Genitourinary trauma involves injury to the kidneys, ureters, bladder, and/or urethra. It may result in high morbidity if not properly identified and managed. The diagnosis of genitourinary trauma typically relies on patient history, physical examination, urinalysis, and imaging (CT, cystoscopy, retrograde urethrogram). Renal trauma is most often an acute condition caused by a blunt abdominal injury and may, if severe, represent a urological emergency. The classical symptoms of renal trauma are hematuria and pain in the affected side following injury. Mild trauma generally only requires monitoring, while high-grade injury may require emergency surgery and intensive care. Injury to the ureters is rare and generally iatrogenic, occurring mostly during operative procedures. Management may require stent placement with surgical repair. Bladder injuries are common in blunt abdominal trauma. Classic symptoms are gross hematuria, an inability to void, and abdominal pain. Extraperitoneal bladder injuries usually resolve with catheterization, while intraperitoneal injury requires surgery, which can help to prevent peritonitis and urosepsis. Urethral injuries may involve the posterior urethra, causing a high-riding prostate and blood at the urethral meatus, or the anterior urethra, causing perineal pain or hematoma. Treatment may be conservative or surgical depending on the severity of injury. Complications of the genitourinary tract include urinary extravasation, urinoma, abscess formation, renal hypertension, and loss of function in the affected kidney.
Renal injuries and ureteral injuries 
- Blunt abdominal trauma (80% of cases)
- Blunt thoracic trauma: associated with lower rib (9th–12th) fractures
- Penetrating trauma (e.g., gunshot or stab wounds)
- Physical or sexual violence
- Blunt abdominal trauma: direct trauma to a distended bladder → increased intravesical pressure → rupture of the bladder dome → intraperitoneal accumulation of urine → increased BUN and creatinine
- Pelvic fractures → pelvic bone fragments → extraperitoneal rupture of the anterior or anterolateral wall of the bladder → urine accumulation in the retropubic space
- Penetrating trauma
- Iatrogenic: transurethral or pelvic surgery
Urethral injuries 
- Almost exclusively seen in men
- Less common in women due to a shorter and more mobile urethra
- Anterior urethral injuries
- Posterior urethral injuries: significant pelvic fracture due to trauma (e.g., a vehicle collision): bulbomembranous junction is commonly injured
In patients with pelvic fractures, always evaluate for possible injury to the genitourinary system.
Renal and ureteral injuries 
- Pain, bruising, hematoma on the affected side
- Possible accompanying injuries (e.g., rib fracture with motion-dependent pain)
- In large perirenal hematoma: shock
- Ureteral injuries are easily overlooked, but can cause palpable flank mass, flank pain, and fever.
- Extraperitoneal and/or intraperitoneal injury
- Intraperitoneal injury
|Overview of urethral injuries|
|Characteristics||Anterior urethral injury||Posterior urethral injury|
|Findings upon examination|| |
Injury to the urinary system can be easily masked by multiple concurrent injuries to other organ systems and is therefore easily overlooked.
General approach to genitourinary trauma 
- Patient history
- Physical examination
Urinalysis: macroscopic hematuria or microscopic hematuria
- The color of the urine does not correlate with injury severity.
- Microscopic hematuria after significant (nonurethral) trauma is common
- No further diagnostic tests are needed in patients who are hemodynamically stable and present without any other signs or symptoms of associated pelvic or abdominal injury.
- Blood analysis: CBC, BUN, creatinine
Evaluate the genitourinary tract in a retrograde fashion, beginning with the external genitalia and urethra.
Renal and ureteral injury
- CT with IV contrast of the abdomen/pelvis: to assess renal and accompanying injuries or intraabdominal fluid retention
- Delayed CT imaging: indicated if injury to the renal pelvis and ureters is suspected
- IV pyelography: to assess for contrast extravasation if delayed CT images are nondiagnostic
- Urethrocystography: if CT is unavailable
American Association for the Surgery of Trauma (AAST) grading system for traumatic renal injury 
|Grading system for traumatic renal injury|
|AAST grade||CT findings|
|Low-grade renal injury||I|
|High-grade renal injury||IV|
- Retrograde cystography or retrograde CT cystography
Retrograde urethrogram: to rule out suspected urethral injury
- First diagnostic step (before catheterization) in a patient with suspected urethral injury
- Findings: contrast extravasation from the urethra at point of injury
Foley catheter placement
- Suspected urethral injury is a relative contraindication for catheterization, as it may worsen the injury.
- In cases of gross hematuria without other clinical signs of urethral injury, a single attempt at Foley catheter placement may be performed.
- Successful catheterization without resistance makes urethral injury an unlikely diagnosis.
- If any resistance is met, retrograde urethrography should be performed.
- Hemodynamically stable patients with minor trauma: observe with Foley catheter placement, if needed, for hematuria and/or oliguria
- Hemodynamically unstable patients: may require immediate surgical intervention for other injuries prior to definitive treatment of genitourinary injuries
Renal and ureteral trauma 
Low-grade renal injury
- Observation and vital sign monitoring with bed rest
- Antibiotic prophylaxis
- Monitor for hematuria
- Angioembolization may be considered for expanding renal hematomas (grade III renal injuries)
High-grade renal injury
- Stable hemodynamics
- Unstable hemodynamics: emergent exploration with surgical defect repair and possible nephrectomy to prevent life-threatening bleeding
- Uncomplicated ureteral injury
Complicated ureteral injuries
- Examples: urinoma, ureteral laceration with complete transsection, ureteral avulsion (a severe but rare complication of ureteroscopy, most commonly caused by instruments that are too large for the ureter or attempted removal of insufficiently fragmented stones) 
- Surgical repair (e.g., ureteroureterostomy, ureteral reimplantation)
- Ureteral ligation followed by delayed ureteral reconstruction if surgical repair is not possible during primary surgery due to concomitant injuries
- May require urinary diversion (e.g., percutaneous nephrostomy, stent placement)
- Goal is to keep the bladder decompressed to minimize bladder wall tension to facilitate healing
- No urethral injury: place Foley catheter to drain bladder; irrigate bladder to clear clots
- Extraperitoneal injury without involvement of bladder neck: insertion of a transurethral indwelling catheter; otherwise suprapubic urinary diversion
- Extraperitoneal injuries involving bladder neck: associated with rectal/vaginal injury and all intraperitoneal injuries (i.e., bladder dome); open surgical repair is indicated
- The goal is to maintain urinary continence and sexual function.
- Urethral catheterization is relatively contraindicated.
- Place suprapubic catheter to decompress bladder (diverts urine from the healing urethra and anastomosis)
- Anterior urethral injury
Posterior urethral injury
- Endoscopic approach: early realignment (within 1 week) with combined transurethral and percutaneous transvesical approach
- Surgical approach: place suprapubic catheter → delayed urethroplasty (6–12 weeks after initial injury)
We list the most important complications. The selection is not exhaustive.