Overview of Urinary Tract Injury

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The kidneys and the rest of the urinary tract may become injured in a number of ways. Examples include injuries from a blunt force (most commonly motor vehicle collisions, falls, or sports injuries) or a pentrating force (most commonly gunshot or stab wounds), or surgery. Injuries to the urinary tract often occur with injuries to other organs, especially abdominal organs. In men, the penis and testes may also be injured (see Penile and Testicular Disorders: Injuries to the Penis
and Scrotum).

Because the function of the kidneys is to continuously filter out metabolic wastes from the blood and remove them from the body through the urinary tract, injuries to the kidneys or urinary tract can lead to the inability to perform these functions (kidney failure). Other complications of injury include bleeding, leakage of urine from the urinary tract into surrounding tissues, and infection. Preventing permanent damage to the urinary tract and even death may depend on prompt diagnosis and treatment.

Bladder Injuries

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A bladder injury often occurs when the pelvis is injured, as in a high-speed motor vehicle collision or a fall. Penetrating wounds, usually from gunshots, also can injure the bladder. In addition, a bladder injury may occur unintentionally during surgery involving the pelvis or lower abdomen (such as hysterectomy, cesarean section, or colectomy). If bladder injuries are not promptly treated, complications, such as frequent and urgent urination, uncontrollable loss of urine (urinary incontinence), and infection, may develop.

Symptoms and Diagnosis

The most common symptoms of a bladder injury are blood in the urine, difficulty in urinating, and pain in the pelvis and lower abdomen. If the lowermost portion of the bladder (where the muscle that helps to control urination is located) has been injured, the person may experience frequent urination or urinary incontinence. The diagnosis of a bladder injury is best established by cystography, a procedure in which a radiopaque dye (contrast agent), which is visible on x-rays, is injected into the bladder and a computed tomography (CT) scan or x-rays are taken to look for leakage. Bladder injuries that occur during a surgical procedure are usually recognized promptly and imaging tests are not needed.

Treatment
Minor bladder injuries, either bruises or tears (lacerations), may be treated by inserting a

catheter into the urethra for 5 to 10 days while the bladder heals. For more extensive bladder injuries or any injury resulting in leakage of urine into the abdominal cavity, surgery should be performed to determine the extent of the injury and to repair all tears. The urine can then be more effectively drained from the bladder using two catheters, one inserted through the urethra (a transurethral catheter) and one inserted directly into the bladder through the skin over the lower abdomen (a suprapubic catheter). These catheters are removed in 7 to 10 days or once the bladder has healed satisfactorily. If complications develop, they must be treated. When a bladder injury is recognized during a surgical procedure, it is treated at that time.

Kidney Injuries

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The kidney is injured more often than any of the organs along the urinary tract. Blunt force due to motor vehicle collisions, falls, or sports injuries is the usual cause of injury. Penetrating kidney injuries can result from gunshot or stab wounds. Less commonly, injuries can occur during diagnostic tests, such as a kidney biopsy, or during various treatments, such as those for kidney stones, including extracorporeal shock wave lithotripsy. Most blunt kidney injuries are minor. However, some are serious. If serious blunt or penetrating kidney injuries are not treated, complications, such as kidney failure, high blood pressure, delayed bleeding, and infection, may result.

Symptoms and Diagnosis

Symptoms of a blunt kidney injury may include pain in the upper abdomen or flank (the area between the ribs and hip), bruising of the flank, blood in the urine, marks near a kidney made by a seat belt, or pain resulting from fractures of the lower ribs. With severe kidney injuries, low blood pressure (shock) and anemia may occur if the person loses a significant amount of blood.

Kidney Injuries: Minor to Severe

The severity of kidney injuries varies widely. When an injury is minor, the kidney may only be bruised. When an injury is more severe, the kidney may be cut or torn (lacerated), and urine and blood may leak into the surrounding tissue. If the kidney is torn from its attachment to blood vessels, bleeding may be profuse, resulting in shock or death. Most kidney injuries

result in blood in the urine.

The history of events that led to the injury, the person's symptoms, and a physical examination help doctors recognize kidney injuries. A sample of urine is taken and examined to see whether blood is present. Blood in the urine in a person with an injury to the trunk suggests that the injury involves the kidney. The blood may be visible with the naked eye (gross hematuria) or visible only using a microscope (microscopic hematuria). With penetrating injuries, the location of the wound (whether in the upper or mid part of the abdomen, back, or flank) may help doctors determine whether the kidney is involved. Adults who have mild symptoms and blood in the urine that is visible only with a microscope probably have a minor bruise that will heal on its own. Further tests are usually not needed. For children, and for adults in whom doctors suspect a more serious injury, computed tomography (CT) with radiopaque dye (contrast agent) is done. Occasionally, additional imaging tests may be needed to confirm the diagnosis.

Treatment
For minor kidney injuries, careful control of fluid intake and bed rest are often the only treatment needed, because these measures allow the kidney to heal itself. For more serious injuries, treatment begins with steps to control blood loss and to prevent shock. Fluids and sometimes blood are given intravenously to help keep blood pressure within a normal range and stimulate urine production. Only the most serious injuries, such as when the kidney is torn from its attachments to blood vessels, require surgical repair. Rarely, the injured kidney needs to be removed. Most people recover from even serious kidney injuries, provided the injuries are diagnosed and treated promptly. Kidney failure, when it develops, may require lifelong treatment. Other complications of kidney injuries that require treatment include high blood pressure, delayed bleeding, and infection.
Last full review/revision June 2007 by Noel A. Armenakas, MD Print Topic Email Topic

Ureteral Injuries

Most injuries to the ureter occur during pelvic or abdominal operations, such as removal of the uterus (hysterectomy) or the colon (colectomy) or repair of an abdominal aortic aneurysm, or during ureteroscopy (an examination of the ureter with a rigid or flexible viewing tube). Another cause of ureteral injury is penetration by either a gunshot or stab wound. A ureteral injury from a direct blow to the body is uncommon. Rarely, blunt injuries, particularly those that cause the trunk to bend backward, can separate the upper part of the ureter from the kidney. If ureteral injuries are untreated, complications, such as formation of a fistula (abnormal connection to another abdominal structure), stricture (narrowing of the ureter), or persistent

urinary leakage and infection, may result.

Symptoms and Diagnosis

People may complain simply of pain in the abdomen or flank (the area between the ribs and hip), or they may notice urine leaking from their wound. Fever may accompany an infection caused by persistent urinary leakage. Blood may appear in the urine. Because ureteral injury is rarely the most likely cause of such symptoms, an injury to the ureter may not be recognized promptly. Usually, doctors suspect an injury when a person who has symptoms has had a recent surgical procedure or when a person has a wound that has penetrated the abdomen. When a ureteral injury is suspected, imaging tests are needed. The initial test is often computed tomography (CT) with radiopaque dye (contrast agent) or intravenous urography. Occasionally, retrograde urography (an x-ray taken after a radiopaque dye is instilled directly into the end of the urethra) may be done. Sometimes, ureteral injuries are identified during surgery.

Treatment
Some minor ureteral injuries can be treated by placing a flexible tube (stent) in the ureter either through the bladder or through the kidney via a small incision in the side (percutaneous nephrostomy). These treatments divert urine from flowing through the ureter, usually for 2 to 6 weeks, allowing the ureter to heal. If the ureteral injury does not heal despite the use of a stent, additional surgery may be needed. In people with more severe injuries, surgery may be required to reconstruct the ureter. Treatment helps to prevent complications of ureteral injuries. If complications occur despite efforts to prevent them, they must be treated.
Last full review/revision June 2007 by Noel A. Armenakas, MD

Urethral Injuries

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Most urethral injuries occur in men. Common causes include pelvic fractures and straddle injuries (injuries to the area between the legs). The urethra can also be injured unintentionally during surgical procedures performed directly on the urethra or during procedures in which instruments are passed into the urethra, such as bladder catheterization or cystoscopy (passing a flexible viewing tube through the urethra into the bladder). Occasionally, injuries result from gunshot wounds. Rarely, urethral injuries can be self-inflicted when a person inserts a foreign object directly into the urethra. Some injuries to the urethra are limited to bruising. Injury to the urethra can also tear the lining, resulting in leakage of urine into the tissues of the penis, scrotum, abdominal wall, or perineum

(the area between the anus and vulva or scrotum). Complications that can result from urethral injuries include infection, bleeding, permanent narrowing (stricture), erectile dysfunction, and uncontrollable loss of urine (urinary incontinence).

Symptoms and Diagnosis

The most common symptoms include blood at the tip of the penis in men or the urethral opening in women, blood in the urine, an inability to urinate, and pain during urination. Bruising may be visible between the legs or in the penis. Other symptoms may arise when complications develop. For example, if urine leaks into surrounding tissues, infection may result. In addition, the injury may cause the urethra to narrow (stricture) near or at the site of injury. Men may also experience impairment in the ability to have an erection (erectile dysfunction), caused by damage to the nerves or blood supply to the penis. The diagnosis of a urethral injury is usually confirmed by retrograde urography, an x-ray taken after a radiopaque dye (contrast agent) is instilled directly into the end of the urethra. Retrograde urography is done before a catheter is passed through the urethra into the bladder.

Treatment
For urethral bruises that do not result in any leakage of urine, a doctor can place a catheter through the urethra into the bladder for several days to drain the urine while the urethra heals. For urethral tears, the urine should be diverted from the urethra using a catheter placed directly into the bladder through the skin over the lower abdomen. The urethra is repaired surgically after all other injuries have healed or after 8 to 12 weeks (when inflammation has resolved). Rarely, urethral tears heal without surgery. Treatment helps to prevent some complications of urethral injuries. Complications that cannot be prevented are treated.
Last full review/revision June 2007 by Noel A. Armenakas, MD

Background
Trauma to the male urethra must be efficiently diagnosed and effectively treated to prevent serious long-term sequelae. Patients with urethral stricture disease secondary to poorly managed traumatic events are likely to have significant voiding problems and recurring need for further interventions. Many of these men have significant orthopedic and neurologic injuries, as well. Rehabilitation requires reconstruction of the urinary tract in a manner that does not interfere with the healing process.

History of the Procedure

Most urethral injuries are associated with well-defined events, including major blunt trauma such as caused by motor vehicle collisions or falls. Penetrating injuries in the area of the urethra may also cause urethral trauma. Straddle injuries may cause both short- and long-term problems. Iatrogenic injury to the urethra from traumatic catheter placement, transurethral procedures, or dilation is not uncommon.

Problem

Urethral injuries can be classified into 2 broad categories based on the anatomical site of the trauma. Posterior urethral injuries are located in the membranous and prostatic urethra. These injuries are most commonly related to major blunt trauma such as motor vehicle collisions and major falls, and most of such cases are accompanied by pelvic fractures. Injuries to the anterior urethra are located distal to the membranous urethra. Most anterior urethral injuries are caused by blunt trauma to the perineum (straddle injuries), and many have delayed manifestation, appearing years later as a urethral stricture. External penetrating trauma to the urethra is rare, but iatrogenic injuries are quite common in both segments of the urethra. Most are related to difficult urethral catheterizations.

Epidemiology
Frequency
Posterior urethral injuries are most commonly associated with pelvic fracture, with an incidence of 5%-10%. With an annual rate of 20 pelvic fractures per 100,000 population, these injuries are not uncommon.[1] Anterior urethral injuries are less commonly diagnosed emergently; thus, the actual incidence is difficult to determine. However, many men with bulbar urethral strictures recall an antecedent perineal blunt injury or straddle injury, making the true frequency of anterior urethral injury much higher. Penetrating injury to the urethra is rare, with major trauma centers reporting only a few per year.

Etiology
As with many traumatic events, the etiology of a urethral injury can be classified as blunt or penetrating. In the posterior urethra, blunt injuries are almost always related to massive deceleration events such as falls from some distance or vehicular collisions. These patients most often have a pelvic fracture involving the anterior pelvis.[2] Blunt injury to the anterior urethra most often results from a blow to the bulbar segment such as occurs when straddling an object or from direct strikes or kicks to the perineum. Blunt anterior urethral trauma is sometimes observed in the penile urethra in the setting of penile fracture. Penetrating trauma most often occurs to the penile urethra. Etiologies include gunshot and stab wounds. Iatrogenic injuries to the urethra occur when difficult urethral catheterization leads to mucosal injury with subsequent scarring and stricture formation. Transurethral procedures such as prostate and tumor resections and ureteroscopy can also lead to urethral injury.

Pathophysiology
Injury to the posterior urethra occurs when a shearing force is applied at the prostatomembranous junction in blunt pelvic trauma. The prostatic urethra is fixed in position because of the attachments of the puboprostatic ligaments. Displacement of the bony pelvis from a fracture type injury thus leads to either tearing or stretching of the membranous urethra.[3] Anterior urethral injury most often results from a blunt force blow to the perineum, producing a crushing effect on the tissues of the urethra. The initial injuries are often ignored by the patient, and urethral injury manifests years later as a stricture. The stricture results from scarring induced by ischemia at the site of the injury. Penetrating injuries also occur in the anterior urethra as a result of external violence.

Presentation
Diagnosis of urethral injuries requires a reasonably high index of suspicion. Urethral injury should be suspected in the setting of pelvic fracture, traumatic catheterization, straddle injuries, or any penetrating injury near the urethra. Symptoms include hematuria or inability to void. Physical examination may reveal blood at the meatus or a high-riding prostate gland upon rectal examination. Extravasation of blood along the fascial planes of the perineum is another indication of injury to the urethra. "Pie in the sky" findings revealed by cystography usually indicate urethral disruption. The diagnosis of urethral trauma is made by with retrograde urethrography, which must be performed prior to insertion of a urethral catheter to avoid further injury to the urethra. Extravasation of contrast demonstrates the location of the tear. Further management is predicated on the findings of urethrography in combination with the patient's overall condition. See the images below.

Urethrogram demonstrating partial urethral disruption.

Urethrogram demonstrating complete urethral disruption.

Relevant Anatomy
The male urethra may be divided into 2 portions. The posterior urethra includes the prostatic urethra, which extends from the bladder neck through the prostate gland. It then joins the membranous urethra, which lies between the prostatic apex and the perineal membrane. The anterior urethra begins at that point and includes 3 segments. The bulbar urethra courses through the proximal corpus spongiosum and ischial cavernosus-bulbospongiosus muscles to reach the penile urethra. The penile urethra then extends through the pendulous portion of the penis to the final segment, the fossa navicularis. The fossa navicularis is invested by the spongy tissue of the glans penis. Potential areas for injury can be deduced from further study of the urethral anatomy. The membranous urethra is prone to injury from pelvic fracture because the puboprostatic ligaments fix the apex of the prostate gland to the bony pelvis and thus cause shearing of the urethra when the pelvis is displaced. The bulbar urethra is susceptible to blunt force injuries because of its path along the perineum. Straddle-type injuries from falls or kicks to the perineal area can result in bulbar trauma. Conversely, the penile urethra is less likely to be injured from external violence because of its mobility, but iatrogenic injury from catheterization or manipulation can occur, which is also possible in the fossa navicularis.

