At the Bedside

  • Start with trauma priorities: ABCs, hemorrhage control, pelvic stabilization if unstable pelvic fracture, FAST/eFAST, trauma activation as appropriate.
  • Key history/mechanisms:
  • Blunt flank/abdomen trauma, deceleration injury → renal vascular/pedicle injury.
  • Pelvic fracture, straddle injury → urethral/bladder injury.
  • Penetrating flank/abdomen/genital trauma → assume GU involvement until proven otherwise.
  • Exam clues:
  • Flank ecchymosis, abdominal tenderness, lower rib fractures → renal injury.
  • Suprapubic pain/distention, inability to void → bladder injury.
  • Blood at urethral meatus, perineal/scrotal ecchymosis, high-riding/nonpalpable prostate, pelvic fracture, inability to void → suspect urethral injury.
  • Testicular pain/swelling, abnormal lie, hematocele → testicular rupture/torsion differential.
  • Urinalysis:
  • Gross hematuria is high risk.
  • Microscopic hematuria alone in stable adults usually does not mandate renal imaging unless hypotension, significant mechanism, or associated injuries.
  • Imaging decision points:
  • CT abdomen/pelvis with IV contrast + delayed/excretory phase for:
  • Gross hematuria.
  • Microscopic hematuria + hypotension.
  • Penetrating trauma near GU tract.
  • Significant flank trauma, deceleration injury, rib/transverse process fractures.
  • Retrograde urethrogram before Foley if signs of urethral injury.
  • CT cystogram for suspected bladder injury: gross hematuria + pelvic fracture, inability to void, suprapubic pain, low urine output, pelvic fluid.
  • Scrotal ultrasound with Doppler for blunt scrotal trauma/testicular rupture concern.
  • Initial ED management:
  • Resuscitate with blood products if hemorrhagic shock; activate massive transfusion if needed.
  • Avoid blind Foley if urethral injury suspected.
  • If no urethral injury signs and urinary retention/monitoring needed, place Foley.
  • Pain control, antiemetics, tetanus update, antibiotics for open/penetrating injuries.
  • Definitive management:
  • Renal injury: Most stable blunt renal injuries managed nonoperatively with observation, serial Hgb, urology/trauma consult. Unstable renal hemorrhage → IR angioembolization or OR.
  • Ureteral injury: Rare, often penetrating/iatrogenic; delayed contrast extravasation. Needs urology, stenting or repair.
  • Bladder rupture:
  • Extraperitoneal: usually Foley drainage 10–14 days; surgery if bone spicule, bladder neck injury, rectal/vaginal injury, or operative pelvic fixation.
  • Intraperitoneal: operative repair.
  • Urethral injury: suprapubic catheter or endoscopic realignment; urology consult.
  • Testicular rupture: urgent urologic exploration, ideally within 72 hours.
  • Disposition:
  • Admit trauma/urology for confirmed renal, bladder, urethral, ureteral, testicular injuries.
  • Discharge may be reasonable for minor contusion/isolated microscopic hematuria with benign exam, stable vitals, reliable follow-up, and no high-risk mechanism.
A Classic Presentation
A 27-year-old motorcyclist presents after a high-speed crash with pelvic pain and inability to void. He is tachycardic, has perineal ecchymosis, and blood at the urethral meatus. Pelvic x-ray shows an open-book pelvic fracture. The correct next step is retrograde urethrogram before Foley placement. Urology is consulted, pelvic binder remains in place, blood products are prepared, and urinary drainage is achieved via urologic management rather than blind catheterization.

Study Directive

  • Draw a GU trauma algorithm from memory: renal → ureter → bladder → urethra → genital.
  • Practice the imaging triggers: list indications for CT IV contrast delayed phase, CT cystogram, and retrograde urethrogram.
  • Review 5 CT cystogram images and identify intraperitoneal vs extraperitoneal contrast extravasation.
  • Memorize: “blood at meatus, perineal ecchymosis, pelvic fracture, inability to void = RUG before Foley.”
  • Do 10 board questions on GU trauma and specifically track errors related to imaging choice.

Recent Literature