
Avoid entering the pelvic hematoma
Assess both ureters
Remove all blood clots from the bladder
Repair in two layers with absorbable suture
Urethral catheter ± suprapubic tube
Drain

Never touch a stable pelvic hematoma
In any bladder trauma, and particularly a penetrating one, check the ureters
If an injury is suspected but not seen during exploration, perform a cystotomy to identify the area
Post-operatively: broad-spectrum antibiotics for 3 days and again on catheter removal
Follow-up cystography 7–10 days post-op for complex repairs

When the extraperitoneal injury does not close

Cystogram at 14 days; antibiotic cover for at least a week — the pelvic hematoma is at risk of infection
If the catheter stops draining well around day 10, check for clot retention; if there is no blockage, check catheter position with a conventional cystogram
If the cystogram at two weeks still shows extravasation: first keep the catheter several more weeks and repeat it. Formal repair is the second step, not the first

Bladder perforation from cystoscopy procedure:

Do cystogram first
Extraperitoneal → bladder drainage
Intraperitoneal: small → bladder drainage
Repair if → large, suspected intra-abdominal injury, protruding into bladder, ileus, peritonitis, significant bleeding, or urethral catheter clogging
What decides management: extent of post-operative hematuria · need for post-operative anticoagulation · significance of the perforation · whether continuous bladder irrigation is anticipated · whether abdominal distension developed during the endoscopy

Urethral Injury

Classification / Pathogenesis

Partial or complete disruption
Male: posterior (membranous) vs. anterior (penile/bulbar)
Posterior → almost exclusively pelvic fracture
- Bulbomembranous junction most vulnerable (posterior urethra adherent to pubis via UG diaphragm + puboprostatic ligaments)
Anterior → blunt (straddle = urethra crushed against pubis) or penetrating; bulbar urethra most common

AAST Urethral Injury Scale

Grade	Injury type	Description
I	Contusion	Blood at the meatus, normal retrograde urethrogram
II	Stretch injury	Elongation of the urethra without extravasation on RUG
III	Partial disruption	Extravasation at the injury site with contrast still reaching the bladder
IV	Complete disruption	Extravasation at the injury site without contrast in the bladder, <2 cm urethral separation
V	Complete disruption	Complete transection with >2 cm separation, or extension into the prostate or vagina

Clinical indicators (5)

Blood at the meatus = most common
Inability to urinate; perineal/genital ecchymosis
Male: high-riding prostate; Female: labial edema / vaginal blood
Buck's fascia disrupted → "butterfly" hematoma (urine below Dartos into scrotum, up abdominal wall below Scarpa's; posterior limit = Colles')

Imaging

Retrograde urethrogram (RUG) — perform immediately when injury suspected
Avoid blind catheter passage before RUG
Technique: oblique position (bottom leg flexed); 12-Fr Foley/syringe in fossa navicularis; penis on traction; inject 20–25 mL undiluted water-soluble contrast
If Foley already placed + meatal blood → pericatheter RUG (3-Fr/angiocath in fossa navicularis)
Balloon inflated with 1–2 mL of saline in the fossa navicularis; patient supine oblique, penis laterally over the proximal thigh with moderate traction
Films: 30° LAO with the right leg abducted and knee flexed · supine PA · 30° RAO with the left leg abducted and knee flexed
Spasm of the external sphincter is common and prevents filling of the deep bulbar, membranous and prostatic urethra — slow, gentle pressure overcomes it
A RUG should be followed by a micturating cystourethrogram to demonstrate the proximal urethra
Female suspected urethral injury → urethroscopy (in lieu of RUG)

Management — general

Immediate goal = secure bladder drainage
Partial disruption (contrast passes proximally) → single gentle catheter attempt by experienced team

