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Emergency Management of Renal and Genitourinary Trauma: Best Practices Update

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Table of Contents
 
About This Issue

For trauma patients in the ED, life- and limb-threatening injuries take priority, but renal and genitourinary injury can have long-term consequences for patients, including chronic kidney disease, erectile dysfunction, incontinence, and other serious problems. This issue offers a review of the literature regarding treatment of renal and GU injuries, from diagnosis to management to disposition.

The mechanism of the trauma can be a clue to the injury sustained:

Rapid deceleration forces can injure the kidney, from contusions to shattering

Most injuries to the ureter are a result of penetrating trauma

Bladder injuries are often seen in pelvic fractures

Injuries to the external genitalia are more likely from sports or sexual intercourse

Gross hematuria is the best indicator of injury, but its absence does not rule out injury; in penetrating trauma, there is no correlation between the amount or even presence of hematuria and the degree of injury.

The type of injury suspected will dictate the diagnostic studies needed: CT, CT cystography, intravenous pyelogram, retrograde urethrogram, or ultrasound.

With grade IV or V kidney injuries, 10-minute-delayed IV contrast CT scans should be obtained.

Do not place a urinary catheter if there is a possibility of urethral injury.

In the last 20-30 years, conservative management therapies have become standard. 

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Epidemiology
  6. Etiology and Pathophysiology
    1. Kidney and Ureter
    2. Bladder
    3. Male Genitalia
    4. Female Genitalia
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Ability to Void, Dysuria, and Hematuria
    3. Physical Examination
  10. Diagnostic Studies
    1. Urinalysis
    2. Baseline Renal Function
    3. Computed Tomographic Imaging
    4. Computed Tomographic Cystography
    5. Computed Tomographic Angiography
    6. Retrograde Urethrogram
    7. Ultrasound
  11. Treatment
    1. Catheters and Urinary Diversion
      1. Suprapubic Catheterization
      2. Alternative Methods of Urinary Diversion
    2. Surgery
    3. Interventional Radiology
    4. Admission
  12. Special Populations
    1. The Pediatric Patient
    2. The Elderly
  13. Controversies and Cutting Edge
    1. Magnetic Resonance Imaging
    2. Nonoperative Management
    3. Contrast-Enhanced Ultrasound
  14. Disposition
    1. Consultation
    2. Urinary Catheter Care
  15. Summary
  16. Risk Management Pitfalls for Renal and Genitourinary Trauma
  17. Time- and Cost-Effective Strategies
  18. Case Conclusions
  19. Clinical Pathway for Evaluation of Blunt Renal Trauma in Adults
  20. Tables and Figures
    1. Table 1. Potential Sequelae of Renal and Genitourinary Injuries
    2. Table 2. Expert Guidelines in Renal and Genitourinary Trauma
    3. Table 3. Renal and Genitourinary Organ Injuries
    4. Table 4. American Association for the Surgery of Trauma Kidney Injury Scoring Scale
    5. Table 5. Key Historical Questions in Renal and Genitourinary Trauma
    6. Table 6. American College of Radiology Guidelines Appropriateness Criteria® for Computed Tomographic Imaging in Renal and Genitourinary Trauma
    7. Table 7. Recommendations for Use of Computed Tomographic Cystography
    8. Table 8. Antibiotic Prophylaxis and Renal Injury
    9. Figure 1. Anatomy of the Normal Male Urethra
    10. Figure 2. Diagram of The American Association for the Surgery of Trauma Grading System for Renal Injury
    11. Figure 3. Eggplant Deformity
    12. Figure 4. Positive Computed Tomographic Cystogram in a Patient With Penetrating Trauma and Bladder Rupture
    13. Figure 5. Retrograde Urethrogram Performed in a Patient With a Penile Fracture
  21. References

Abstract

In up to 10% of patients who experience abdominal trauma, renal and urogenital systems will be involved. In polytrauma patients with other potentially life-threatening injuries, renal and genitourinary trauma may be overlooked initially, but a delayed or missed diagnosis of these injuries may result in preventable complications. This review provides a best-practice approach to the diagnosis and management of renal and genitourinary injuries, with an emphasis on the systematic approach needed to identify subtle injuries and avoid long-term urinary sequelae such as hypertension, incontinence, erectile dysfunction, chronic kidney disease, and nephrectomy.

Case Presentation

You’ve just arrived for a long Saturday overnight when the EMS notification pager goes off. Your first patient is a 23-year-old man who was in an altercation outside a bar. He is intoxicated, has bruises and red marks that look like shoe prints all over his abdomen, flanks, and chest, and tells you it hurts “everywhere.” On his right flank, he has a 1- by 2-centimeter wound that he thinks was made by a screwdriver. You put out a trauma page, and in the interim, you wonder: will a urinalysis really help in working up this patient? What kind of special imaging is he going to need? Should I order pre-op labs?”

Into the next trauma bay arrives a 46-year-old woman, also intoxicated, who was the unrestrained and ejected passenger in a high-speed, rollover motor vehicle crash. She is hypotensive and tachycardic. She has a pelvic binder on, with a tense, swollen belly extending above it. During the resuscitation, you notice she is bleeding briskly from her vagina. Your nursing colleague asks if you want a Foley catheter. Should you place one? Do you need to page urology as well as trauma? Is it necessary to alert interventional radiology of this patient’s arrival?