Contraindications
In cases of urethral trauma, patients often have multiple injuries. Immediate urethral repair is relatively contraindicated because life-threatening injuries must be corrected first in any trauma algorithm. Urethral repair should be undertaken after the patient has stabilized, when hemorrhage is less of a concern. If open repair is planned, it is better to allow the pelvic hematoma to subside prior to the procedure. Penetrating anterior urethral injuries should be explored; however, defects longer than 2 cm in the bulbar urethra and longer than 1.5 cm in the penile urethra should never be emergently repaired. They should be reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue transfers required for the repair.[4] Proceed to Workup

Imaging Studies

These studies have become even more important as trauma services rely more on initial CT scanning as the major imaging modality. The "trauma" CT may well miss lower urinary tract injuries to the urethra and bladder and thus any suspicion for urethral injury should lead one to perform these studies in addition to any others.[5]

Retrograde urethrography
The retrograde urethrography is the standard imaging study for the diagnosis of urethral injury. It is performed using gentle injection of 20-30 mL of contrast into the urethra. Examination is made for extravasation, which pinpoints the existence and location of the urethral tear.

Cystography
The static cystography allows for concurrent bladder injury to be excluded in the acute setting. When a delayed repair is being considered, voiding cystography (performed through the suprapubic catheter) demonstrates the bladder neck and prostatic urethral anatomy and allows for proper surgical planning.

Diagnostic Procedures
Cystoscopy can be a valuable adjunct in the evaluation of a male urethral injury. In the acute setting, the feasibility of early endoscopic realignment can be determined (see Treatment). In the delayed setting, the quality of the urethra can be evaluated for surgical repair. When cystoscopy is combined with retrograde urethrography and cystography, a more accurate estimation of stricture length can be made, facilitating decisions in operative strategy. Proceed to Treatment & Managemen

Surgical Therapy
When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopedic specialists. Lifethreatening injuries must be corrected first in any trauma algorithm.[6] The traditional intervention for men with posterior urethral injury secondary to pelvic fracture is placement of a suprapubic catheter for bladder drainage and subsequent delayed repair. This is the safest approach because it establishes urinary drainage and does not require either urethral manipulation or entrance into the hematoma caused by the fracture of the pelvis. This allows a formal repair to be carried out several weeks later under controlled circumstances and after resolution of the hematoma. The suprapubic catheter can be safely placed either percutaneously or via an open approach with a small incision. Ultrasound guidance can aid in the percutaneous approach. Some advocate immediate realignment through a number of different techniques, although much controversy exists on this topic. Ultimate repair of the posterior urethral injury can be performed 6-12 weeks after the event, after the pelvic hematoma has resolved and the patient's orthopedic injuries have stabilized. It is often carried out via a perineal approach, and repair consists of mobilizing the urethra distally to allow a direct anastomosis after excision of the stricture. To prevent tension on the anastomosis, the distal urethra can be mobilized to the penoscrotal junction. Further length can be achieved with division of the septum between the corpora cavernosa and with inferior pubectomy. A urethral catheter is left indwelling to stent the repair, and the suprapubic catheter may be removed. Transpubic approaches for this repair have also been described and may be useful in men with fistulous tracts complicating a membranous urethral injury. Combining a perineal and abdominal approach with pubectomy provides maximum exposure of the prostatic apex.[7, 8, 9, 10] Early realignment of posterior urethral injuries is also a treatment option. This has been performed at the time of injury, using interlocking sounds or by passage of catheters from both retrograde and antegrade approaches. Also, direct suture repair has been attempted in the immediate postinjury period. Another approach could be careful insertion of a urethral catheter under fluoroscopic guidance by a urologist experienced in that approach. These approaches have the disadvantage of possible entrance into and contamination of the pelvic hematoma with ensuing hemorrhage and sepsis.

Early endoscopic realignment (within 1 week postinjury) using a combined transurethral and percutaneous transvesical approach may be safer. If performed 5-7 days postinjury, the pelvic hematoma has stabilized and hemorrhage is less of a concern. The patient's overall condition has usually improved by this time, and sepsis is less of a concern.[11, 6] Bulbar urethral injuries often manifest months to years following blunt perineal trauma. The presentation for these injuries is often that of decreased stream and voiding symptoms. The diagnosis of urethral stricture is then made with urethrography and cystoscopy. These strictures may be managed with excision of the stricture and end-to-end anastomosis via a perineal approach. Most are short (< 2 cm). Longer strictures may require flaps (penile fasciocutaneous) or grafts (buccal mucosa) to achieve a tensionless anastomosis.[12] Penetrating anterior urethral injuries should be explored. The area of injury should be examined, and devitalized tissue should be debrided carefully to minimize tissue loss. Defects of up to 2 cm in the bulbar urethra and up to 1.5 cm in the penile urethra can be repaired primarily via a direct anastomosis over a catheter with fine absorbable suture. This is the preferred method of repair for these injuries. Longer defects should never be repaired emergently; they should be reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue transfers required for the repair. Urinary diversion can be accomplished with a suprapubic catheter during this interval.[13] Female urethral injuries are uncommon but deserve special consideration. The mechanism involves shearing of the urethra away from the pubic symphysis by the pelvic fracture and can be associated with significant vaginal and bladder injury. Blood is often found in the vaginal vault on pelvic examination, and passage of a urethral catheter is impossible or yields no urine. Urethrography is difficult to obtain; the diagnosis is often clinical. Concomitant bladder injury must often be ruled out with CT cystography. These women commonly have multiple injuries, and the management approach must reflect this. Bladder drainage must be established; the easiest and fastest method is placement of a suprapubic catheter followed by delayed evaluation and reconstruction. If the patient is being explored for other injuries or if a percutaneous suprapubic catheter cannot be safely placed, cystotomy with antegrade urethral catheter may provide for early definitive repair and minimize further morbidity. Careful followup is needed to manage any resulting incontinence or gynecologic disturbance.

Preoperative Details
In all urethral injuries, the location of the injury should be localized with repeat urethrography, antegrade cystogram through the suprapubic tube, and cystoscopy, if needed. If an open perineal repair is performed, the patient should be positioned in an exaggerated lithotomy position with the legs well padded. Deep venous thrombosis prophylaxis with compression stockings is preferred. Access to the bladder via the indwelling suprapubic catheter is also useful. If endoscopic realignment is contemplated, a more relaxed lithotomy position is better. A wide variety of endoscopes, graspers, and wires is needed. This procedure is often best performed using a C-arm for fluoroscopy because of the ease in obtaining oblique views. Exploration for penile urethral injuries can be performed in the supine position, although lithotomy may also be helpful if dissection must be carried down into the scrotum. Flexible cystoscopy may also be of assistance during the procedure.

Intraoperative Details
In open urethral reconstruction, careful dissection of the urethra is important. Anastomoses must be performed in a mucosa-to-mucosa fashion to ensure proper healing without further scarring. All anastomoses should be performed over a catheter for stenting purposes. Excessive mobilization of the urethra must be avoided to prevent tethering of the penis. If a gap of more than 2 cm must be bridged, performing a flap procedure rather than placing the anastomosis under tension or tethering the penis, which causes curvature, is better. This should be performed as part of a delayed reconstruction and not in the acute setting.

Local flaps should be handled meticulously to avoid devascularization. Buccal mucosal grafts should be harvested from the inner cheek and carefully tubularized over a catheter. These may also be effectively used in an onlay fashion. In endoscopic realignment, having 2 urologists working simultaneously with fluoroscopy is preferable. One should pass a scope transurethrally and the other should work via the suprapubic tract. Often, injuries thought to be a complete disruption are found to be partial disruptions, and the intact mucosa can be followed into the bladder. If the scopes can meet and pass wires to one another, then a catheter may be placed transurethrally over the wire.

Postoperative Details
In open repairs, the suprapubic catheter may be removed immediately, leaving the urethral catheter for drainage and stenting. The patient may be mobilized on the day following surgery and discharged when tolerating a diet. Antibiotics are maintained for 2 weeks, and the catheter is removed after 4 weeks. A similar pattern is followed for the endoscopic procedure except that the urethral catheter is left indwelling for 6 weeks. After either type of procedure, retrograde urethrography may be indicated to ensure extravasation is not occurring prior to catheter removal. This is particularly true for patients with poor wound healing such as people with diabetes.

Follow-up
In all instances of urethral injury, follow-up should include assessment of the patient's voiding history, continence status, and potency. Undoubtedly, follow-up should be life-long, although in the trauma population this is often difficult to achieve. Repeat cystourethrography and cystoscopy should be used whenever changes occur following reconstruction.

Complications
The main complication following reconstruction of posterior injuries is recurrent stricture. When managed with standard urethroplasty techniques, recurrent stricture requiring major repeat operation should be observed in only 1%-2% of patients, although 10%-15% may require either dilation or incision of a short recurrence. Endoscopic realignment by experienced physicians appears to produce similar results. When performed at 5-7 days postinjury, rare infectious complications occur despite the presence of the organized pelvic hematoma. Continence rates approach 100% in all series, particularly if the bladder neck is not involved. Potency status is probably related to the extent of the injury itself rather than the management of the problem. Several series have demonstrated only a small group of men losing erectile capabilities following the urethroplasty when they are potent following the actual injury. Complications of reconstruction of anterior urethral injuries are similar to those observed in posterior urethral repairs.

Outcome and Prognosis

Men with urethral injuries have an excellent prognosis when managed correctly. Problems arise if a urethral injury is unrecognized and the urethra is further damaged by attempts at blind catheterization. In those instances, future reconstruction may be compromised and recurrent stricture rates rise. When managed well, these men have an excellent chance of becoming totally rehabilitated from a urinary standpoint

Bladder Trauma

Author: Raymond Rackley, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...

Overview Treatment
Updated: Jan 23, 2012

Background History of the Procedure Problem Epidemiology Etiology Pathophysiology Presentation Indications Relevant Anatomy Contraindications

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Background
Bladder injuries are caused by blunt or penetrating trauma.[1, 2] The probability of bladder injury varies according to the degree of bladder distention; therefore, a full bladder is more likely to become injured than an empty one. Although uniformly fatal in the past, a timely diagnosis with appropriate medical and surgical management now offers an excellent outcome. Early clinical suspicion, appropriate and reliable radiologic studies, and prompt surgical intervention, when indicated, are the keys to successful diagnosis and management of bladder trauma.[3] For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Procedures Center. Also, see eMedicine's patient education articles Blood in the Urine, Intravenous Pyelogram, Cystoscopy, and Foley Catheter.

History of the Procedure

Patients with signs and symptoms suggestive of a bladder injury have a history typical for pelvic trauma, which is fairly straightforward for motor vehicle collisions, deceleration injuries, or assaults to the lower abdomen. If the patient is unconscious, family members or, more often, emergency services personnel may be able to provide the history. Bladder injury from a motor vehicle collision may occur from direct impact with the car or indirectly from the steering wheel or seatbelt. Deceleration injuries of the urinary bladder usually result from falling from a great height and landing on unyielding ground. Assault to the lower abdomen by a sharp kick or blow may result in a bladder perforation. Penetrating injuries to the bladder usually result from high-velocity gunshots or sharp stab wounds to the suprapubic area.[4]

Problem
Blunt trauma
Deceleration injuries usually produce both bladder trauma (perforation) andpelvic fractures. Approximately 10% of patients with pelvic fractures also have significant bladder injuries. The propensity of the bladder to sustain injury is related to its degree of distention at the time of trauma. [5, 6,
7]

Penetrating trauma
Assault from a gunshot or stabbing typifies penetrating trauma. Often, concomitant abdominal and/or pelvic organ injuries are present.

Obstetric trauma
During prolonged labor or a difficult forceps delivery, persistent pressure from the fetal head against the mother's pubis can lead to bladder necrosis. Direct laceration of the urinary bladder is reported in

0.3% of women undergoing acesarean delivery. Previous cesarean deliveries with resultant adhesions are a risk factor. Undue scarring may cause obliteration of normal tissue planes and facilitate an inadvertent extension of the incision into the bladder. Unrecognized bladder injuries may lead to vesicouterine fistulas and other problems.

Gynecologic trauma
Bladder injury may occur during a vaginal or abdominal hysterectomy. Blind dissection in the incorrect tissue plane between the base of the bladder and the cervical fascia results in bladder injury.

Urologic trauma
Perforation of the bladder during a bladder biopsy, cystolitholapaxy,transurethral resection of the prostate (TURP), or transurethral resection of a bladder tumor (TURBT) is not uncommon. Incidence of bladder perforation is reportedly as high as 36% following bladder biopsy.

Orthopedic trauma
Orthopedic pins and screws can commonly perforate the urinary bladder, particularly during internal fixation of pelvic fractures. Thermal injuries to the bladder wall may occur during the setting of cement substances used to seat arthroplasty prosthetics.

Idiopathic bladder trauma

Patients diagnosed with alcoholism and individuals who chronically imbibe a large quantity of fluids are susceptible to this type of injury. Previous bladder surgery is a risk factor. In reported cases, all bladder ruptures were intraperitoneal. This type of injury may result from a combination of bladder overdistention and minor external trauma (eg, a simple fall).

Epidemiology
Frequency
Frequency of bladder rupture varies according to the following mechanisms of injury: External trauma (82%) Iatrogenic (14%) Intoxication (2.9%) Spontaneous (< 1%) Of all bladder injuries, 60%-85% are from blunt trauma and 15%-40% are from a penetrating injury.[8] The most common mechanisms of blunt trauma are motor vehicle collisions (87%), falls (7%), and assaults (6%). In penetrating traumas, the most frequent culprit is gunshot wounds (85%), followed by stabbings (15%). Approximately 10%-25% of patients with a pelvic fracture also have urethral trauma. Conversely, 10%-29% of patients with posterior urethral disruption have an associated bladder rupture. Traumatic bladder ruptures Of traumatic ruptures, extraperitoneal bladder perforations account for 50%-71%,[9] intraperitoneal accounts for 25%-43%, and combined perforations account for 7%-14%.[10] The incidence of intraperitoneal bladder rupture is significantly higher in children because of the predominantly intraabdominal location of the bladder prior to puberty. Combined intraperitoneal and extraperitoneal ruptures account for approximately 10% of all traumatic bladder-perforating injuries. Mortality rates in these patients approach 60%, as compared to 17%-22% overall, reflecting the severity of concomitant injuries associated with combined bladder ruptures. Associated bowel injuries Among patients with bladder trauma due to a gunshot, the incidence of associated bowel injuries is reportedly as high as 83%. Colon injuries are reported in 33% of patients with stab wounds, and vascular injuries are reportedly as high as 82% in patients with a penetrating trauma (with a 63% mortality rate).

