Snapshot A 28-year-old male was hit by a car while crossing the road. He sustained abrasions to the face, hands, and bruising over both iliac crests. Blood pressure is 90/55 mmHg and pulse is 110/min. Two large bore IVs are inserted and he was given 1L of Lactated Ringer's, and 2L of crossmatched pRBCs. Scrotal and perineal ecchymosis and swelling, blood at the urethral meatus, and bladder distension up to the umbilicus are present. AP radiographs of the pelvis reveal pelvic fracture (bilateral pubic rami fracture). Retrograde cystourethrogram shows a torn posterior urethra; a suprapubic catheter and a pelvic binder are applied. Introduction Genitourinary trauma involves kidney, bladder, and/or urethra 80% is from blunt trauma (MVCs, assaults, falls, crush) vs 20% penetrating (GSW/SW) Blunt trauma to genitourinary organs is associated with pelvic fracture in 97% cases Urethral injury etiology can be divided by posterior and anterior urethra posterior: junction of membranous and prostatic urethra is common site of injury due to shearing force on fixed membranous and mobile prostatic urethra anterior: straddle injury causing crush injury to bulbar urethra against pubic rami iatrogenic: instrumentation, penile fracture Presentation History mechanism of injury hematuria, blood on underwear dysuria, urinary retention prolonged labor and delivery pubic symphysis diastasis Physical exam abdominal/flank pain, CVA tenderness, upper quadrant mass, perineal lacerations DRE: sphincter tone, position of prostate, presence of blood scrotum: ecchymoses, lacerations, testicular disruption, hematomas females: bimanual/speculum exam bladder if extraperitoneal rupture: pelvic instability, suprapubic tenderness from mass of urine or extravasated blood if intraperitoneal rupture: acute abdomen urethra flank, scrotal or perianal swelling and bruising gross hematuria high-riding or nonpalpable prostate penile or scrotal swelling or ecchymosis blood in the urethral meatus Evaluation Pelvis: radiograph with AP, inlet, and outlet views Urethra: retrograde urethrogram (RUG) if blood at meatus, do NOT insert Foley catheter; perform RUG first Bladder: urinalysis, urethrogram, retrograde cystoscopy +/- cystogram Ureter: retrograde ureterogram Kidney: intravenous pyelogram, CT scan (if hemodynamically stable) Treatment Primary and secondary survey with resuscitation (massive transfusion protocol for hemodynamically unstable patients Pelvis: mechanical stabilization of pelvis pelvic binder at the level of the greater trochanters external fixator reduces pelvic volume FAST (Focused assessment with sonography for trauma) exam to assess for intra-abdominal fluid If positive, emergent trip to OR to stop bleeding If negative, can perform diagnostic peritoneal aspirate (DPA) to look for blood If DPA positive, to OR to stop bleeding If DPA negative or not performed (some hospitals do not have this available), can defer OR and continue pelvic stabilization, external fixation, angiography/embolization, or resuscitative endovascular balloon occlusion of the aorta Pelvic angiography and embolization of bleeding vessels may also be performed in hemodynamically stable patients who have evidence of active bleeding on a CT scan of the abdomen/pelvis only stops arterial bleeding does NOT address venous bleeding or bony hemorrhage Urethra: based on location of tear seen on retrograde urethrogram anterior: conservative management if voiding limited: suprapubic cystostomy and antibiotics posterior: suprapubic cystostomy (avoid catheterization) +/- surgical repair Bladder: based on extra vs intraperitoneal rupture extraperitoneal if minor, Foley catheter drainage if major, surgical repair intraperitoneal drain abdomen and surgical repair Ureter: ureterouretostomy Kidney: depends on grade of hematoma / laceration and HD stability minor: conservative management major: surgical repair