Current Management of Urinary Tract Injuries

  • Nicolaas LumenEmail author
  • Florence Desmidt


Injury to the urinary tract and scrotum can be due to blunt or penetrating trauma. In many circumstances, injuries to the urogenital tract occur in the setting of a polytrauma patient. Therefore, these patients require a multidisciplinary approach. The majority of urogenital injuries are not directly life-threatening and have thus a low priority in the trauma management of a polytrauma patient. Nevertheless, adequate early diagnosis and management are warranted as inadequate diagnosis and treatment can provoke severe long-term complications and invalidity. The standard diagnostic modality of renal (and ureteral) injury is multiphase contrast-enhanced CT if the condition of the patient allows for this. CT cystography is preferred to diagnose bladder injury, whereas retrograde urethrography is the standard for urethral injury. Except in case of hemodynamic instability, renal injury is treated conservatively, if needed, with adjuvant angioembolization. Early recognition of ureteral trauma is crucial as the ureteral injury is usually less complex to repair at that moment. Intraperitoneal bladder injuries need exploration with surgical repair and urinary diversion until bladder healing. Uncomplicated extraperitoneal bladder injuries can be managed by urinary diversion only, until spontaneous bladder healing is achieved. Placement of a suprapubic catheter under echographic or direct vision is always a good solution in the initial management of urethral injury. Early exploration and repair of a testicular rupture are required to salvage the testicle.


Renal trauma Ureteral trauma Bladder trauma Urethral trauma Scrotal trauma Hematuria 


  1. 1.
    Serafetinides E, Kitrey ND, Djakovic N, Kuehhas FE, Lumen N, Sharma DM, et al. Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 2015;67(5):930–6.PubMedGoogle Scholar
  2. 2.
    Smith J, Caldwell E, D’Amours S, Jalaludin B, Sugrue M. Abdominal trauma: a disease in evolution. ANZ J Surg. 2005;75(9):790–4.PubMedGoogle Scholar
  3. 3.
    Sangthong B, Demetriades D, Martin M, Salim A, Brown C, Inaba K, et al. Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank. J Am Coll Surg. 2006;203(5):612–7.PubMedGoogle Scholar
  4. 4.
    Kansas BT, Eddy MJ, Mydlo JH, Uzzo RG. Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center. J Urol. 2004;172(4 Pt 1):1355–60.PubMedGoogle Scholar
  5. 5.
    Najibi S, Tannast M, Latini JM. Civilian gunshot wounds to the genitourinary tract: incidence, anatomic distribution, associated injuries, and outcomes. Urology. 2010;76(4):977–81; discussion 81PubMedGoogle Scholar
  6. 6.
    Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989;29(12):1664–6.PubMedGoogle Scholar
  7. 7.
    Zinman LN, Vanni AJ. Surgical management of urologic trauma and iatrogenic injuries. Surg Clin North Am. 2016;96(3):425–39.PubMedGoogle Scholar
  8. 8.
    Morey AF, McAninch JW, Tiller BK, Duckett CP, Carroll PR. Single shot intraoperative excretory urography for the immediate evaluation of renal trauma. J Urol. 1999;161(4):1088–92.PubMedGoogle Scholar
  9. 9.
    Heller MT, Schnor N. MDCT of renal trauma: correlation to AAST organ injury scale. Clin Imaging. 2014;38(4):410–7.PubMedGoogle Scholar
  10. 10.
    Fischer W, Wanaselja A, Steenburg SD. JOURNAL CLUB: incidence of urinary leak and diagnostic yield of excretory phase CT in the setting of renal trauma. AJR Am J Roentgenol. 2015;204(6):1168–72; quiz 73PubMedGoogle Scholar
  11. 11.
    Schmidlin FR, Rohner S, Hadaya K, Iselin CE, Vermeulen B, Khan H, et al. The conservative treatment of major kidney injuries. Ann Urol. 1997;31(5):246–52.Google Scholar
  12. 12.
    Buckley JC, McAninch JW. Selective management of isolated and nonisolated grade IV renal injuries. J Urol. 2006;176(6 Pt 1):2498–502; discussion 502PubMedGoogle Scholar
  13. 13.
    Jansen JO, Inaba K, Resnick S, Fraga GP, Starling SV, Rizoli SB, et al. Selective non-operative management of abdominal gunshot wounds: survey of practise. Injury. 2013;44(5):639–44.PubMedGoogle Scholar
  14. 14.