Etiology
Main causes of bladder injury are penetrating and blunt trauma. Iatrogenic causes include surgical misadventures from gynecologic, urologic, and orthopedic operations near the urinary bladder. Less common causes involve obstetric trauma. Spontaneous or idiopathic bladder injuries without an obvious underlying pathology constitute the remainder.

Pathophysiology
Bladder contusion is an incomplete or partial-thickness tear of the bladder mucosa. A segment of the bladder wall is bruised or contused, resulting in localized injury and hematoma. Contusion typically occurs in the following clinical situations: Patients presenting with gross hematuria after blunt trauma and normal imaging findings Patients presenting with gross hematuria after extreme physical activity (ie, long-distance running) The bladder may appear normal or teardrop-shaped on cystography. Bladder contusions are relatively benign, are the most common form of blunt bladder trauma, and are usually a diagnosis of exclusion. Bladder contusions are self-limiting and require no specific therapy, except for short-term bedrest until hematuria resolves. Persistent hematuria or unexplained lower abdominal pain requires further investigation.

Extraperitoneal bladder ruptures

Traumatic extraperitoneal ruptures are usually associated with pelvic fractures (89%-100%). Previously, the mechanism of injury was believed to be from a direct perforation by a bony fragment or a disruption of the pelvic girdle. It is now generally agreed that the pelvic fracture is likely coincidental and that the bladder rupture is most often due to a direct burst injury or the shearing force of the deforming pelvic ring. These ruptures are usually associated with fractures of the anterior pubic arch, and they may occur from a direct laceration of the bladder by the bony fragments of the osseous pelvis. The anterolateral aspect of the bladder is typically perforated by bony spicules. Forceful disruption of the bony pelvis and/or the puboprostatic ligaments also tears the wall of the bladder. The degree of bladder injury is directly related to the severity of the fracture. Some cases may occur by a mechanism similar to intraperitoneal bladder rupture, which is a combination of trauma and bladder overdistention. The classic cystographic finding is contrast extravasation around the base of the bladder confined to the perivesical space; flame-shaped areas of contrast extravasation are noted adjacent to the bladder. The bladder may assume a teardrop shape from compression by a pelvic hematoma. Starburst, flame-shape, and featherlike patterns are also described. With a more complex injury, the contrast material extends to the thigh, penis, perineum, or into the anterior abdominal wall. Extravasation will reach the scrotum when the superior fascia of the urogenital diaphragm or the urogenital diaphragm itself becomes disrupted. If the inferior fascia of the urogenital diaphragm is violated, the contrast material will reach the thigh and penis (within the confines of the Colles fascia). Rarely, contrast may extravasate into the thigh through the obturator foramen or into the anterior abdominal wall. Sometimes, the contrast may extravasate through the inguinal canal and into the scrotum or labia majora. See the image below.

CT scan of extraperitoneal bladder rupture. The contrast extravasates from the bladder into the prevesical space.

Intraperitoneal bladder rupture

Classic intraperitoneal bladder ruptures are described as large horizontal tears in the dome of the bladder. The dome is the least supported area and the only portion of the adult bladder covered by peritoneum. The mechanism of injury is a sudden large increase in intravesical pressure in a full bladder. When full, the bladder's muscle fibers are widely separated and the entire bladder wall is relatively thin, offering relatively little resistance to perforation from sudden large changes in intravesical pressure. Intraperitoneal bladder rupture occurs as the result of a direct blow to a distended urinary bladder. Resulting increase in intravesical pressure causes a horizontal tear along the intraperitoneal portion of the bladder wall. This is the weakest part of the bladder, since its muscle fibers are most widely separated. This type of injury is common among patients diagnosed with alcoholism or those sustaining a seatbelt or steering wheel injury. Since urine may continue to drain into the abdomen, intraperitoneal ruptures may go undiagnosed from days to weeks. Electrolyte abnormalities (eg,hyperkalemia, hypernatremia, uremia, acidosis) may occur as urine is reabsorbed from the peritoneal cavity. Such patients may appear anuric, and the diagnosis is established when urinary ascites are recovered during paracentesis. Intraperitoneal ruptures demonstrate contrast extravasation into the peritoneal cavity, often outlining loops of bowel, filling paracolic gutters, and pooling under the diaphragm. An intraperitoneal rupture is more common in children because of the relative intra-abdominal position of the bladder. The bladder usually descends into the pelvis by age 20 years. See the image below.

Cystogram of intraperitoneal bladder rupture. The contrast enters the intraperitoneal cavity and outlines loops of bowel.

Combination of intraperitoneal and extraperitoneal ruptures

Cystogram reveals contrast outlining the abdominal viscera and perivesical space. External penetrating injuries deserve special mention. A penetrating injury of the urinary bladder results from a high-velocity bullet traversing the bladder, knife wounds, or impalement by various sharp objects. These may result in intraperitoneal, extraperitoneal, or a combined bladder injury. See the image below.

Cystogram of extraperitoneal bladder rupture. Note the fractured pelvis and contrast extravasation into the space of Retzius.

The high incidence of associated injury to abdominal viscera and vascular structures mandates surgical exploration in virtually every case. Often, cystography is bypassed, and the diagnosis is made during an exploratory laparotomy. Cystography results may be falsely negative in patients with penetrating bladder injuries secondary to small-caliber bullet wounds. In such patients, these injuries may not be appreciated until exploratory surgery is performed.

Presentation

Clinical signs of bladder injury are relatively nonspecific; however, a triad of symptoms is often present (eg, gross hematuria, suprapubic pain or tenderness, difficulty or inability to void). Most patients with bladder rupture complain of suprapubic or abdominal pain, and many can still void; however, the ability to urinate does not exclude bladder injury or perforation. Hematuria invariably accompanies all bladder injuries. Gross hematuria is the hallmark of a bladder rupture. More than 98% of bladder ruptures are associated with gross hematuria, and 10% are associated with microscopic hematuria; conversely, 10% of patients with bladder ruptures have normal urinalysis results. An abdominal examination may reveal distention, guarding, or rebound tenderness. Absent bowel sounds and signs of peritoneal irritation indicate a possible intraperitoneal bladder rupture. A rectal examination should be performed to exclude rectal injury and, in males, to evaluate prostate position. If the prostate is "high riding" or elevated, it may further suggest proximal urethra and bladder disruption. In the setting of a motor vehicle collision or a crush injury, bilateral palpation of the bony pelvis may reveal abnormal motion, indicating an open-book fracture or a disruption of the pelvic girdle. If blood is present at the urethral meatus, suspect a urethral injury. Perform retrograde urethrography to assess the integrity of the urethra before attempting to blindly pass a Foley catheter.

Indications
Foley catheter
Blood at the urethral meatus is an absolute indication for retrograde urethrography. Approximately 10%-20% of men with a posterior urethral injury have an associated bladder injury; therefore, do not place a urethral catheter in these patients. Passage of a urethral catheter may convert a partially disrupted urethra into a complete tear. Place a Foley catheter only after urethral injuries are excluded. In the setting of a posterior urethral injury, insert a percutaneous suprapubic catheter.

CT scanning
This is often the first test performed in patients with blunt abdominal trauma. The CT scan of the pelvis provides information on the status of the pelvic organs and osseous pelvis and has replaced conventional cystography as the most sensitive test for bladder perforation. Once the urethra has been cleared by a retrograde urethrogram, a urethral catheter can be placed. Dilute Cysto-Conray is then passed through the urethral catheter, and an abdominal/pelvic CT scan is performed. Subtle perforations are often revealed, and the intraperitoneal and extraperitoneal nature of these ruptures can be determined.

Cystography
The criterion standard for imaging a suspected bladder injury is a well-performed cystography. Although it is preferable to perform the examination under fluoroscopy, clinical circumstances often do not permit this. A static cystography is satisfactory, even when performed at the bedside with portable equipment. Most patients with bladder trauma have multiple injuries and require abdominal or pelvic CT scans as part of their trauma evaluation. This does not preclude obtaining a separate contrast cystogram if the bladder findings of the CT scan are equivocal.[11] A properly performed cystography consists of an initial kidney-ureter-bladder (KUB) followed by anteroposterior (AP) and oblique views of the bladder filled with contrast, plus another AP film obtained after drainage. The following procedure is recommended: Obtain a scout radiograph. Place a urethral catheter in the bladder. Using a diluted contrast medium, slowly fill the bladder by gravity (approximately 75 cm above the pelvis) to a volume of 300-400 mL. (Diluted contrast media are usually 50% contrast and 50% sterile saline or water). Use a contrast media suitable for absorption.

Obtain a single AP film of the pelvis and lower abdomen after the first 100 mL of contrast is instilled. If gross extravasation is noted, discontinue the procedure. If extravasation is absent, give the patient the remainder of the contrast. Obtain a KUB, followed by a postdrainage film of the pelvis. Obtain the postdrainage film after a complete drainage of the contrast. This is the most critical part of the study because it checks for extravasation that may be hidden by the distended bladder. If possible, obtain lateral and oblique films of the bladder. In children, obtain the estimated filling for the cystogram based on the following formula: Bladder capacity = 60 mL + (30 mL X age in years) The importance of proper filling and drainage films cannot be overemphasized. A significant number of injuries may be missed if the cystogram is not performed correctly. As oblique films may be difficult to obtain in a trauma patient with pelvic fractures, they may be omitted in selected cases. The volume infused is less important than achieving an adequate bladder pressure to demonstrate small bladder injuries that may go undetected. Small puncture wounds or lacerations may be self-sealing because of mucosal edema. Overlying hematomas, omentum, a sigmoid colon, or a small bowel may seal the wound. Full distention helps to prevent this falsenegative result, and the accuracy of a well-performed static cystogram ranges from 85%-100%. If the patient is immediately taken to the operating room for an exploratory laparotomy and/or placement of a formal suprapubic cystostomy, the bladder is inspected at the time of surgery and the bladder injury is repaired. If surgery is delayed or an exploratory laparotomy is not contemplated, perform the cystogram via a percutaneous suprapubic tube (SPT) so that no bladder injury is overlooked.[12] Although static cystography is used to accurately diagnose a bladder injury, the same cannot be said of intravenous pyelography (IVP). The inaccuracy of IVP stems from incomplete bladder distension, poor opacification, or a combination of both.

Relevant Anatomy
The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the space of Retzius. The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis. In males, the bladder neck is contiguous with the prostate, which is attached to the pubis by puboprostatic ligaments. In females, pubourethral ligaments support the bladder neck and urethra. The body of the bladder receives support from the urogenital diaphragm inferiorly and the obturator internus muscles laterally. The superior fascia of the urogenital diaphragm is continuous and includes the pelvic, obturator, and endopelvic fasciae. The inferior fascia of the urogenital diaphragm fuses with the Colles fascia. It continues as the Scarpa fascia anteriorly, the dartos muscle and fascia in the scrotum, and the fascia lata of the thigh. The type of extravasation (intraperitoneal or extraperitoneal) depends upon the location of the laceration and its relationship with the peritoneal reflection. If the perforation is above the peritoneal reflection, the extravasation is intraperitoneal. If the injury is below the peritoneal reflection, the extravasation is extraperitoneal. With an anterosuperior perforation, urinary extravasation may be intraperitoneal, extraperitoneal (space of Retzius), or both. If the tear is posterosuperior, fluid can spread intraperitoneally and/or retroperitoneally. In a bladder rupture, the superior fascia of the urogenital diaphragm, when intact, prohibits extravasation from escaping the pelvis. Inferior fascia of the urogenital diaphragm, when intact, also prevents urinary extravasation from flowing into the perineum.

Contraindications

Posterior urethral injury is a specific contraindication to insertion of a urethral Foley catheter. Suspect a posterior urethral injury if blood is present at the meatus, in all pelvic fractures, or if a high-riding prostate is found on digital rectal examination. When posterior urethral injury is suspected, perform a retrograde urethrogram before attempting to insert a Foley catheter. Perform a retrograde urethrogram as follows: Gently stretch the penis and hold it at an obtuse angle from the pelvis. Insert a 16F Foley catheter into the distal urethra, and inflate the balloon (3 mL) within the fossa navicularis. Alternatively, if available, a Brodney clamp may be used, which allows a better seal at the urethral meatus. Inject a diluted x-ray contrast medium suitable for intravenous infusion into the catheter using a 60mL piston syringe. Obtain radiographic images of the urethra and the bladder. Oblique views are usually the most helpful. An extravasation indicating urethral injury will be readily apparent. Alternatively, the tip of a 60-mL piston syringe may be engaged into the urethral meatus and contrast injected directly into the urethra. Lead-lined gloves must be worn when contrast is injected directly into the urethra to prevent radiation exposure to the examiner's hands. After excluding posterior urethral injury, radiographic evaluation of suspected bladder injury may commence. In the presence of a documented urethral injury, a percutaneous SPT must be placed and primary urethral realignment attempted once the patient is stable; this is often efficacious in the prevention of severe urethral stricture formation. Primary realignment may often be attempted with flexible cystoscopy at the bedside and may help to obviate the need for a formal urethroplasty at a later date. Proceed to Treatment & Management

Medical Therapy
Most extraperitoneal ruptures can be managed safely with simple catheter drainage (ie, urethral or suprapubic).[13] Leave the catheter in for 7-10 days and then obtain a cystogram. Approximately 85% of the time, the laceration is sealed and the catheter is removed for a voiding trial. [14, 15] Virtually all extraperitoneal bladder injuries heal within 3 weeks. If the patient is taken to the operating room for associated injuries, extraperitoneal ruptures may be repaired concomitantly if the patient is stable.

Surgical Therapy
Intraperitoneal bladder rupture
Most, if not all, intraperitoneal bladder ruptures require surgical exploration.[16, 17] These injuries do not heal with prolonged catheterization alone. Urine takes the path of least resistance and continues to leak into the abdominal cavity. This results in urinary ascites, abdominal distention, and electrolyte disturbances. Surgically explore all gunshot wounds to the lower abdomen. Because of the nature of associated visceral injuries, immediately take patients with high-velocity missile trauma to the operating room, where the bladder injuries can be repaired concomitantly with other visceral injuries. Stab wounds to the suprapubic area involving the urinary bladder are managed selectively. Surgically repair obvious intraperitoneal injuries, and manage small extraperitoneal injuries expectantly with catheter drainage.

Extraperitoneal extravasation
Bladders with extensive extraperitoneal extravasation are often repaired surgically. Early surgical intervention decreases the length of hospitalization and potential complications, while promoting early recovery.

Preoperative Details

Follow the basic trauma protocol (advanced trauma life support [ATLS]), and stabilize the patient. Administer broad-spectrum antibiotics, and obtain a surgical informed consent, if possible. In the setting of emergency trauma, however, there is often no time for a formal surgical consent from the patient.