Male — posterior (PFUI) → immediate suprapubic tube, delayed repair

SPC = gold standard (14-Fr or larger; US/fluoro/18-G needle aspiration to localize displaced bladder); safe even with ORIF
Primary realignment = advance catheter across rupture; may ↓ stricture severity but longer course/more procedures; maintain SPC while awaiting PFUI resolution
- ED setting inappropriate for primary realignment; avoid prolonged endoscopic attempts
- Stable patients only; can be done acutely and up to about 7 days; retrograde rigid and antegrade flexible endoscopy; risk of infection and abscess since it is a prolonged procedure
- Urethral catheter 4–6 weeks. Keep the suprapubic tube closed after the urethral catheter comes out because of the stenosis risk — if the patient voids well, remove it at 14 days. Trial of void at 4–6 weeks, clamp the suprapubic tube, remove at 1–2 weeks
- Even after successful realignment, more than 90% develop a stricture
- Advantages: less invasive; if it fails it brings the two ends closer. Disadvantages: infection of the pelvic hematoma; high chance of failure
- Failed realignment → keep the suprapubic tube and plan urethroplasty 2–3 months later

Suprapubic catheter placement

Trendelenburg · prep and drape · midline · two fingers above the symphysis · local anesthetic · spinal needle to localize · incision of skin and fascia
If the bladder is empty and suprapubic placement fails, an infraumbilical incision allows direct inspection, repair of any concomitant bladder injury, and a large-bore catheter at the bladder dome
If orthopedics plan to plate the pubic fracture, keep the tube and tunnel it cranially at the infraumbilical level — a large-bore (24-Fr) catheter as high on the lower abdominal midline as possible, away from the plated symphysis
Contraindications to a suprapubic catheter in trauma: vaginal laceration (fistula risk) · rectal injury (fistula risk) · bladder neck injury (incontinence)
Immediate sutured repair → unacceptably high ED + incontinence rates (avoid)
Delayed reconstruction: most develop obliterative stricture → open posterior urethroplasty at ≥3 months (ambulatory, injuries stabilized; rupture defect = fibrosis-filled, stable at 3 mo)
- Get cystogram + RUG before repair
- Open perineal anastomotic urethroplasty (excise fibrosis + distal mobilization + primary transecting anastomosis) = best long-term outcomes; limit lithotomy ≤5 h

Posterior urethroplasty — operative steps

High lithotomy · midline or lambda-shaped incision
The bulbar urethra is freed and mobilized from the rupture site to the mid-scrotum; the scar tissue of the rupture defect is excised
The prostatic urethra is identified at the apex of the prostate; all fibrotic tissue is excised from the proximal margin
At least a 28-Fr bougie should pass without resistance; then a tension-free bulbo-prostatic anastomosis

If the anastomosis is under tension — the ladder, in order

Full mobilization of the proximal urethra to the penoscrotal junction — going beyond it risks chordee
Corporeal splitting
Inferior pubectomy
Re-routing
Transpubic urethroplasty — rare, particularly for a fistula or bone deformity

Cases needing an abdominoperineal approach ± partial pubectomy: severe fibrosis · fistula · previous failed anastomotic urethroplasty · associated bladder neck injury · pediatric cases · displacement and disruption of the prostate · severe bone deformity. MRI adds information in these cases

ED after posterior urethroplasty is mostly caused by the injury itself, recovers over 1–2 years, and is multifactorial — cavernous nerve injury, arterial insufficiency, venous leak, direct corporal injury. Associated factors: diastasis of the pubic symphysis, lateral displacement of the urethra, and a long urethral gap
VIU is successful in most recurrent stenoses. Patients with ED and impaired flow on penile Doppler are at particular risk from bulbar ischemia — some advocate pre-operative penile arterial duplex to identify candidates for initial penile revascularization
Also: rectal injury · bleeding · infection · anejaculation · neuropathy from prolonged lithotomy
Complications (3): stricture, ED (from the pelvic fracture), incontinence — follow ≥1 year; recurrent stenosis post-urethroplasty 5–15%; incontinence after reconstruction <4%

