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Management Of Genitourinary Gunshot Wounds

Only 10% of trauma patients have a GU injury, and only 15% of this subset is from penetrating trauma.102 Fortunately, there are few life-threatening GU surgical emergencies other than a shattered kidney or major lacerations of the renal vasculature. The majority (up to two-thirds) of GU injuries are to the external genitalia, and most patients have other, more urgent, nongenitourinary injuries.103 In up to 45% of trauma cases, bladder injuries are due to gunshot wounds, but 90% of traumatic ureteral injuries are due to penetrating trauma.104-106 Only a small percentage (5%-10%) of direct kidney injuries are from penetrating trauma, but many of these injuries require complete nephrectomy.107

The evaluation of GU trauma typically begins with an evaluation of the distal structures and proceeds more proximally to the kidneys. A thorough examination of the external genitalia for blood at the urethral meatus and an evaluation for gross hematuria may indicate the presence of an injury. A lack of external signs and a lack of microscopic or macroscopic hematuria do not rule out significant GU injuries, as a normal urinalysis is present in 25% of upper GU injuries.105,106 If there is concern for a urethral injury, delay placement of a Foley catheter until after further testing in order to avoid making a partial urethral injury worse.

Upon examination, if there is concern for an upper or lower GU injury (or from the potential trajectory of the projectile), diagnostic imaging will likely be necessary. Testing for a GU injury should be delayed in patients who require further evaluation and treatment of more life-threatening injuries. A retrograde urethrogram or cystogram can help determine if there is a urethral or bladder injury and suggest whether the bladder injury is intraperitoneal or extraperitoneal. Retrograde CT cystography can also be performed to assess the extent of injury to distal structures, and the CT can be extended superiorly and should include IV contrast to evaluate for kidney involvement. To assess for contrast leakage proximally at the kidneys, it is indicated to delay abdominal CT scanning for 10 minutes after the IV contrast is administered.107 When other intra-abdominal or pelvic injuries that require surgical exploration are present, the ureters and kidneys can be directly visualized to assess for GU injuries.

When a GU injury is noted and other life-threatening injuries have been treated or excluded, consultation with a urologist for definitive management is indicated. Decompression of the bladder with a catheter is the mainstay of early management of bladder injuries in the ED, but most other injuries to the GU system require surgical management by a urologist. The bladder should be irrigated to help evacuate blood clots. The most important ED management strategy is simply to recognize and test for GU injuries and resuscitate appropriately.

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Last Modified: 07/19/2018
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