Intraoperative Details
Position the patient in a supine fashion. Create a vertical midline abdominal incision. Conduct a thorough inspection of the pelvic viscera, ureters, bowel, and blood vessels. Note the presence of pelvic hematoma and, if present, leave undisturbed. Bivalve the dome of the bladder. Inspect the interior of the bladder. Foreign bodies such as bone or orthopedic hardware are often encountered and should be removed. Identify both ureteral orifices and ensure that they are intact. Once the bladder injury is localized, dbride all nonviable tissue. High-velocity missile injuries may cause extensive damage to the bladder tissues. Close the bladder in a watertight fashion using 3 layers with an absorbable suture. Every effort should be made to protect the closure from any sharp edges or bony protusions from associated pelvic fractures. Omental fat is often interposed on the closure as an additional layer. Test the integrity of the closure by inflating the bladder with saline or water. Place a large-bore suprapubic tube through a separate cystotomy site prior to closing the bladder. Place a pelvic drain in the perivesical space. Close the abdomen in layers, and apply staples to the skin.

Postoperative Details
Continue intravenous antibiotics until the patient is discharged. Remove the pelvic drain when the drainage output is minimal, usually within 48-72 hours. Leave in the SPT and indwelling urethral catheters until x-ray cystography is performed. Discharge the patient when he or she shows diet toleration and is ambulatory, afebrile, and relatively pain-free.

Follow-up
Instruct the patient to return in 7-10 days for staple removal, and check the wound at that time. Obtain the x-ray cystogram 10-14 days after surgery. If the cystogram finding is normal, remove the urethral catheter. Perform a voiding trial via the SPT. Remove the SPT when the patient passes the voiding trial. Advise the patient to return to normal activity within 4-6 weeks after surgery.

Complications
Potential complications of bladder surgery Urinary extravasation Wound dehiscence Hemorrhage Pelvic infection Small-capacity bladder De novo urge incontinence Other complications Despite technically proper reconstruction, urinary extravasation through the bladder closure may occur. This usually responds to extended catheter drainage. Abdominal fascial dehiscence presents as persistent drainage from the incision site. Violation of pelvic hematomas during surgery results in severe hemorrhage. If infected, pelvic hematomas become pelvic abscesses. Aggressive surgical dbridement of the bladder may result in a small bladder, giving rise to bladder spasms and urge incontinence. Over time, the bladder may gradually enlarge to more physiologic volumes.

Outcome and Prognosis

Traumatic bladder ruptures, once uniformly fatal, are currently managed quite successfully. Timely evaluation and proper management are critical for optimal outcomes.

Gross hematuria is the hallmark of bladder injury. Physicians evaluating patients with blunt or penetrating lower abdominal trauma must have a high index of suspicion for urologic injury, especially bladder and urethral injuries. Almost all extraperitoneal bladder ruptures are associated with pelvic fractures. Most extraperitoneal ruptures can be treated conservatively with catheter drainage alone; however, ensure that all intraperitoneal, combined intraperitoneal and extraperitoneal ruptures, and penetrating injuries are treated with immediate exploration and repair in the operating room.

Future and Controversies

Proper treatment of tiny intraperitoneal bladder perforations resulting from urologic transurethral instrumentation is controversial. Most authorities recommend an abdominal exploration and closure of the bladder perforation. Others advocate conservative management with an indwelling urethral Foley catheter and prolonged bladder rest. Currently, no published data support conservative management.

Renal Trauma

Author: Dennis G Lusaya, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...

Overview Workup Treatment

Updated: Oct 20, 2011

Background Problem Epidemiology Etiology Presentation Indications Relevant Anatomy Contraindications

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Background
Renal trauma may manifest in a dramatic fashion for both the patient and the clinician. The incidence of renal trauma somewhat depends on the patient population being considered. Renal trauma accounts for approximately 3% of all trauma admissions and as many as 10% of patients who sustain abdominal trauma. In addition, renal trauma may occur in settings other than those thought of as a classic trauma setting. At most trauma centers, blunt trauma is more common than penetrating trauma, thereby making blunt renal injuries as much as 9 times more common than penetrating injuries. Both kidneys are at equal disposition for injury.[1] The approach to renal injuries has changed over time, requiring diligent attention to recent literature. Namely, the tolerance for nonoperative or expectant management has increased, even in the most seriously injured kidneys, replacing the past tendency toward aggressive renorrhaphy.

Problem
Most renal trauma occurs as a result of blunt trauma. Renal injuries may be generally divided into 3 groups: renal laceration, renal contusion, and renal vascular injury. All subsets of renal trauma require a high index of clinical awareness and prompt evaluation and management.

Epidemiology
Frequency
The frequency of renal injury somewhat depends on the patient population being considered. Renal trauma accounts for approximately 3% of all trauma admissions and as many as 10% of patients who sustain abdominal trauma.

Etiology
The mechanism of injury should alert the clinician to the possibility of renal trauma. The following list is not all-inclusive, but it highlights the major mechanisms that generate renal injuries: Penetrating (eg, gunshot wounds, stab wounds) Blunt - Rapid deceleration (eg, motor vehicle crash, fall from heights); direct blow to the flank (eg, pedestrian struck, sports injury) Iatrogenic (eg, endourologic procedures, extracorporeal shock-wave lithotripsy,[2] renal biopsy, percutaneous renal procedures) Intraoperative (eg, diagnostic peritoneal lavage[3] ) Other (eg, renal transplant rejection, childbirth[4] [may cause spontaneous renal lacerations])

Presentation
The diagnosis of renal injury begins with a high index of clinical awareness. The mechanism of injury provides the framework for the clinical assessment. Particular attention should be paid to complaints of flank or abdominal pain. Urinalysis, both gross and, if necessary, microscopic, should be performed in patients who are thought to have renal trauma. Based on these initial measures, radiographic or operative investigation may follow.

Indications
Most blunt renal injuries are low-grade; therefore, they are usually amenable to treatment with observation and bed rest alone. Penetrating trauma is more likely to be associated with more severe renal injury, thus requiring a higher index of clinical awareness. Further, penetrating trauma is more often associated with other abdominal injuries requiring laparotomy, thus providing the opportunity for intraoperative renal staging and/or repair. Patients with indications for emergent exploration include those with hemodynamic instability. Expanding hematomas or active hemorrhage suggests the possibility of high-grade renal injury. Patients with penetrating trauma who are stable and do not require urgent laparotomy for other possible intra-abdominal injuries may be observed without immediate renal exploration. Unrelenting gross hematuria may require urgent exploration. However, the presence of a renal contusion does not typically require specific intervention. Findings from imaging studies may appear quite alarming, but most renal contusions resolve, particularly if the lesion appears to be of grade I-III.

Relevant Anatomy
In most instances, the kidneys are paired retroperitoneal structures. They lie against the psoas muscles. The superior aspect of the kidneys is somewhat protected by the lower ribs. However, the lower poles are inferior to the 12th ribs. The parenchyma of the kidney has a segmental arterial supply. This anatomic arrangement becomes important in the management of renal lacerations. Blunt injuries tend to fracture along the planes between the segmental vessels, while penetrating injuries cross the segmental vessels. Numerous anatomic variations exist, including pelvic kidneys; horseshoe kidneys; and multiple renal arterial, venous, and ureteral duplications.

Contraindications
For all practical purposes, no specific contraindications exist for surgical exploration of possible renal trauma. However, the general trend is toward a more selective approach. Proceed to Workup

Laboratory Studies

Urinalysis
Urinalysis provides rapidly available information in patients who may have a renal laceration; however, the data obtained must be viewed within a rational framework. If gross hematuria is not present, a microscopic examination is advisable. Although a generalization exists that the degree of hematuria correlates with the likelihood of urinary tract trauma, renal injury with no hematuria has been reported. Reliance on urinalysis as the only modality to help diagnose renal trauma is fraught with difficulty. In fact, injuries such as renal artery laceration or avulsion may not generate any hematuria. One study documents that 63% of patients with multisystem trauma had hematuria, of which 12.5% had a proven injury. Other investigators have shown that as many as 13% of patients with renal gunshot wounds did not have hematuria. Thus, the presence or absence of hematuria should be viewed in the clinical context and not used as the sole decision point in the assessment of a patient with a possible renal laceration.

Imaging Studies
Intravenous pyelography
All penetrating renal and hemodynamically unstable blunt renal trauma patients who require immediate surgical exploration should undergo one-shot, high-dose intravenous urography (IVU) prior to any renal exploration.[5] One-shot trauma IVU consists of 2 mL/kg of body weight of standard 60% ionic or nonionic contrast injected intravenously, followed by a single abdominal radiograph 10 minutes later. No scout film is necessary. In children, 2-3 mL/kg of nonionic contrast is preferred.[6] For a satisfactory study, a systolic blood pressure above 90 mm Hg is needed. In order to save time, the contrast can be injected at the time of the initial resuscitation. Unstable patients who are emergently taken to the operating room, should be stabilized first and undergo one-shot IVU in the operating room once they are stabilized. The major limitation of intravenous pyelography (IVP) is that it can seldom, by itself, define the full extent of the injury.[7] The purpose of the IVU is to determine the presence of 2 functioning renal units, the presence and extent of any urinary extravasation, and, in penetrating injuries, the likely course of the missile. Radiopaque markers (paper clips) taped to the skin at the bullet entrance and exit sites help predict the likelihood of the kidney being in the missile's path. IVU is highly accurate for establishing the presence or absence of renal injury.[8] When it comes to staging parenchymal injury, however, IVU findings are usually nonspecific and not sensitive.[9, 10] Abnormal or equivocal IVU findings warrant further exploration or radiographic staging. For the hemodynamically stable patient, further and more accurate staging can be achieved with CT scanning.[11, 12] For unstable patients with abnormal IVU findings, surgical exploration is warranted. Advantages of IVP are that it (1) allows functional and anatomic assessment of both kidneys and ureters, (2) establishes the presence or absence of 2 functional kidneys, and (3) may be performed in the emergency department or operating room. Disadvantages of IVP are that (1) it requires multiple images for maximal information, although a oneshot technique can be used; (2) the radiation dose is relatively high (0.007-0.0548 Gy); (3) a full IVP usually requires a trip to the radiology suite; and (4) findings do not reveal the full extent of injury. (One investigation of penetrating trauma showed normal findings from 6 IVP examinations out of 27 studies. These 6 patients all had renal injuries.)

Computed tomography
For stable patients, renal injury can be most accurately and completely imaged and staged using computed tomography (CT).[11, 12] CT imaging is both sensitive and specific for demonstrating parenchymal lacerations and urinary extravasations, delineating segmental parenchymal infarcts, and determining the size and location of the surrounding retroperitoneal hematoma and/or associated intra-abdominal injury (spleen, liver, pancreas, and bowel).

CT imaging has largely replaced the once standard IVU and arteriography. In the acute setting, CT scanning has completely replaced arteriography because it can also accurately delineate segmental and major arterial injuries. The present role of arteriography, however, is with delayed renal bleeding or delayed arteriovenous fistula formation, for which super-selective arterial embolization is used.[13] Renal artery occlusion and global renal infarct are noted on CT scans by lack of parenchymal enhancement or a persistent cortical rim sign. Although reliable for demonstrating renal infarct, the disadvantage to using the rim sign is that it is usually not seen until at least 8 hours after injury.[14] In recent years, fast-scanning and image-reconstructing helical CT scanners have been introduced. Turnaround times for abdominal trauma imaging are now in the 10-minute range. Seventy to 90 seconds before initiating helical CT scanning, 150-180 mL of intravenous contrast is given at 2-4 mL per second. Helical CT imaging is so quick (usually under 2 min) that only the arterial phase (20-30 seconds) and the early cortical phase (40-70 seconds) of the kidney are obtained. Arterial-phase imaging helps delineate any renal artery injury, while the early cortical phase still misses most parenchymal injuries. Therefore, in order to complete the proper evaluation and staging of renal injuries, later imaging in the nephrogram phase (>80 seconds) is needed to detect renal parenchymal and venous injury, while delayed images (2-10 min) are often required to detect urine and blood extravasation. On delayed CT images, extravasated urine can be distinguished from blood in that it accumulates, while extravasated arterial contrast dilutes out after the bolus of contrast is stopped. [6, 15] Advantages are that it (1) allows unsurpassed functional and anatomic assessment of the kidneys and urinary tract, (2) helps establish the presence or absence of 2 functional kidneys, and (3) allows for the diagnosis of concurrent injuries. Disadvantages are that (1) it requires intravenous contrast in order to maximize information about functionality, hematoma, and, possibly, bleeding; (2) the patient must be stable enough to go to the scanner; and (3) full urinary assessment is dependent on the timing of contrast and scanning in order to view the bladder and ureters.

Angiography
With the advent of accurate and quick CT imaging, the uses for arteriography with renal trauma have diminished. Renal arteriography does provide the opportunity to stage the injury and, if necessary to embolize bleeding points at the same time.[8] However, in the acute setting, it is rarely used (renal arteriography and embolization for renal trauma) because it is time consuming and patients with active bleeding need to undergo immediate exploratory laparotomy. Furthermore, during laparotomy, the kidney can be explored and surgically reconstructed. Arteriography and superselective embolization continues to play an important role in the evaluation and treatment of symptomatic posttraumatic arteriovenous fistulas or persistent delayed renal bleeding. [13] Advantages are that it (1) has the capacity to aid in both the diagnosis and treatment of renal injuries and (2) may further define injury in patients with moderate IVP abnormalities or with vascular injuries. Disadvantages are that (1) it is invasive; (2) it requires contrast; (3) it requires mobilization of resources to perform the study, which may be time-consuming; and (4) the patient must travel to the radiology suite.

Ultrasonography
Experience with the evaluation of suspected acute renal traumatic injury by ultrasonography has been primarily from Europe.[16] In well-trained and experienced hands, renal lacerations and hematomas can be reliably identified and delineated. Limitations of ultrasonography include an inability to distinguish fresh blood from extravasated urine and an inability to identify vascular pedicle injuries or segmental infarcts. Only with close color and pulsed Doppler interrogation can a vascular injury be diagnosed. Furthermore, concomitant rib fractures, bandages, intestinal ileus, open wounds, or morbid obesity severely limit renal visualization. In general, the accuracy of ultrasonography for evaluating the retroperitoneum is variable, time consuming, and highly operator dependent. Therefore, the routine use of ultrasonography for screening acute renal trauma is not advocated. Ultrasonography, however, has proven useful and reliable for evaluating blunt intra-abdominal injuries by detecting the presence of hemoperitoneum. In hemodynamically unstable patients, it is used as a

less invasive replacement for diagnostic peritoneal lavage. In stable blunt trauma victims, ultrasonography is used to direct patients to CT imaging when hemoperitoneum is noted and to observation in those with negative findings Advantages are that it (1) is noninvasive, (2) may be performed in real time in concert with resuscitation, and (3) may help define the anatomy of the injury Disadvantages are that (1) optimal study results related to anatomy require an experienced sonographer; (2) the focused abdominal sonography for trauma (FAST) examination, does not define anatomy and, in fact, looks only for free fluid; and (3) bladder injuries may be missed.