Rhabdomyolysis after prolonged lithotomy

Presents after a long procedure with buttock pain, tea-colored urine, a rising creatinine and hyperkalemia, with no wound bleeding and a normal blood count
Confirm with a creatine kinase
Treat with hydration, urinary alkalinization, management of the hyperkalemia, serial electrolytes with nephrology referral, and pain control
This is why lithotomy time is limited during posterior urethroplasty

Male — anterior

Contusion / incomplete → urethral catheter alone
Straddle → suprapubic tube (or primary realignment if mild), delayed repair
- Immediate operative repair contraindicated (indistinct injury border); high stricture rate → surveillance
- Delayed anastomotic urethroplasty = procedure of choice for obliterated bulbar urethra
Penetrating → prompt primary repair (spatulated primary repair > delayed reconstruction — contrast to PFUI/straddle); not if unstable / no expertise / extensive tissue loss

Initial management	Indication
Urethral catheter	Contusion · incomplete injury · stretch injury
Suprapubic tube and delayed repair	Major straddle injuries · high-velocity gunshot wounds
Immediate surgical repair	Low-velocity gunshot injuries — limited spongiosal debridement of contused tissue, remove devitalized tissue, anastomose

Deciding the timing of repair

Tissue status	Mechanism	Timing
Minimal devitalization, clean wound edges	Penile fracture · stab wound · low-velocity handgun	Immediate repair
Significant destruction, ischemia in question	Pelvic fracture · straddle injury · high-velocity ballistics · high-speed MVA	Delayed repair

Anastomotic urethroplasty is the procedure of choice for a totally obliterated bulbar urethra after a straddle injury — the typical scar is 1.5–2 cm and can be completely excised with anastomosis after mobilizing the two ends
Endoscopic incision through the scar of an obliterated urethra after a saddle injury is doomed to failure
UroLume stents are contraindicated in traumatic urethral strictures
A traumatic urethral distraction defect is not managed with a graft
Perineal hematoma means an anterior urethral injury with Buck's fascia disrupted

Female → immediate primary repair or realignment over catheter

Avoids urethrovaginal fistula / obliteration; delayed repair problematic (urethra ≈4 cm, too short to mobilize once scarred)

External Genitalia Injury

Penile Fracture

Applied anatomy — Scarpa's fascia in the abdomen, Colles' fascia in the perineum and Dartos fascia in the peno-scrotum are ONE continuous layer.

Buck's intact → hematoma stays between skin and tunica → eggplant deformity
Buck's ruptured → extends into scrotum, perineum and suprapubic region
A bruised penis with a butterfly hematoma means Buck's has been breached and Colles' is intact — Colles' is what contains it
Butterfly boundaries: laterally the inferior pubic rami and fascia lata · anteriorly it can track to the clavicles, since Dartos is continuous with Scarpa's · posteriorly the perineal body
The corpora cavernosa, tunica albuginea and posterior urethra are unlikely to be involved in a straddle injury — posterior urethral injuries occur above the pelvic diaphragm and go with a pelvic fracture, not a straddle
Definition: disruption of tunica albuginea with rupture of corpus cavernosum
Mechanism: most often vigorous intercourse (penis strikes perineum/pubis → buckling)
Bilateral corporal tears in 10%

Diagnosis — reliable on Hx + exam

"Cracking/popping/snapping" + immediate detumescence; eggplant deformity (Buck's intact) or butterfly (Buck's disrupted); palpable fracture line; deviates away from tear
Imaging only if equivocal: US (preferred — rapid, cheap, accurate); penile MRI = most accurate
Urethral evaluation (RUG/urethroscopy) — urethral injury in 10–22% (more with bilateral corporal injury); indications = blood at meatus, gross hematuria, inability to void