    Baniel J, Schein M. The management of penetrating trauma to the urinary tract. J Am Coll Surg. 1994;178(4):417–25.PubMedGoogle Scholar
  15. 15.
    Lanchon C, Fiard G, Arnoux V, Descotes JL, Rambeaud JJ, Terrier N, et al. High grade blunt renal trauma: predictors of surgery and long-term outcomes of conservative management. A prospective single center study. J Urol. 2016;195(1):106–11.PubMedGoogle Scholar
  16. 16.
    Shoobridge JJ, Bultitude MF, Koukounaras J, Martin KE, Royce PL, Corcoran NM. A 9-year experience of renal injury at an Australian level 1 trauma centre. BJU Int. 2013;112(Suppl 2):53–60.PubMedGoogle Scholar
  17. 17.
    van der Wilden GM, Velmahos GC, Joseph DK, Jacobs L, Debusk MG, Adams CA, et al. Successful nonoperative management of the most severe blunt renal injuries: a multicenter study of the research consortium of New England Centers for Trauma. JAMA Surg. 2013;148(10):924–31.PubMedGoogle Scholar
  18. 18.
    Charbit J, Manzanera J, Millet I, Roustan JP, Chardon P, Taourel P, et al. What are the specific computed tomography scan criteria that can predict or exclude the need for renal angioembolization after high-grade renal trauma in a conservative management strategy? J Trauma. 2011;70(5):1219–27; discussion 27–8PubMedGoogle Scholar
  19. 19.
    Armenakas NA, Duckett CP, McAninch JW. Indications for nonoperative management of renal stab wounds. J Urol. 1999;161(3):768–71.PubMedGoogle Scholar
  20. 20.
    McAninch JW, Carroll PR, Klosterman PW, Dixon CM, Greenblatt MN. Renal reconstruction after injury. J Urol. 1991;145(5):932–7.PubMedGoogle Scholar
  21. 21.
    Gonzalez RP, Falimirski M, Holevar MR, Evankovich C. Surgical management of renal trauma: is vascular control necessary? J Trauma. 1999;47(6):1039–42; discussion 42–4PubMedGoogle Scholar
  22. 22.
    Pereira BM, Ogilvie MP, Gomez-Rodriguez JC, Ryan ML, Pena D, Marttos AC, et al. A review of ureteral injuries after external trauma. Scand J Trauma Resusc Emerg Med. 2010;18:6.PubMedPubMedCentralGoogle Scholar
  23. 23.
    McGeady JB, Breyer BN. Current epidemiology of genitourinary trauma. Urol Clin North Am. 2013;40(3):323–34.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int. 2004;94(3):277–89.PubMedGoogle Scholar
  25. 25.
    Siram SM, Gerald SZ, Greene WR, Hughes K, Oyetunji TA, Chrouser K, et al. Ureteral trauma: patterns and mechanisms of injury of an uncommon condition. Am J Surg. 2010;199(4):566–70.PubMedGoogle Scholar
  26. 26.
    Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol. 2003;170(4 Pt 1):1213–6.PubMedGoogle Scholar
  27. 27.
    Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am. 2006;33(1):55–66, viPubMedGoogle Scholar
  28. 28.
    Smith TG 3rd, Coburn M. Damage control maneuvers for urologic trauma. Urol Clin North Am. 2013;40(3):343–50.PubMedGoogle Scholar
  29. 29.
    Chung BI, Hamawy KJ, Zinman LN, Libertino JA. The use of bowel for ureteral replacement for complex ureteral reconstruction: long-term results. J Urol. 2006;175(1):179–83; discussion 83-4PubMedGoogle Scholar
  30. 30.
    Meng MV, Freise CE, Stoller ML. Expanded experience with laparoscopic nephrectomy and autotransplantation for severe ureteral injury. J Urol. 2003;169(4):1363–7.PubMedGoogle Scholar
  31. 31.
    Lumen N, Kuehhas FE, Djakovic N, Kitrey ND, Serafetinidis E, Sharma DM, et al. Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 2015;67(5):925–9.PubMedGoogle Scholar
  32. 32.
    Figler BD, Hoffler CE, Reisman W, Carney KJ, Moore T, Feliciano D, et al. Multi-disciplinary update on pelvic fracture associated bladder and urethral injuries. Injury. 2012;43(8):1242–9.PubMedGoogle Scholar
  33. 33.