Diagnostic Procedures
Operative diagnosis
Depending on the mechanism of injury, many patients who sustain renal laceration have associated intra-abdominal injuries that require urgent exploration. The clinical situation may have precluded the opportunity to perform the aforementioned diagnostic modalities. The surgeon should be prepared to make the diagnosis of renal injury intraoperatively. Lateral retroperitoneal hematomas may alert the surgeon to the presence of renal laceration. Direct evidence of penetrating trauma should also provide evidence of renal laceration. Other renal trauma, including renal pelvis or ureteral injuries, should be sought and identified. Although the medical consensus is not complete, evidence exists that not all perirenal hematomas discovered at laparotomy require exploration. Theories range from simple observation to exploration with vascular control. The optimal course depends on the physician's experience and the institution's resources. Increasingly, even severe renal injuries are being safely managed nonoperatively.

Staging
Using the clinical information, the indications for radiographic imaging may be tailored to detect patients with a significant chance of having a major renal laceration (considered grades 3-4). Based on the experience of Brandes and McAninch at San Francisco General Hospital, they recommend imaging patients with the following categories of injuries[17] : (1) Blunt trauma and gross hematuria; (2) blunt trauma, microscopic hematuria, and shock; (3) major deceleration injury; (4) microscopic or gross hematuria after penetrating flank, back, or abdominal trauma or missile path in line with the kidney; (5) pediatric trauma patient with significant microscopic or gross hematuria; and (6) associated injuries suggesting underlying renal injury. These are discussed in more detail below. Blunt trauma and gross hematuria Gross hematuria is the most reliable indicator for serious urological injury. The degree of hematuria, however, does not correlate with the degree of injury. In fact, renal pedicle avulsion or acute thrombosis of segmental renal arteries can occur in the absence of hematuria, while renal contusions can present with gross hematuria. Blunt trauma, microscopic hematuria, and shock Significant microscopic hematuria is greater than 5 red blood cells per high-power field (RBC/HPF) in the first voided or catheterized specimen. Shock is any presence of systolic blood pressure less than 90 mm Hg during transport or upon arrival in the emergency department. Blunt trauma patients with microhematuria and no shock have minor renal injuries in nearly all cases. Miller and McAninch, based on findings in more than 2000 blunt renal trauma injuries, determined that in less than 0.2% of cases will a grade 2 or more severe renal injury be missed. [1] These patients are the victims of multiple trauma, and, thus, during the evaluation of other intra-abdominal injuries, most of the missed major renal injuries are be detected. When patients who were imaged for associated intra-abdominal injuries are included, only 0.03% of significant renal injuries were not identified. Major deceleration injury

The kidney primarily floats free in a bed of fat contained within the envelope of the Gerota fascia. The kidney is fixed at only 2 points, the ureter and the vascular pedicle. Because of poor fixation, the kidney can be easily dislocated by sudden acceleration or deceleration. Kidney dislocation can result in tearing of the collecting system at the ureteropelvic junction (UPJ) or tearing of renal artery intima, resulting in partial-to-complete vessel occlusion. Such injuries can occur with major deceleration, as in head-on motor vehicle accidents (MVA) or falls from great heights, or from marked flexion extension, as with pedestrian versus motor vehicle collisions. Pediatric patients are particularly prone to this mechanism of injury. In general, all rapid deceleration injuries warrant renal imaging, even in the absence of hematuria.[5, 18] Microscopic or gross hematuria after penetrating flank, back, or abdominal trauma; or missile path in line with the kidney Pediatric trauma patient with significant microscopic or gross hematuria In comparison to adults, childrens kidneys are relatively much larger for their body size. The kidneys are also not as well protected with perirenal fat, which is usually scant, and lower ribs that are incompletely ossified. Therefore, children are particularly prone to injury. However, the majority of blunt renal injuries are contusions that require no active therapy. Hypotension is often an unreliable predictor of significant renal injury, as children can maintain a normal blood pressure despite extensive blood loss.[19] Traditionally, all children with any degree of microscopic hematuria after blunt trauma have undergone renal imaging. In a meta-analysis of all reported series of children with hematuria and suspected renal injury,[20] Morey et al noted that only 2% (11 of 548) of patients with insignificant microscopic hematuria (< 50 RBC/HPF) had a significant renal injury. Furthermore, these 11 patients all had other significant injuries that required abdominal and, thus, renal imaging. They concluded that renal injury is suggested in children in stable condition with gross or significant microscopic hematuria (>50 RBC/HPF) or with moderate-to-severe multisystem trauma (regardless of the hematuria degree), and these children should undergo renal imaging. Patients who do not initially undergo renal imaging who have persistent or worsening hematuria should also be imaged. Although renal pedicle injuries can occur without hematuria, they are likely to be associated with severe multisystem trauma that requires abdominal imaging anyway. For suspected renal injury, CT scanning is the best study for staging a solid organ injury. Associated injuries suggesting underlying renal injury These include blunt trauma and a flank ecchymosis, lumbar vertebral or transverse process fractures, lower rib (11th or 12th) fractures, and severe mechanism of injury. Another indication for imaging is a penetrating flank or abdominal injury with which the entrance and exit sites (or radio-opaque density) are in the path of the kidney, regardless of the degree of hematuria. Also see the Medscape Reference article Imaging in Kidney Trauma and the flow chart in the image below.

Flow chart for adult renal injuries; a guide for decision making. CT, computed tomography; IVP, intravenous pyelography; RBC/HPF, red blood cells per high-power field; SBP, systolic blood pressure.

Injury scaling
In order to determine the appropriate management for a renal injury, the renal injury first needs to be accurately staged. The American Association for the Surgery of Trauma (AAST) has defined renal trauma in 5 grades, as follows[21, 22] : Grade 1 - Renal contusion or nonexpanding subcapsular hematoma without a parenchymal laceration Grade 2 - Nonexpanding perirenal hematoma or a renal cortex laceration (< 1 cm) without urinary extravasation Grade 3 - Renal cortex laceration (>1 cm) and no urinary extravasation Grade 4 - Renal cortical laceration extending into the collecting system (as noted by contrast extravasation), or a segmental renal artery or vein injury (noted by a segmental parenchymal infarct), or main renal artery or vein injury with a contained hematoma Grade 5 - Shattered kidney, avulsion of the renal pedicle, or thrombosis of the main renal artery Proceed to Treatment & Management

Medical Therapy
Nonoperative treatment
In the setting of blunt renal trauma and selected instances of penetrating renal trauma, a nonoperative approach may be selected. Patient selection is the preliminary step in adopting a nonoperative management strategy to renal trauma. One series, with predominantly blunt mechanisms of injury, documented that 85% of patients were treated successfully without surgery. Ultimately, the exclusion of concurrent injury may be the key point in treating patients nonoperatively. The anatomic structure of the kidney lends itself to nonoperative management in the setting of blunt trauma. The kidney has an end artery blood supply with a segmental pattern of division that supplies the renal parenchyma. When subjected to blunt force that causes a laceration, the laceration tends to occur through the parenchyma. The resulting hematoma may displace renal tissue, but the segmental vessels themselves often are not lacerated. The closed retroperitoneal space around the kidney also promotes tamponade of bleeding renal injuries. Finally, the kidney is rich in tissue factor, the molecule that activates the extrinsic coagulation cascade, further promoting hemostasis after injury. Interventional radiology has extended the ability to use a nonoperative approach. Percutaneous drainage of perinephric fluid collections or urinomas has been used to address one clinical complication of a nonoperative approach. In addition, angiography with selective embolization has been used in the setting of isolated renal trauma.[23] Another method to enhance a nonoperative approach includes endourologic stenting. With these approaches, successful nonoperative management of renal lacerations may be achieved in a greater number of patients.

Surgical Therapy
Operative treatment
The goals of operative therapy for renal laceration incorporate the 2 basic principles of hemorrhage control and renal tissue preservation, which must be balanced for each individual patient. Attempts to find a universal plan for this approach have generated controversy in the medical literature. The mindset of the medical community has also been changing as established practice patterns have been examined, challenged, and reassessed. An additional benefit of operative therapy is the ability to address concurrent injuries. One study documented that 80% of patients with renal laceration had other associated injuries. In that same study, 47% of the patients with renal laceration had an associated injury that required immediate laparotomy.

Indications for renal exploration

In order to select a renal injury for nonoperative management, the injury needs to be imaged and accurately staged. An incompletely staged renal injury requires surgical exploration. Not all penetrating renal injuries require surgical exploration. The use of the improved imaging technique of

CT has largely been responsible for the decreased rate of renal explorations at the authors institution. Guidelines for the surgical exploration of the injured kidney vary. The only absolute indication for surgical renal exploration is a patient with external trauma and persistent renal bleeding. Signs of continued renal bleeding are a pulsatile, expanding, or uncontained retroperitoneal hematoma. Another sign is avulsion of the main renal artery or vein as noted by CT or arteriography. Relative indications include nonviable tissue. Substantial devitalized renal parenchyma (>25%) is a relative indication for exploration. Husmann and Morris[24] noted that injuries with significant nonviable renal tissue (25-50%) associated with parenchymal laceration that are managed nonoperatively have a high complication rate (82%). Husmann et al further compared the results of the nonoperative and surgical management of major renal lacerations and devitalized renal fragments after blunt trauma. Their findings demonstrated that when such renal injuries are associated with an intraperitoneal organ injury, the postinjury complication rate is much higher unless the kidney is surgically explored and repaired. By surgically repairing such injuries, they reduced the overall morbidity from 85% to 23%. Concomitant pancreatic and bowel injuries were particularly associated with higher rates of infected urinomas and abscesses. Furthermore, since nearly all blunt trauma patients with intraperitoneal organ injuries undergo celiotomy by the general surgeon, this offers the opportunity to explore and repair the kidney with such major parenchymal injuries. Additional relative indications include patients with a major devitalized segment, injury associated with urinary extravasation, extensive renal injury, and a large retroperitoneal hematoma, even without intraperitoneal injury.

Urinary extravasation
Urinary extravasation in itself does not demand surgical exploration. Extravasation confirms the diagnosis of a major renal injury. Persistent extravasation or signs of sepsis usually require intervention. In general, urinary extravasation resolves spontaneously in the majority of patients with blunt trauma. In select patients, expectant management does not reduce the renal salvage rate and does not prolong hospitalization. Nonoperative therapy may also require delayed intervention. However, the usual complications of urinoma and persistent urinary leak can be successfully managed by either percutaneous or endoscopic techniques, thus avoiding celiotomy and renal exploration. Matthews et al [25] reported that in patients with major renal injury and urinary extravasation who are managed conservatively, urinary extravasation spontaneously resolved in 87%. Extravasation persisted in 13% and was successfully managed endoscopically (eg double-J stent). Overall hospitalization lasted 8 days and was not prolonged by the need for delayed intervention. Ureteropelvic junction (UPJ) injuries rarely heal spontaneously and thus are often best managed by surgical repair at the time of injury. Conservative management of such injuries is fraught with persistent urine leakage, urinoma formation, ileus, and infection.

Incomplete staging
Only complete definition of the renal injury by appropriate imaging studies permits the selection of nonoperative management. Incomplete staging demands either further imaging or renal exploration and reconstruction. In the unstable patient who requires emergent celiotomy, the kidney can only be imaged by one-shot IVU on the operating room table. The nephrogram of the injured kidney is often poorly opacified due to the injury and is worsened by any hemodynamic instability. In so doing, the full extent of the injury is indeterminate. In such circumstances, the kidney should be explored after obtaining proximal vascular control. The unexpected finding of a retroperitoneal hematoma upon celiotomy should be evaluated by on-table, one-shot IVU. If IVU results are abnormal or indeterminate or if the kidney is persistently bleeding, then the kidney should be explored.

Arterial thrombosis
Major deceleration injuries can result in stretching on the renal artery and tearing of the vessel intima, resulting in thrombosis of the main renal artery or its segmental branches and thus causing infarction

of the renal parenchyma. Prompt diagnosis and the time until operation of a unilateral complete arterial thrombosis is vital to salvaging the kidney. The chance of renal salvage is remote after 12 hours of ischemia. If the contralateral kidney is healthy, there is some controversy as to whether to attempt revascularization or to observe. If renal ischemia exceeds 12 hours, the kidney should be allowed to slowly atrophy. Nephrectomy should be performed only if delayed celiotomy is being performed for an associated injury or if persistent hypertension develops postoperatively. Bilateral complete renal artery thrombosis or a solitary kidney demands more immediate exploration and revascularization.

Penetrating trauma
The only absolute indication for exploration is persistent renal bleeding. Nearly all penetrating renal injuries should be managed surgically. The exception is stable patients with no missile penetration of the peritoneum in whom the injury is well staged by computed tomography. Wessels et al[26] have shown that gunshot wound victims who have no intra-abdominal organ injury and a demonstrated grade 1-2 renal injury, when managed conservatively, are relatively complication free. In sharp contrast, 1 of 4 expectantly managed grade 3-4 injuries were complicated by delayed renal bleeding. A study by Bjurlin et al found that Selective nonoperative management of penetrating renal injuries resulted in lowered mortality rate, decreased incidence of blood transfusion, and shortened mean ICU and hospital stay compared with with nephrectomy; however, results were similar to renorrhaphy. Rates of complication were low with selective nonoperative management and were comparable to operative management.[27] Stab wounds posterior to the posterior axillary line are less likely to have an associated visceral injury. When the diagnostic peritoneal lavage or CT scan is negative for intraperitoneal organ injury and the renal injury not severe, observation of the renal injury may be appropriate. Most abdominal penetrating injuries undergo celiotomy by the general surgeons. The presence of an unexpected retroperitoneal hematoma upon exploratory laparotomy when the renal injury has not been fully staged radiographically usually warrants renal exploration. Some controversy remains with the use of postoperative drains in the setting of renal trauma. The general trend has been away from the routine use of drains in this setting, although some centers still advocate their use. Suction drains should be avoided after renal repair.

Preoperative Details
Patients with renal injuries should be managed with initial attention to the basic ABCDEs outlined in Advanced Trauma Life Support protocols. Because many patients have multisystem trauma with concurrent injuries, a systematic approach to the initial assessment and resuscitation allows for identification of other injuries. The decision-making process becomes more involved as additional injuries are found. For additional details, see Critical Care Considerations in Trauma or Initial Evaluation of the Trauma Patient.