Management → prompt exploration + surgical repair

Benefits (7): faster recovery, ↓ morbidity, ↓ complications, ↓ ED, ↓ long-term curvature, ↓ cavernosal diverticulum, ↓ chronic pain
Delay up to 7 days does not adversely affect repair
Approach: distal circumcising/degloving (uncertain location — exposes all 3 compartments) OR incision at the site of injury OR ventral midline
Repair tunica with interrupted 2-0/3-0 absorbable (Vicryl); artificial erection (saline + methylene blue) to localize/test
Urethral injury: partial → oversew over catheter; complete → debride, mobilize, tension-free repair over catheter
Post-op: broad-spectrum antibiotics + 1 month sexual abstinence

Operative sequence

Cystoscopy, pass a wire into the bladder, place the catheter over the wire
Occluding tourniquet at the base of the penis
Incision and degloving
Evacuate the hematoma
Lacerated urethra — dissect out, excise devitalized tissue, close water-tight with absorbable 4-0 or 5-0 in a Heineke-Mikulicz fashion to preserve lumen diameter, then close the tunica of the corpus spongiosum
Lacerated tunica albuginea — debride devitalized tunica, close with absorbable suture
Close the skin

If the tear cannot be found intra-operatively, perform an artificial erection and look for the leak
Injuries associated with intercourse are usually ventral or lateral, where the tunica albuginea is thinnest
In an uncircumcised patient a distal circumcising incision may leave the distal prepuce ischemic — if it is required, strongly consider a limited circumcision at the end of the repair
Avoid deep corporeal vascular ligation and excessive debridement of the delicate underlying erectile tissue
Because urethrography is time-consuming and can be inaccurate, intra-operative flexible cystoscopy is now often performed routinely just before catheter placement when urethral injury is suspected
Additional points to elicit: cracking or popping sound · pain · rapid detumescence · discoloration · shaft swelling · urethral bleeding · hematuria · inability to urinate · an erection after the incident · tenderness and deviation
The cost of managing conservatively: penile curvature · ED · penile fibrosis · abscess or debilitating plaques in 25–30% · longer hospitalization and recovery

Penile Penetrating / Other

GSW: immediate exploration, copious irrigation, excise foreign matter, antibiotic prophylaxis, surgical closure
- Low-velocity urethral injury → primary closure; high-velocity / shotgun → staged repair + SP diversion
Bites: dog → irrigation, debride, primary closure with drain + broad-spectrum antibiotics (amox/clav, cefoxitin, clindamycin+cipro) + tetanus/rabies; human bites → do NOT close primarily
Amputation: "double bag" — distal penis rinsed in saline, wrapped in saline gauze, sealed bag in outer bag with ice; transfer to microsurgical center
- Reimplant viable: <16 h cold OR <6 h warm ischemia; macrovascular repair preserves erectile/urethral function, microvascular needed for skin + sensation
- Instructions to the referring team: rinse the part with saline · wrap in saline-soaked gauze · seal in a sterile bag · place that bag in ice · IV access, fluids, antibiotics
- Management involves vascular and plastic input, microvascular reconstruction, and psychiatric consultation later where the injury was self-inflicted
- Operative steps: suprapubic cystostomy · closure of the tunica albuginea · urethral closure over a catheter · microscopic anastomosis of the dorsal artery · microscopic dorsal vein repair · epineural repair of the dorsal nerve · skin coverage

	Microsurgical	Macrosurgical
Vessel and nerve reconstruction	Yes	No
Erectile function restored	Yes	Yes
Urethral stricture, skin loss, sensory abnormality	Less	More
Returns normal penile sensation	More than 80%	0–10%
Penile skin necrosis	Less	More

Erectile outcome is equal between the two — about 50% in each group will have ED
Urethral injury occurs in 15–50% of penile gunshot wounds — strongly consider RUG, especially with high-velocity injuries, blood at the meatus, difficulty voiding, or a trajectory near the urethra. Intra-operative retrograde methylene blue or indigo carmine may identify the site and confirm closure; pericatheter injection helps if a catheter is already in
Electrical penile injury is managed with a suprapubic catheter until the full extent is known
Artificial erection after repair — plication may be needed
Zipper injury (boys/intoxicated): penile block, lubricate with mineral oil, single unzip attempt; failing that → bone cutter