    Cinman NM, McAninch JW, Porten SP, Myers JB, Blaschko SD, Bagga HS, et al. Gunshot wounds to the lower urinary tract: a single-institution experience. J Trauma Acute Care Surg. 2013;74(3):725–30; discussion 30–1PubMedPubMedCentralGoogle Scholar
  34. 34.
    Pereira BM, de Campos CC, Calderan TR, Reis LO, Fraga GP. Bladder injuries after external trauma: 20 years experience report in a population-based cross-sectional view. World J Urol. 2013;31(4):913–7.PubMedGoogle Scholar
  35. 35.
    Matlock KA, Tyroch AH, Kronfol ZN, McLean SF, Pirela-Cruz MA. Blunt traumatic bladder rupture: a 10-year perspective. Am Surg. 2013;79(6):589–93.PubMedGoogle Scholar
  36. 36.
    Quagliano PV, Delair SM, Malhotra AK. Diagnosis of blunt bladder injury: a prospective comparative study of computed tomography cystography and conventional retrograde cystography. J Trauma. 2006;61(2):410–21; discussion 21–2PubMedGoogle Scholar
  37. 37.
    Wirth GJ, Peter R, Poletti PA, Iselin CE. Advances in the management of blunt traumatic bladder rupture: experience with 36 cases. BJU Int. 2010;106(9):1344–9.PubMedGoogle Scholar
  38. 38.
    Wu CW, Lin CH, Lin CH. One-stage posttraumatic bladder reconstruction and soft-tissue coverage of the lower abdomen or perineum. Ann Plast Surg. 2010;64(1):65–8.PubMedGoogle Scholar
  39. 39.
    Inaba K, Okoye OT, Browder T, Best C, Branco BC, Teixeira PG, et al. Prospective evaluation of the utility of routine postoperative cystogram after traumatic bladder injury. J Trauma Acute Care Surg. 2013;75(6):1019–23.PubMedGoogle Scholar
  40. 40.
    Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. J Trauma. 2009;67(5):1033–9.PubMedGoogle Scholar
  41. 41.
    Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol. 1996;77(6):876–80.PubMedGoogle Scholar
  42. 42.
    Brandes S. Initial management of anterior and posterior urethral injuries. Urol Clin North Am. 2006;33(1):87–95, viiPubMedGoogle Scholar
  43. 43.
    Tausch TJ, Cavalcanti AG, Soderdahl DW, Favorito L, Rabelo P, Morey AF. Gunshot wound injuries of the prostate and posterior urethra: reconstructive armamentarium. J Urol. 2007;178(4 Pt 1):1346–8.PubMedGoogle Scholar
  44. 44.
    Elgammal MA. Straddle injuries to the bulbar urethra: management and outcome in 53 patients. Int Braz J Urol. 2009;35(4):450–8.PubMedGoogle Scholar
  45. 45.
    Bjurlin MA, Kim DY, Zhao LC, Palmer CJ, Cohn MR, Vidal PP, et al. Clinical characteristics and surgical outcomes of penetrating external genital injuries. J Trauma Acute Care Surg. 2013;74(3):839–44.PubMedGoogle Scholar
  46. 46.
    Kommu SS, Illahi I, Mumtaz F. Patterns of urethral injury and immediate management. Curr Opin Urol. 2007;17(6):383–9.PubMedGoogle Scholar
  47. 47.
    Amit A, Arun K, Bharat B, Navin R, Sameer T, Shankar DU. Penile fracture and associated urethral injury: experience at a tertiary care hospital. Can Urol Assoc J. 2013;7(3–4):E168–70.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Cavalcanti AG, Krambeck R, Araujo A, Rabelo PH, Carvalho JP, Favorito LA. Management of urethral lesions in penile blunt trauma. Int J Urol. 2006;13(9):1218–20.PubMedGoogle Scholar
  49. 49.
    Rosenstein DI, Alsikafi NF. Diagnosis and classification of urethral injuries. Urol Clin North Am. 2006;33(1):73–85, vi–viiPubMedGoogle Scholar
  50. 50.
    Mundy AR, Andrich DE. Urethral trauma. Part I: introduction, history, anatomy, pathology, assessment and emergency management. BJU Int. 2011;108(3):310–27.PubMedGoogle Scholar
  51. 51.