Intraoperative Details
Techniques for renal exploration and repair
Primary vascular control is achieved prior to all renal explorations by routinely obtaining proximal vascular control. For vascular control, to isolate the ipsilateral renal artery and vein individually with vessel loops. The kidney is then exposed by incising the Gerota fascia lateral to the colon. When brisk bleeding is encountered, the renal artery is temporarily occluded with Rummel tourniquets. Warm ischemic time should not greatly exceed 30 minutes, in order to avoid permanent renal ischemic damage. If bleeding persists, the renal vein is occluded by Rummel tourniquet placement, in order to eliminate back bleeding. Temporary occlusion of the renal artery is needed in patients with renal vascular injuries, those in shock, and those with large or expanding retroperitoneal hematomas. Renal reconstruction In the absence of persistent hemodynamic instability or coagulopathy, renal reconstruction is safe and effective. The method of kidney reconstruction is dictated by the degree and location of the injury, and not by the associated intra-abdominal injuries. In the face of concomitant major pancreatic or colonic

injuries with frank fecal contamination, renal reconstruction is successful, with only a slightly increased complication rate. The reconstructive principles for renal injures are as follows: Adequate and broad exposure of the kidney and injured area Temporary vascular occlusion for brisk renal bleeding not well controlled by manual compression of the parenchyma Sharp excision of all nonviable parenchyma Meticulous hemostasis (particularly, arterial) Watertight closure of the collecting system Parenchymal defect closure by approximation of the capsular/parenchymal edges over a Gel-foam bolster or coverage with omentum, perinephric fat, peritoneum, or polyglycolic acid mesh Interposition of an omental pedicle flap between any vascular, colonic, or pancreatic injury and the injured kidney Ureteral stent placement for a renal pelvis or ureteral injury Retroperitoneal drain placement: The authors prefer to use a Penrose drain. Unless drainage is excessive, the Penrose drain is removed after 48 hours. Additionally, the urinary tract injury and the pancreatic injury are always drained separately.

Indications for nephrectomy

When proximal vascular control is initially achieved before all renal explorations, nephrectomy is required in less than 12% of cases.[28] When primary vascular control is not achieved and massive bleeding is encountered, in the rush to control bleeding, a kidney that could have been salvaged is unnecessarily sacrificed. Overall, nephrectomy is required when the patient is persistently hemodynamically unstable and, thus, is a life-saving maneuver. Other indications for nephrectomy are grade 5 injuries that are deemed irreparable, such as major vascular pedicle injury, particularly on the right side. Indications for nephrectomy are shattered kidney, multiple concurrent injuries, and uncontrolled hemorrhage. Indications for partial nephrectomy are avulsed fragments, polar penetrating mechanism of injury, and collecting system repair. Adjuncts include absorbable mesh wrap, topical thrombostatic agents, and omentum.

Postoperative Details
As with all trauma patients, the postoperative course should be monitored to ensure successful hemostasis. Serial hematocrit measurements should be considered. In patients in whom a damaged but perfused kidney is left in situ, renovascular hypertension remains a theoretical possibility and the patient should be monitored clinically for this entity.

Follow-up
For patient education resources, see the Kidneys and Urinary System Center, as well as Intravenous Pyelogram and Blood in the Urine.

Complications
Complications that can follow renal trauma are dependent on the grade of the initial renal injury and the method of management. In most cases, resulting complications are usually of minimal long-term morbidity, can be successfully managed by endourologic and percutaneous techniques, and do not significantly prolong the mean days of hospitalization.[29, 30]

Early complications
Early complications, those that occur within 1 month of injury, are urinoma, delayed bleeding, urinary fistula, abscess, and hypertension. Prolonged urinary extravasation is the most common complication after renal trauma.[2, 29] Urinomas occur in less than 1% of renal trauma cases. Small, uninfected, and stable collections do not require intervention. Larger collections are usually successfully managed by the endoscopic or percutaneous placement of a ureteral/nephrostomy tube.

Delayed renal bleeding most commonly occurs within 2 weeks of injury. When bleeding is heavy or symptomatic, transfusions, angiography, and superselective embolization [13] may be required. Urinary fistulas can occur in association with an undrained collection or from large segments of devitalized renal parenchyma. Abscesses of the retroperitoneum are associated with ileus, high fever, and sepsis. Most collections can be easily drained percutaneously. The extent of the abscess and the presence of loculations are well delineated by CT imaging. Hypertension in the early postoperative period is usually renin mediated and transient, and it does not require any treatment.

Late complications
Late complications after renal trauma are hydronephrosis, arteriovenous fistula, pyelonephritis, calculus formation, and delayed hypertension. Scarring in the region of the renal pelvis and ureter after renal trauma can result in urinary obstruction and, subsequently, lead to stone formation and chronic infections. Arteriovenous fistula more commonly occurs after a renal stab wound and can present with delayed bleeding.[13] Angiography can help determine the size and location of the fistula. In most cases, vessel embolization can be used to successfully close the fistula. Long-term hypertension from renal trauma is a rare complication that is overdiagnosed. The experience at San Francisco General Hospital is that sustained hypertension occurs in only 0.2% of cases.[1] The etiology for hypertension after renal injury is renal ischemia stimulating the reninangiotensin axis. Long-term follow-up of renal trauma patients is important in order to not miss these late complications, which are often of insidious onset and silent progression.

Outcome and Prognosis

In many cases of renal trauma, the outcome and prognosis depend on the associated injuries. In situations in which nonoperative management is used, concern exists about leaving perfused but nonviable renal tissue in situ, which may lead to hypertension. However, the occurrence of hypertension in this setting seems to be rare. One study documents no evidence of hypertension after 5 years of follow-up in children who had sustained renal trauma. Other series report only isolated instances of hypertension. Therefore, the risk of hypertension alone does not seem to warrant surgical exploration in cases with nonperfused renal segments.

Future and Controversies

Preoperative IVP for penetrating trauma
Proponents of the one-shot IVP point out that it can be performed as the patient is being prepared for surgery and that it allows a quick assessment of the functionality of the contralateral kidney. Opponents believe that preservation of renal tissue is always a goal as long as the approach is safe for the patient. Knowledge of the functional status of the contralateral kidney does not change whether or not trying to salvage the kidney is safe. The timing of the injection may yield suboptimal views, and often, more time is needed to obtain images than is anticipated. The consensus on this technique remains incomplete. Intraoperative IVP can potentially allow leaving a perinephric hematoma unexplored if the study shows findings of a completely normal system. Some practitioners make extra efforts to succeed with operative salvage of a damaged kidney if the contralateral kidney is known to be absent.

Operative technique (central vascular control)

Proponents believe that data demonstrate enhanced renal salvage when vascular control is obtained outside the Gerota fascia. This technique allows controlled assessment of the nature of the renal laceration, and it may impart less trauma on the vessels compared to more urgent control measures.

Opponents believe that not all renal injuries have sufficient bleeding to warrant central control of vessels. The technique requires some operative time and exposes the renal vessels to potential operative trauma. Anatomic variants, such as multiple arteries or veins, may not be recognized and may elicit a false sense of security.

Hypertension
Although concern exists that leaving perfused but nonviable renal tissue in situ potentially leads to hypertension, the occurrence of hypertension in this setting seems to be rare. One study documents no evidence of hypertension after 5 years of follow-up in children who had sustained renal trauma. Other series report only isolated instances of hypertension. Therefore, the risk of hypertension alone does not seem to warrant surgical exploration in cases with nonperfused renal segments.

Nonperfused kidney
Controversy exists regarding whether to revascularize a nonperfused kidney. The incidence rate of renal salvage in the setting of a nonperfused kidney due to trauma has been reported to be approximately 0%. Isolated case reports of success do exist. Most centers advocate an expectant management approach. The need for ultimate nephrectomy also remains somewhat controversial. Possible or documented renovascular injury continues to be a controversial arena of renal injury management. Only aggressive intervention provides the opportunity for renal salvage. However, the clinician must be aware that the salvage rate is low, and, ultimately, the life of the patient must take priority over the life of the kidney. Continued investigation and evolution of surgical techniques may help resolve this controversy.

Conclusion
The approach to the diagnosis and management of renal trauma continues to evolve. In the setting of significant hemodynamic instability, operative exploration remains the diagnostic and therapeutic modality of choice. In patients with blunt trauma and in certain cases of penetrating trauma, a progressive trend is towards nonoperative management of renal trauma. Continued change in the approach to renal trauma is almost a certainty. Interventional radiology and endourologic manipulation have increased the ability to successfully treat patients without surgery and to address common complications of renal trauma. Numerous diagnostic options exist in the setting of a stable patient. With awareness of these modalities, the clinician can provide each patient with optimal treatment.

Penile Fracture and Trauma

Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS more...

Overview Workup Treatment

Updated: Jun 24, 2011

Background History of the Procedure Epidemiology Etiology Pathophysiology Presentation Indications Relevant Anatomy Contraindications

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Multimedia Library References

Background
Traumatic penile injury can be due to multiple factors. Penile fracture, penile amputation, penetrating penile injuries, and penile soft tissue injuries are considered urologic emergencies and typically require surgical intervention. The goals of treatment for penile trauma are universal: preservation of penile length, erectile function, and maintenance of the ability to void while standing. Traumatic injury to the penis may concomitantly involve the urethra.[1]Urethral injury and repair is beyond the scope of this article but details can be found in Urethra, Trauma.

Penile fracture
Penile fracture is the traumatic rupture of the corpus cavernosum. Traumatic rupture of the penis is relatively uncommon and is considered a urologic emergency. Sudden blunt trauma or abrupt lateral bending of the penis in an erect state can break the markedly thinned and stiff tunica albuginea, resulting in a fractured penis. One or both corpora may be involved, and concomitant injury to the penile urethra may occur. Urethral trauma is more common when both corpora cavernosa are injured. Penile rupture can usually be diagnosed based solely on history and physical examination findings; however, in equivocal cases, diagnostic cavernosography or MRI should be performed. Concomitant urethral injury must be considered; therefore, preoperative retrograde urethrographic studies should generally be performed.

Small penile fracture involving the right corpus cavernosum.

More severe penile fracture.

Penile amputation
Penile amputation involves the complete or partial severing of the penis. A complete transection comprises severing of both corpora cavernosa and the urethra. Amputation of the penis may be accidental but is often self-inflicted, especially during psychotic episodes in individuals who are mentally ill.

Partial penile amputation.

Penetrating injury
Penetrating injury is the result of ballistic weapons, shrapnel, or stab injuries to the penis. Penetrating injuries are most commonly seen in wartime conflicts and are less common in civilian medicine. Penetrating injuries can involve one or both corpora, the urethra, or penile soft tissue alone.

Gunshot wound to the penis.

Penile soft tissue injury

Penile soft tissue injury can result through multiple mechanisms, including infection, burns, human or animal bites, and degloving injuries that involve machinery. The corpora, by definition, are not involved.

History of the Procedure

Penile fracture
Historically, conservative management was considered the treatment of choice for penile fractures. Conservative therapy consisted of cold compresses, pressure dressings, penile splinting, antiinflammatory medications, fibrinolytics, and suprapubic urinary diversion with delayed repair of urethral injuries. This concept has fallen into disfavor because of the high complication rates (29-53%) of nonoperative therapy. Complications of conservative management included missed urethral injury, penile abscess, nodule formation at the site of rupture, permanent penile curvature, painful erection, painful coitus, erectile dysfunction, corporourethral fistula, arteriovenous fistula, and fibrotic plaque formation. [2] The primary goals of surgical repair are to expedite the relief of painful symptoms, to prevent erectile dysfunction, to allow normal voiding, and to minimize potential complications due to delay in diagnosis. Currently, the vast majority of authors favor immediate surgical repair, citing fewer complications, increased patient satisfaction, shorter hospital stays, and better outcomes.

Penile amputation
Ehrich et al[3] reported the first macroscopic reimplantation of a penile amputation, in which arterial anastomosis is not performed. Functional and cosmetic results were satisfactory, but penile skin necrosis was common. Tamai et al later modified the technique to include microsurgical reanastomosis of the penile blood vessels and nerves, thereby reducing the risk of penile skin necrosis. Reanastomosis requires the amputated penile remnant. In the case of distal penile loss, phallus reconstruction can be performed using a forearm free flap.

Epidemiology
Frequency
Penile fracture The frequency of penile fracture is likely underreported in the published literature. Trauma during sexual relations is responsible for approximately one third of all cases; the female-dominant position is most commonly reported. The mechanism of action may lead to embarrassment, causing patients to avoid seeking treatment and contributing to late presentation. As of 2001, 1331 cases were reported in the literature. The incidence of concomitant urethral injury in reported cases is 10-58%. Penile amputation Penile amputation is rare, with most cases being reported sporadically. Cases are typically associated with self-mutilation related to acute psychotic episodes or gender dysphoria. Felonious assaults account for the remainder of cases. Penetrating injury Gunshot wounds account for 35% of all genital injuries. In 25% of cases, the penis alone is involved. In another 25% of cases, both the penis and scrotum are involved. The frequency of stab wounds to the penis is relatively rare, accounting for only 4% of penetrating penile injuries. Penile soft tissue injury Soft tissue skin loss of the penis is a rare phenomenon. Fournier gangrene accounts for approximately 75% of cases that involve genital skin loss. This infectious process is beyond the scope of this article and can be found inFournier Gangrene. The remainder of soft tissue loss cases are typically due to avulsion injuries, human or animal bites, and burns.

Etiology
Penile fracture
In the Western Hemisphere, penile fracture usually occurs during sexual intercourse when the penis slips out of the vagina and strikes the perineum or the pubic symphysis. Other potential causes include industrial accidents, masturbation, gunshot wounds, or any other mechanical trauma that causes forcible breaking of an erect penis. In Middle Eastern countries, the injury is usually due to penile manipulation to achieve detumescence. Additional rare etiologies include turning over in bed, a direct blow, forced bending, or hastily removing or applying clothing when the penis is erect.

Penile amputation
Penile amputation frequently occurs as a result of mental illness; in fact, most cases of penile amputation in the Western world are due to mental illness. The rate of mental illnessrelated penile amputation is as high as 87%. Most of these patients (51%) have acutely decompensated schizophrenia. The literature reports a high rate of associated gender identity in nonpsychotic occurrences; most of these amputations result from an attempt at gender conversion. Cases of assault are also reported. A rash of these attacks occurred in Thailand during the 1970s, when a large number of enraged wives amputated the penises of their adulterous husbands.

Penetrating injury
Most penetrating penile injuries occur during wartime. As solid-organ abdominal injuries and subsequent death rates have been reduced with the use of body armor in modern warfare, the frequency of penetrating genital injuries has increased. This is because of two factors. The first is that body armor does not traditionally cover the genitals. The second is that genital injuries were likely underreported in previous wars because unprotected individuals tended to die of massive abdominal injuries. Extraction of injured soldiers from the combat theater and improvements in the treatment of trauma patients have also increased survival rates, leading to increased reporting of injuries to the penis.

Penile soft tissue injury

Avulsion injuries to the penis are typically due to entrapment of the penile skin within the clothing. This clothing is caught on moving machinery, such as motorcycles or farm implements, which rends the soft tissue from the stronger underlayer of the tunica albuginea.