Testicular Trauma

Consider rupture in all blunt scrotal trauma (rupture of tunica albuginea)
Testicular injury is blunt in about 75% of cases

Differential diagnosis of the acute traumatic scrotum

Hematocele without rupture — though 80% of hematoceles are caused by rupture
Reactive hydrocele · hematoma of the epididymis or spermatic cord
Dislocation — can often be replaced manually
Intratesticular hematoma — needs exploration and drainage to avoid pressure necrosis, atrophy and delayed orchiectomy
Torsion of the testis or an appendage
A non-palpable testis in a trauma patient should raise the possibility of dislocation OUT of the scrotum — typically after motorcycle crashes, into the superficial inguinal pouch in 50%, or a pubic, penile, pelvic, abdominal or perineal location
Complications of managing a rupture conservatively: infection · atrophy · necrosis · chronic unrelenting pain · delayed orchiectomy
Complex scrotal avulsion injuries are initially observed for 24 hours to allow clear demarcation of tissue viability
Hematoma degree does not correlate with injury
US reliable for blunt (limited for penetrating): heterogeneous parenchyma + tunica albuginea contour disruption
- Normal/equivocal US should not delay exploration if exam suggests rupture

Scrotal exploration indications (6)

Imaging findings of rupture; equivocal imaging but suspected rupture; large hematoma (explore + drain even without rupture → prevent pressure necrosis/atrophy); clear physical findings; penetrating scrotal injury (>50% have rupture); significant hematocele (up to 80% from rupture)
GSW → 30% injure both testes → consider contralateral exploration; ligate injured vas with non-absorbable suture, delayed reconstruction

Repair

Early exploration + repair benefits (6): ↑ salvage, ↓ ischemic atrophy, ↓ infection, preserved fertility/hormonal function, ↓ convalescence, faster return
Salvage >90% if repair within 72 h; orchiectomy 3–8× higher with delayed surgery
Technique: transverse scrotal incision; remove necrotic/extruded tubules; close tunica albuginea with small absorbable suture; tunica vaginalis flap/graft for large defects; orchiectomy if non-salvageable
Large tunical defects: excise testicular tissue and close; if still not closable, cover with a tunica vaginalis flap. Synthetic grafts are NOT recommended

Genital Skin Loss

Most common cause of extensive loss = Fournier gangrene (polymicrobial necrotizing infection)
Exploration + limited debridement (genital skin well vascularized, marginal tissue may survive); multiple OR trips before definitive reconstruction
Burn + urethral catheter → remove after 72 h (prevent urethral slough/fistula)
Penile reconstruction: thick (0.012–0.015"), non-meshed split-thickness graft (meshed contracts); excise residual subcoronal skin (avoids lymphedema); foreskin flap best for small distal loss; shaft grafts never regain normal sensation (glans sensation preserves function)
Scrotal reconstruction: defects up to 60% closed directly; meshed STSG preferred; extensive → testes in thigh pouches/vacuum dressing (not in active infection)
- With tension despite being within the directly-closable range → local scrotal advancement flap, or healing by secondary intention
- Beyond it, or extending beyond the scrotum → split-thickness graft with or without tissue adhesive, or flap reconstruction
If there is penile skin necrosis, debride and cover — split-thickness graft, or bury the phallus in the scrotum and leave it buried for 8 weeks
For genital skin loss or infection, strongly consider early suprapubic urinary diversion in extensive injuries, to simplify wound care and prevent the urethral complications of prolonged catheterization

Circumcision trauma

Excess penile skin removed → wet-to-dry dressings plus antibiotic ointment, healing by secondary intention
If totally degloved, the penile shaft skin can often be salvaged, defatted and replaced as a full-thickness graft
If the skin is lost or cannot be salvaged, use a split-thickness graft