    Kamdar C, Mooppan UM, Kim H, Gulmi FA. Penile fracture: preoperative evaluation and surgical technique for optimal patient outcome. BJU Int. 2008;102(11):1640–4; discussion 4PubMedGoogle Scholar
  52. 52.
    Chapple C, Barbagli G, Jordan G, Mundy AR, Rodrigues-Netto N, Pansadoro V, et al. Consensus statement on urethral trauma. BJU Int. 2004;93(9):1195–202.PubMedGoogle Scholar
  53. 53.
    Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol. 1999;161(5):1433–41.PubMedGoogle Scholar
  54. 54.
    Koraitim MM. Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol. 1996;156(4):1288–91.PubMedGoogle Scholar
  55. 55.
    Mundy AR, Andrich DE. Urethral trauma. Part II: types of injury and their management. BJU Int. 2011;108(5):630–50.PubMedGoogle Scholar
  56. 56.
    Koraitim MM. Effect of early realignment on length and delayed repair of postpelvic fracture urethral injury. Urology. 2012;79(4):912–5.PubMedGoogle Scholar
  57. 57.
    Kizer WS, Armenakas NA, Brandes SB, Cavalcanti AG, Santucci RA, Morey AF. Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting. J Urol. 2007;177(4):1378–81; discussion 81–2PubMedGoogle Scholar
  58. 58.
    Tausch TJ, Morey AF, Scott JF, Simhan J. Unintended negative consequences of primary endoscopic realignment for men with pelvic fracture urethral injuries. J Urol. 2014;192(6):1720–4.PubMedGoogle Scholar
  59. 59.
    Feng C, Xu YM, Barbagli G, Lazzeri M, Tang CY, Fu Q, et al. The relationship between erectile dysfunction and open urethroplasty: a systematic review and meta-analysis. J Sex Med. 2013;10(8):2060–8.PubMedGoogle Scholar
  60. 60.
    Lumen N, Hoebeke P, Troyer BD, Ysebaert B, Oosterlinck W. Perineal anastomotic urethroplasty for posttraumatic urethral stricture with or without previous urethral manipulations: a review of 61 cases with long-term followup. J Urol. 2009;181(3):1196–200.PubMedGoogle Scholar
  61. 61.
    Webster GD, Ramon J. Repair of pelvic fracture posterior urethral defects using an elaborated perineal approach: experience with 74 cases. J Urol. 1991;145(4):744–8.PubMedGoogle Scholar
  62. 62.
    Singh O, Gupta SS, Mathur RK. Urogenital fistulas in women: 5-year experience at a single center. Urol J. 2010;7(1):35–9.PubMedGoogle Scholar
  63. 63.
    Wang Z, Yang JR, Huang YM, Wang L, Liu LF, Wei YB, et al. Diagnosis and management of testicular rupture after blunt scrotal trauma: a literature review. Int Urol Nephrol. 2016;48(12):1967–76.PubMedGoogle Scholar
  64. 64.
    Wasko R, Goldstein AG. Traumatic rupture of the testicle. J Urol. 1966;95(5):721–3.PubMedGoogle Scholar
  65. 65.
    Hudak SJ, Hakim S. Operative management of wartime genitourinary injuries at Balad Air Force Theater Hospital, 2005 to 2008. J Urol. 2009;182(1):180–3.PubMedGoogle Scholar
  66. 66.
    Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: a 30-year single institution experience. J Urol. 2008;180(1):192–5; discussion 5–6PubMedGoogle Scholar
  67. 67.
    Simhan J, Rothman J, Canter D, Reyes JM, Jaffe WI, Pontari MA, et al. Gunshot wounds to the scrotum: a large single-institutional 20-year experience. BJU Int. 2012;109(11):1704–7.PubMedGoogle Scholar
  68. 68.
    Shefi S, Mor Y, Dotan ZA, Ramon J. Traumatic testicular dislocation: a case report and review of published reports. Urology. 1999;54(4):744.PubMedGoogle Scholar
  69. 69.
    Morey AF, Brandes S, Dugi DD 3rd, Armstrong JH, Breyer BN, Broghammer JA, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–35.PubMedPubMedCentralGoogle Scholar
  70. 70.
    Altarac S. Management of 53 cases of testicular trauma. Eur Urol. 1994;25(2):119–23.PubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of UrologyGhent University HospitalGhentBelgium
  2. 2.Department of UrologyGronau St. Antonius HospitalGronauGermany

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