Pathophysiology
The penis is composed of 3 bodies of erectile tissue: the corpus cavernosum (left and right) and the corpus spongiosum. Both corpora cavernosa are contained by the tunica albuginea. All three corpora are surrounded individually by Buck fascia. All three corporal cylinders are capable of considerable enlargement with sanguineous engorgement during normal erection. The corpora cavernosa are composed of sinusoids that fill with arterial blood during erection. The internal pudendal arteries provide the blood supply to the penis and the urethra. Each artery divides into the dorsal penile artery, the cavernosal artery, and the bulbourethral artery. The cavernosal artery supplies the corpus cavernosum.

Penile fracture
In the flaccid state, injury to the penis is rare because of the mobility and flexibility of the organ. During an erection, the arterial inflow to the penis causes the erectile bodies to enlarge longitudinally and transversely. This causes the flaccid penis to become fully erect and less mobile. As the penis changes from a flaccid state to an erect state, the tunica albuginea thins from 2 mm to 0.25-0.5 mm, stiffens, and loses elasticity. The expansion and stiffness of the tunica albuginea impede venous return and are responsible for maintaining tumescence during male erection. Sudden direct trauma to the penis or an abnormal bending of the penis in an erect state can cause a 0.5-4 cm transverse tear of the tunica albuginea, with injury to the underlying corpus cavernosum. Oblique or irregular tears are less common, but reported. The injury typically results in injury to one corpus cavernosa, but both can be involved. This may result in penile laceration and urethral injury.

Penile amputation
Penile amputation is not a physiological process.

Penetrating injury
The penis is somewhat resistant to penetrating injury owing to its location and relative mobility. The penis is shielded by the surrounding bony pelvis posteriorly and upper thighs laterally, thereby preventing injury.

Penile soft tissue injury

The penis is particularly susceptible to avulsion injuries. The overlying skin of the penis is loose and elastic. The penile skin must be highly mobile to accommodate both the rigid and flaccid state of the penis. This loose base predisposes the skin to be ripped easily from the penis.

Presentation
Penile fracture
The clinical presentation of a penile fracture is often fairly straightforward. Diagnosis is made based on history and physical examination findings.[4]Most affected patients report penile injury coincident with sexual intercourse. Patients usually report that the female partner was on top, straddling the penis. During sexual relations, the penis slipped out, hitting the perineum or the pubis of the female partner. Patients sometimes report that they were having sexual relations on a desk (with the patient on top) and the penis slipped out, hitting the edge of the desk. Patients describe a popping, cracking, or snapping sound with immediate detumescence. They may report minimal to severe sharp pain, depending on the severity of injury.

Upon physical examination, evidence of penile injury is self-evident. In a typical penile fracture, the normal external penile appearance is completely obliterated because of significant penile deformity, swelling, and ecchymosis (the so-called "eggplant" deformity).

Eggplant deformity.

Upon inspection, significant soft tissue swelling of the penile skin, penile ecchymosis, and hematoma formation are apparent. The penis is abnormally curved, often in an S shape. The penis is often deviated away from the site of the tear secondary to mass effect of the hematoma. If the urethra has also been damaged, blood is present at the meatus. If the Buck fascia is intact, penile ecchymosis is confined to the penile shaft. If the Buck fascia has been violated, the swelling and ecchymosis are contained within the Colles fascia. In this instance, a "butterfly-pattern" ecchymosis may be observed over the perineum, scrotum, and lower abdominal wall. The fractured penis is often quite tender to the touch. Because of the severity of pain, a comprehensive penile examination may not be possible. However, a "rolling sign" may be appreciated when a judicious examination is performed on a cooperative patient. A rolling sign is the palpation of the localized blood clot over the site of rupture. The clot may be felt as a discreet firm mass over which the penile skin may be rolled. Patients with a rupture of the deep dorsal vein of the penis can present with findings similar to those of a penile fracture. Associated swelling and ecchymosis of the penis ("eggplant" sign) is present. Injury commonly occurs during sexual intercourse. However, the patient does not typically hear a crack or popping sound. In addition, detumescence does not immediately occur. However, because of similar physical examination findings, a deep dorsal vein rupture should be surgical explored, as it is often difficult to differentiate from penile fracture. Patients with concomitant urethral trauma report hematuria upon postinjury voiding. Approximately 30% of men with penile fractures demonstrate blood at the meatus. Some patients may also report dysuria or experience acute urinary retention. Retention may be secondary to urethral injury or periurethral hematoma that is causing a bladder outlet obstruction. Urinary extravasation may be a late complication of unrecognized urethral injury. Successful voiding does not exclude urethral injury; therefore, retrograde urethrography is required whenever urethral injury is suspected. Signs and symptoms of urethral injury are described below.

Penile amputation
Diagnosis of the amputated penis is obvious on physical examination. A thorough history must be taken to determine the patient's mental state and if self-mutilation is responsible for the amputation. Many patients present to the hospital for evaluation because of the alarming, although seldom lifethreatening, volume of blood loss. Determination of the psychiatric state helps with operative planning. The literature suggests that, in cases of self-amputation, resolution of the acute psychotic episode and treatment of the underlying mental illness typically results in a desire for penile preservation. The only exception may involve men who have repeatedly attempted amputation. The risks of future self-mutilation must be weighed against the effects of no penile replacement. Examination of the penis and remnant (if available) is important to determine the possible reconstructive options. The condition of the graft bed is closely inspected. Destruction of the amputated segment precludes reimplantation, and the patient should be prepared for future phallic

reconstruction. Patients with adequate penile stumps may avoid reimplantation altogether, although this is typically a less desirable outcome. The cancer literature suggests that a penile length of 2-3 cm is necessary for directing the urinary stream while standing to void. The length required for sexual intercourse is likely longer but depends on body habitus and partner preference. Extensive physical examination should not delay operative intervention, as a better examination is likely to be obtained in the operating room with the patient under anesthesia.

Penetrating injury
Diagnosis of a penetrating penile injury is obvious based on both history and physical examination findings. Care must be paid to the patient's other associated injuries, which can be life-threatening and should take precedence over genital injuries. Significant associated injuries are present in 5080% of cases. The patient must be medically stabilized prior to surgical repair of the injured penis. Blood in the meatus can indicate urethral injury and should be suspected in any penetrating trauma to the penis. The authors routinely perform retrograde urethrography to evaluate for urethral injury. Penetrating injuries to the corpora cavernosa often have a hematoma that overlies the defect and have a "rolling sign" similar to that of penile fracture.

Penile soft tissue injury

Examination of the penis reveals soft tissue loss. Those who have undergone laceration secondary to a human bite usually present in a delayed fashion because of embarrassment of the injury. This places them at increased risk for infection, which may be seen in the form of abscess, cellulitis, or tissue necrosis.

Urethral Injury
Signs and symptoms of urethral injury should be considered in all forms of penile trauma. The mechanism of penile injury and physical examination findings must be considered. The diagnostic test of choice is retrograde urethrography. The key indications of urethral injury are as follows: Blood at the meatus Gross hematuria Microscopic hematuria (>5 RBCs per high-power field) Dysuria Urinary retention

Indications
Penile fracture
Indications for immediate surgical intervention include the presence of obvious clinical signs and symptoms of penile fracture. Diagnostic imaging studies are not normally required in this setting. Surgery is also warranted if diagnostic cavernosography or MRI findings are equivocal but clinical findings are consistent with penile fracture.[5]

Penile amputation
Penile amputation is a surgical emergency. Imaging studies are not necessary. The patient should be taken to the operating room for penile replantation or revision of the penile stump, with or without plans for future phallic reconstruction.

Penetrating injury
The signs of penetrating penile injury should be an indication for surgical exploration. The only contraindication to surgery is medial instability due to other associated injuries. In rare instances, penile trauma can be treated nonoperatively. In one series, 10 of 26 patients were managed without surgery. These patients had two factors that contributed to nonoperative treatment. One group (3 patients) had minimal injuries with a single shotgun pellet lodged in the penis. The other group had only superficial or isolated foreskin injuries.

Penile soft tissue injury

Surgical repair of soft tissue loss to the penis should be undertaken quickly. Prolonged exposure of the denuded penis increases the risk of secondary infection.

Relevant Anatomy
The penis is divided into 3 parts. The root lies under the pubic bone and provides stability when the penis is erect. The body comprises the major portion of the penis and is composed of 2 cavernosal bodies and a corpus spongiosum. The urethra traverses the corpus spongiosum to exit through the meatus. The 2 cavernosal bodies (ie, corpus cavernosa, erectile bodies) produce erections when filled with blood. The glans is the distal expansion of the corpus spongiosum. The loose skin of the prepuce normally covers the glans of an uncircumcised penis. The penis is innervated by the left and right dorsal nerves, which are the main sensory nerve supply. These nerves are typically located at the 10- and 2-o'clock positions, but, in reality, their locations significantly vary. Care must be taken with surgical exploration of any penile injury to avoid iatrogenic injury to the dorsal nerves. The penis is also innervated by branches of the pudendal nerve. The penis is a highly vascular organ and is supplied by the internal pudendal artery. The internal pudendal artery rises from the internal iliac artery (ie, hypogastric artery), which then branches into the deep artery of the penis, the bulbar artery, and the urethral artery. The deep artery of the penis becomes the cavernosal arteries, which supply the entire corpus cavernosum. The urethral artery supplies the glans penis and corpus spongiosum. The bulbar artery supplies the bulbar urethra and the bulbospongiosus muscle

Contraindications
Contraindications to surgical therapy include intolerance to general anesthesia and a history of penile trauma but completely normal physical examination findings. In patients with polytrauma, lifethreatening injuries must be prioritized; delayed penile repair can be considered when the patient becomes medically stable.[6] Patients with penile trauma require fluid resuscitation prior to operative intervention. Proceed to Workup

Laboratory Studies
Although no specific laboratory studies are required for penile trauma, a standard preoperative laboratory panel should be considered on a case-by-case basis in all patients. This includes the following: Electrolytes Complete blood count Coagulation studies Type and screen Urinalysis Microscopic hematuria should raise suspicion of a possible urethral injury. Urine culture should be considered in those with obvious signs of a urinary tract infection.

Imaging Studies
Imaging studies to assess penile trauma are not usually required and should be used with reservation. They increase medical costs and delay definitive therapy. The physical examination findings alone are often used to establish the diagnosis. When the diagnosis is equivocal, surgical exploration is warranted to assess the injury, diagnose the injury, and render appropriate surgical repair. Imaging studies of the penis can be considered when injury is not evident on physical examination; in this case, the radiologic test is used only to confirm a conservative course of nonoperative management. Retrograde urethrography is the only imaging study for which there should be a low threshold of use. Retrograde urethrography should be performed if urethral injury is suspected based on the presence of blood at the meatus, hematuria of any form, dysuria, or urinary retention. The test is easy to perform and inexpensive.

Retrograde urethrography: Retrograde urethrogram reveals the extravasation of contrast material from the urethra into the penile soft tissues, indicating urethral injury. It can be performed by insertion of a 12-14F Foley catheter into the fossa navicularis (distal urethra). The Foley balloon is inflated with 1-2 mL of sterile water. Contrast is injected from a 60-mL piston syringe with the penis placed on stretch. Oblique radiographs are taken and the continuity of the urethra is examined. An alternative technique is forgoing placement of a catheter with intubation of the urethral meatus with a piston syringe and injection of contrast directly into the urethra. Penile cavernosography: Penile cavernosography reveals extravasation of contrast material from the corpus cavernosum into the penile soft tissues, indicating an injury of the tunica albuginea. It can be performed by direct injection of 15-70 mL of quartertohalf-strength nonionic contrast into the uninjured corpora until penile tumescence is achieved. Fluoroscopic images during injection and 10 minutes postinjection reveal filling defects or extravasation. This technique is thought to cause corporal scarring and should be used with reservation. Cavernosography rarely precludes surgical exploration in both penetrating trauma and fracture of the penis. Its use should not delay definitive surgical treatment. Penile magnetic resonance imaging (MRI): An MRI of the penis provides excellent delineation of anatomy and thus can reveal tunical tears and urethral injury. The technique is expensive and timeconsuming. Its availability is often limited depending on time of patient presentation and can cause undue delay in definitive surgical management. It is best reserved for patients in whom injury appears absent and who would support nonoperative treatment. Proceed to Treatment & Management

Medical Therapy
The medical management of penile trauma is limited and usually depends on surgical optimization of the patient in preparation for the operating room. Penile trauma is often accompanied by other associated injuries, some of which may be life-threatening. Fluid resuscitation and stabilization of the patient should be the focus. Administration of preoperative antibiotics should be considered in patients with open wounds. If penile reconstruction must be delayed in the setting of a urethral injury, suprapubic urinary diversion may be performed. If surgical therapy must be delayed, initial medical therapy consists of cold compresses, pressure dressings, and anti-inflammatory medications, followed by definitive surgical therapy.

Penile amputation
Pretreatment of the patient with an amputated penis has unique requirements. In the face of an acute psychotic episode, psychological stabilization is required, often with the aid of a psychiatrist. Management of the amputated penile remnant is imperative to a successful reimplantation. The severed penis should be cleaned of debris and wrapped in sterile, saline-soaked gauze. The wrapped penis should be placed into a sealed bag and placed inside a second container filled with an ice-slush mix. This helps to reduce the ischemic injury to the severed penis. Reimplantation should be performed as quickly as possible.

Penile soft tissue loss

Bite injuries to the penis require extra care, as they have the potential for infection with unique organisms. Dog bites, the most common animal bite, consist of multiple pathogens such as Staphylococcus and Streptococcusspecies, Escherichia coli, and Pasteurella multocida. Antibiotic treatment should generally include oral dicloxacillin or cephalexin. Patients with possible Pasteurella resistance can be treated with penicillin V. Chloramphenicol has also been shown to have good efficacy. Human bites are considered infected by definition and should not be closed. They can be treated with antibiotics similar to those used in animal bites despite the fact that bacterial cultures may differ.

Surgical Therapy
No matter the form of penile trauma, the goals of surgery for the traumatized penis are universal: restore the penis to its preinjury state, prevent erectile dysfunction, maintain penile length, and allow normal voiding.[7, 8, 9]

Penile fracture
In the reported literature, surgical therapy has consistently resulted in fewer complications. Muentener et al reported good outcomes in 92% of patients treated surgically versus only 59% in those treated conservatively. In addition, surgery provides good outcomes after varying timing of presentation after injury. A study by El-Assmy et al found no substantial difference in recovery based on early or delayed presentation of penile fracture with subsequent surgery. Patients were divided into group I early presentation (1-24 hours after injury) and group II delayed presentation (30 hours to 7 days after injury). Mean follow-up was 105 months for group I and 113 months for group II.[10] Principles of surgical therapy are as follows: Optimize the surgical exposure. Evacuate the hematoma. Identify the site of injury. Correct the defect in the tunica albuginea. Repair the urethral injury. Three types of incisions are generally used to repair penile fracture: incision directly over the defect, circumscribing-degloving incision, and inguinal-scrotal incision. An incision directly over the identified defect in the corpus cavernosum allows minimal dissection of neurovascular bundles but does not afford complete evaluation of both the corpora cavernosa and the corpus spongiosum. The authors do not advocate this type of entry. A circumferential-degloving incision begins 1 cm proximal to the coronal sulcus and affords excellent exposure. However, decreased penile sensation has been reported with this type of incision. The inguinal-scrotal incision provides excellent exposure of the base, root, and dorsal surfaces of the penis. If necessary, the entire penis may be averted inside out to maximize surgical exposure. At the authors' institution, a circumferential-degloving incision is routinely used with excellent results. On occasion, the authors have also used an inguinal-scrotal incision for more complex injuries located near the base of penis.

Penile amputation
An amputated penis should be immediately and expeditiously repaired to prevent further ischemic injury to the penile remnant. This should be undertaken at a center of excellence, and the patient should be stabilized and transferred if a reconstructive urologist or plastic surgeon is not available at the presenting institution. Principles of surgical therapy are as follows: Optimize the surgical exposure. Judiciously debride necrotic tissue. Anastomose the severed urethra over a Foley catheter to provide stabilization. Repair the tunica albuginea. Use microsurgery to repair the dorsal nerves, arteries, and veins of the penis.

Penetrating injury
Expeditious surgical repair of the penis should be undertaken as soon as possible. Principles of surgical therapy are as follows: Optimize the surgical exposure. Judiciously debride necrotic tissue. Repair injured urethra. Repair tunica albuginea injuries.

Penile soft tissue injury

Surgical repair should be initiated as soon as possible in soft tissue injuries. This prevents colonization of the wound. The only exception is that of the human bite because of the high risk of polymicrobial infection.

Principles of surgical therapy are as follows: Debridement of necrotic tissue Copious irrigation of wound with Povidine and antibiotic solution Closure of injury with exception of human bites Skin grafting and harvest to cover large defects

Preoperative Details
The use of perioperative antibiotics varies among authors, with no clear consensus. The authors routinely administer broad-spectrum intravenous antibiotics (cefazolin) 1 hour before surgery. Informed consent that outlines the risks is obtained. Risks include but are not limited to bleeding, infection, erectile dysfunction, penile curvature, decrease in penile sensation, and the possible need for circumcision. The patient must be informed that erectile dysfunction may result because of the nature of injury rather than the operation itself.

Intraoperative Details
Penile fracture
The patient is placed in a supine position. The lower abdomen and genitalia are prepared and draped in a sterile fashion. A circumferential incision is made. The incision is carried through the dartos fascia and down to the Buck fascia. The penis is degloved to the base of the penis, taking care not to injure the dorsal neurovascular bundle. Both corpora cavernosa and the corpus spongiosum are thoroughly inspected. If both corpora are injured, the corpus spongiosum must be carefully inspected because of the high associated incidence of urethral injury. If the corpus spongiosum is involved, both corpora cavernosa must be thoroughly examined for possible injury. The presence of corporal hematoma strongly suggests an injury to the tunica. Upon encountering a corporal hematoma, the Buck fascia is opened and the hematoma is evacuated. Upon evacuating the hematoma, a defect in the tunica will be apparent. A recent series by Shaeer revealed that intraoperative injection of methylene blue into the corpora helped reveal the tunical injury and thereby reduced unnecessary tissue dissection and operative time and simplified the repair.[11] Freshen the edges of the tunica albuginea. The type and method of suture repair of the tunica albuginea varies widely, but all authors insist on a watertight closure. The authors use 1-0 braided nonabsorbable suture in an interrupted fashion. Invert the sutures so the knots will not be palpable. Alternatively, a 2-0 delayed absorbable suture such as polydioxanone may be used. At this juncture, an artificial saline-induced erection may be induced to test for watertight integrity. Close the fascia. Suture the penile shaft skin to the coronal skin with 3-0 chromic sutures in an interrupted fashion. Typically, drains are not required. Partial and complete urethral transections that are clean require a primary anastomosis over a catheter. Additionally, urinary diversion via a suprapubic tube may be considered. Close the urethral defect with 4-0 chromic or 5-0 polydioxanone sutures in an interrupted fashion, and leave an indwelling urethral catheter for 2-3 weeks. If a devitalized urethral segment is identified, minimal judicious debridement may be performed. If a complete tear is noted, mobilize the urethra proximally and distally. Spatulate the proximal and distal ends of the urethra and insert a urethral catheter. Approximate the urethral margins with 5-0 polydioxanone sutures in an interrupted fashion.

Penile amputation
The patient is placed in a supine position. The lower abdomen and genitalia are prepared and draped in a sterile fashion. Bleeding from the penile stump is controlled by wrapping the base of the penis circumferentially with a small Penrose drain and securing with a hemostat. Minimal debridement of

any necrotic tissue is performed. The penile remnant should be cleaned and irrigated with antibiotic solution and minimally dbrided, as necessary. Under loupe or microscopic magnification, the penile skin from both the stump and amputated shaft should be undermined for 1 cm. This allows exposure and identification of the dorsal veins, artery, and nerves. The urethra should be spatulated opposite of each other. A Foley catheter is then used to bridge and stabilize the amputated segment. The urethral mucosa is reapproximated using 5-0 polydioxanone sutures on the mucosa and a second layer on the spongiosum. The deep cavernosal arteries do not need to be anastomosed unless the amputation is very proximal and the erectile tissue will be minimally injured. This remains somewhat controversial and often depends on the author. If the deep cavernosal arteries are repaired, 11-0 nylon should be used. The tunica albuginea of each corporal body should be reapproximated with 2-0 slowly absorbing suture. Once the main shaft of the penis and urethra are reanastomosed, attention can be turned to repairing the dorsal neurovascular bundles of the penis. The dorsal arteries are anastomosed with 11-0 monofilament nylon; 10-0 monofilament nylon is used for the dorsal nerves. The epineurium of the dorsal nerve is reapproximated with 10-0 nylon. Once the dorsal neurovascular bundles are microsurgically repaired, the dartos fascia can be closed with interrupted 2-0 self-absorbable sutures. The skin is then closed with running 4-0 cat gut. Some authors elect to leave a small Penrose drain to prevent hematoma accumulation. Most authors choose to leave a suprapubic cystotomy drain. The penis is wrapped in loose circumferential gauze. If microsurgical reanastomosis is not possible, penile stump advancement should be performed by dividing the suspensory ligament of the penis from the pubic symphysis. Free lateral forearm flap phalloplasty can be performed as a staged procedure once the patient has recovered from his initial insult. This is a highly specialized procedure and fraught with complications. As a result, only highly trained specialized surgeons should perform the procedure.

Repair of partial penile amputation after primary closure (without replantation of

penile remnant).

Penile amputation in the initial stage of replantation.

Penile amputation after replantation.

Penetrating injury
The technique for repair of penetrating injuries to the penis is similar to that used in penile fracture. Incisions can be made directly over the site of injury, as an inguinal-scrotal approach, or as a circumferential degloving of the penis. The authors prefer a circumferential degloving incision as described above. When the underlying Buck fascia is exposed, the corpora cavernosa and spongiosum are examined. The hematoma is evacuated and the injury site inspected. Necrotic areas should be dbrided. Caution should be used to avoid overdebridement, as hematoma can be confused with dead tissue. Small corporal injuries of the tunica albuginea are repaired via primary closure using 1-0 braided nonabsorbable sutures or 2-0 delayed absorbable sutures such as polydioxanone. Larger defects may require placement of xenograft material such as Tutoplast cadaveric dermis or small intestinal submucosa (SIS). Urethral transactions are completed with primary anastomosis over a Foley catheter. Defects can be closed using 4-0 polydioxanone. Large defects that cannot be closed primarily can be diverted with a suprapubic cystotomy with delayed repair. An indwelling urethral catheter should be left in place for 2 weeks.

Penile soft tissue injury

No standard approach is used to treat soft tissue injuries to the penis, as the mechanism of injury is quite varied. Individualized approaches should be used for each patient. Standard treatment includes debridement of necrotic tissue. The wound must be copiously irrigated with povidine and antibiotic solution. Bite injuries with puncture type wounds to the corpora cavernosa and urethra can be repaired in a similar fashion to that of penetrating injuries of the penis. Care should be used to avoid closure of skin and subcutaneous tissues in the case of a human bite and injuries with signs of gross infection. Primary closure of animal bites can be performed, as infection is rare. Lacerations of the penis can be closed primarily if they are small. Larger avulsion injuries often require skin grafting. The two methods typically used for grafting are controversial: meshed versus unmeshed split-thickness skin grafts.

Postoperative Details
Penile fracture
The patient is discharged with pain medications and oral antibiotics 1-3 days after the operation. If no urethral injury was detected intraoperatively, the Foley catheter is removed prior to discharge. Light compressive dressings are applied for one week. Some authors advocate formal suppression of spontaneous erections with diazepam or stilboestrol. Others believe that the painful stimuli are sufficient control to prevent spontaneous erections, and the sedating effects of the medication may be avoided. In the authors' clinical experience, troublesome spontaneous erections are not encountered after this type of penile reconstruction.

Penile amputation
An area of controversy is the use of anticoagulation in the immediate postoperative period. If anticoagulation is desired, some authors recommend 500 mL of low molecular dextran for 72 hours. The patient should be kept on intravenous antibiotics until the remnant appears to be taking appropriately. The patient can then be switched to oral therapy for one week.

Penetrating injury
The postoperative care for penetrating injury to the penis is similar to that of penile fracture.

Penile soft tissue injury

Circumferential compressive dressings to the penis may be required until the graft takes if skin grafting has been performed. Antibiotic treatment should be continued as described above. In general, patients should abstain from sexual relations for 6-8 weeks following most penile trauma.

Follow-up
For patients with urethral reconstruction, the urethral catheter may be removed in 2 weeks. After removal of the urethral catheter, retrograde urethrography should be performed in a gentle fashion. Alternatively, voiding cystourethrography may be performed via the suprapubic tube. The cystotomy tube can be removed after normal voiding no leak is present. If extravasation from the urethra is present, the cystotomy should be continued for an additional 2 weeks or the Foley catheter replaced if cystotomy tube was not used in the original repair.

Complications
Penile fracture
Potential complications of penile fracture include erectile dysfunction (which may result from a cavernosospongiosal fistula), abnormal penile curvature, painful erections, formation of fibrotic plaques, penile abscess, urethrocutaneous fistula, corporourethral fistula, and painful nodules along the site of injury. Patients treated with conservative management have a significantly higher incidence of complications compared with those treated with prompt surgical therapy.

Penile amputation
Similar to the possible complications following correction of penile fracture, penile amputation can be associated with penile curvature, erectile dysfunction, hematoma, abscess formation, urethrocutaneous fistula, and corporourethral fistula. In addition, urethral stricture can occur. Penile skin necrosis was more common prior to microvascular anastomosis of the dorsal neurovascular complexes. The necrosis that typically occurs is less frequent and often superficial.

Penetrating injury
Similar to the possible complications following correction of penile fracture, penetrating corpora cavernosal injuries carry with them complications of erectile dysfunction, penile curvature, fibrotic plaques, abscess, and painful erections. Patients with urethral injuries risk corporourethral fistula, urethral stricture, and urethrocutaneous fistula

Penile soft tissue injury

The most frequent complication of soft tissue injury is postoperative infection. If the graft does not take in patients who undergo split-thickness skin grafting, the consequences can be devastating. As described above, complications such as erectile dysfunction, curvature, and fistula are associated risks.

Outcome and Prognosis

Penile fracture
Penile fracture is a urologic emergency that may have devastating physiologic and psychologic consequences. However, with prompt diagnosis and expedient surgical management, outcomes remain excellent and complications are minimal.[12]

Penile amputation
Erectile function remains in up to 86% of patients who undergo microvascular reanastomosis of the dorsal arteries. Penile sensation is maintained in up to 82% of patients, although this may be

diminished when compared with preinjury. Urethral strictures develop in up to 20% of patients. Skin loss occurs in approximately half of all patients but is often superficial.

Penetrating injury
Patients who undergo exploration and primary repair of penetrating penile injury have good outcomes. Potency is maintained in up to 80-100% of patients in some series. This depends on the degree and severity of injury. Some authors anecdotally report that patients who have suffered close-range shotgun blasts have poorer outcomes secondary to massive tissue destruction.

Penile soft tissue injury

The long-term results of soft tissue injury to the penis are somewhat limited. Outcomes depend on the mechanism of injury and volume of tissue loss. Wound contracture and cosmesis is a concern in those who undergo skin grafting. Penile sensation is decreased in those with significant penile skin loss.

Future and Controversies

Penile fracture
Some debate surrounds the usefulness of imaging studies in diagnosing cavernosal injury. Most authors report accurate diagnoses without any imaging studies. Imaging studies have a limited role in the detection of penile fractures and should be reserved for cases in which clinical history does not correlate with examination findings or for those in which no injury is apparent and imaging would confirm nonoperative management. MRI provides excellent anatomic images of the penis and has been shown to be highly accurate in the detection of penile fractures. However, it appears to minimally affect treatment outcomes, is expensive, and is subject to limited availability in some institutions, especially after-hours. Penile ultrasonography, although widely available and inexpensive, heavily depends on the operator and requires specific expertise in the technique. False-negative rates are common. The most recent debate surrounds the use of penile cavernosography. False-negative findings are common, tissue reaction to the contrast material and increased corporal fibrosis are risks. Most authors report using penile cavernosography if physical examination findings are equivocal but the history indicates a possible injury. In most cases, prompt surgical exploration should be accomplished in lieu of preliminary penile imaging (other than urethrography).

Penile amputation
Cavernosal artery repair remains controversial. Some authors always attempt repair, especially when injury is more proximal, where the arteries may be larger, more easily sutured, and necessary to survival of the amputated stump. Other authors contend that the arteries do not provide a significant amount of vascular flow, add more operative time, and result in damage to the erectile tissue. Anticoagulation remains problematic. Most authors agree that anticoagulation leads to excessive bleeding and hematoma formation. Some contend that this prevents vascular occlusion of the freshly sutured dorsal artery and vein. To date, no studies have compared postoperative outcomes of penile amputation with or without anticoagulation.

Penile soft tissue injury

Split-thickness skin grafting is routine in the repair of penile skin loss. The choice of graft is largely up to the surgeon. Many authors have traditionally used unmeshed sheet grafts. This can be problematic because of fluid accumulation beneath the graft and infection of the graft bed. A recent series by Black et al showed that meshed unexpanded grafts achieved excellent cosmetic and functional results. However, a randomized controlled trial has not been undertaken to compare results.