Since bad news comes in threes, you are immediately called to a third trauma patient. This one is a 54-year-old man who was in a high-speed motorcycle collision. He is screaming in pain and has an obvious chest wall deformity with crepitus. What he’s screaming about, however, is his genitals, making a number of medical students and residents blush. He has a massive hematoma to his perineum and scrotum, a testicle that appears dislocated and free from the scrotal sack, and a deformity to his penile shaft. There is gross blood at the urethral meatus. Where do you begin in assessing this patient’s genitourinary trauma? Should you place a suprapubic catheter? Is an ultrasound, CT, or MRI best for fully assessing the extent of his injury and helping your urology colleagues plan for treatment?

Introduction

Worldwide, approximately 250,000 traumatic renal injuries occur annually.1 The urological organ most commonly injured is the kidney, followed by the testicles and the bladder.2 Depending on the data set used, renal and genitourinary (GU) trauma is present in 5% to 10% of all abdominal trauma patients.3-5 Over the last 20 to 30 years, the care of renal and GU injuries has evolved, becoming more conservative and expectant. Advances in military medicine, where 5% of all combat injuries are GU-related, have accelerated the pace of this change and advances in care.6

The principles of effective trauma care are to prioritize life- and limb-threatening injuries.7 Blunt and penetrating trauma that affects the kidneys or other GU organs is rarely isolated, and nearly all patients with penetrating or high-grade blunt abdominal trauma have multiple injured organs.8,9 As a result, renal, bladder, and other GU injuries can be missed in the rush to contend with emergent interventions.7,10,11 Indeed, in one case series performed at a specialized trauma center, 20% to 25% of all bladder and urethral injuries associated with pelvic fracture were missed initially.12

Patients with GU injuries tend to be sicker than their cohorts without such injuries.13-15 Missed renal and GU injuries are associated with increased morbidity and mortality.14,16 Coordinated trauma care, particularly care that takes place in a designated trauma center, reduces the risk of nephrectomy and inpatient mortality in renal trauma.17 Table 1 lists potential sequelae of renal and GU injuries.16,18-20

Long-term consequences of renal and GU injuries include hypertension, chronic kidney disease, erectile dysfunction, incontinence and voiding issues, hydronephrosis, fistula, recurrent pyelonephritis, and nephrolithiasis.4,16,21,22 Although hypertension is relatively rare as a late consequence (approximately 5%), it is emblematic of the need to accurately and quickly diagnose these types of injuries to avoid unnecessary morbidity.23 Recognizing and initiating treatment of these non–life-threatening GU injuries is vital in reducing the incidence of future strictures, impotence and other sexual dysfunction, and incontinence.24-26 This issue of Emergency Medicine Practice will review common and uncommon traumatic GU emergencies and provide a best-practice framework for diagnosis and management.

Critical Appraisal of the Literature

A literature search was performed using PubMed and the services of a medical research librarian using the search terms kidney trauma, renal trauma, ureteral trauma, bladder trauma, urethral trauma, genital trauma, penile trauma, urological trauma, and genitourinary trauma. A total of 383 articles from 1968 to the present were reviewed. There are no reviews in the Cochrane Database on this topic. We searched the National Guideline Clearinghouse created by the United States Agency for Healthcare Research and Quality (www.guideline.gov). This, in addition to our literature search, yielded 5 core, evidence-based and consensus guidelines, listed in Table 2. We also reviewed guidelines by the American Association for the Surgery of Trauma (AAST) organ injury severity system.

The majority of recommendations on this topic are based on retrospective reviews, case studies, and consensus. Well-designed prospective trials are rare in GU trauma.27 Most articles are case reports, expert opinion pieces, or single-institution retrospective case series. One sizable study randomized penetrating renal trauma patients to direct exploration of the kidney versus early vascular control. This study, and a limited number of large retrospective reviews, are the exception; the rest of the literature is weak.1,28 One expert, lamenting this dearth of quality literature on GU trauma noted, “Most studies repeat the same old messages/prejudices. One could argue that there has been no major advance in the (early) treatment of urethral trauma since 1757.”29 Although we disagree with that grim assessment of the recent advances in this field, expert consensus is the norm in the literature presented here.

Risk Management Pitfalls for Renal and Genitourinary Trauma

1. “I ruled out kidney damage with a normal urinalysis and sent her home. She came back with renal necrosis.”

While a urinalysis can help risk stratify and identify the severity of some types of renal trauma, a normal urinalysis is not sufficient to rule out the diagnosis. There are many case reports of patients with severe injuries and normal urinalyses, especially in vascular injury and penetrating trauma.

2. “He only had a little blood at the meatus on examination, so I went ahead and tried to place a Foley.”

In any patient for whom you have a concern for possible urethral injury, based on history, physical examination, presence of significant pelvic fractures on x-ray, or suspicious findings on initial CT scan, you should perform a RUG prior to attempting placement of a Foley catheter. Without this test, you risk turning a minor urethral injury into a major one.

3. “Radiology hedged their read on our CT because we did the RUG before he went to CT.”

The contrast from a RUG can make accurately reading a subsequent CT of the abdomen with IV contrast or a CT cystogram very difficult. Since the placement of a Foley catheter is not emergent, the CT imaging should be performed first before performing a urethrogram to rule out urethral injury.

4. “I diagnosed her posterior rib fractures with an x-ray after she was hit on the flank. Her belly examination and blood pressure were normal, so I sent her home. She came back with a grade IV renal laceration.”

Patients presenting with blunt or penetrating trauma to the lower thorax, upper abdomen, or flank should raise your suspicion for underlying renal trauma. Depending on history, mechanism of injury, adjacent injuries (such as vertebral fractures) and presence and degree of hematuria, such presentations may require additional imaging for possible renal injury.

5. “When we found his pelvic fracture, I called orthopedics and trauma, but I didn’t think about a urethral injury.”

Pelvic fractures (apart from acetabular fractures), are highly correlated to urethral injury. In patients who have difficulty or pain with voiding, or hematuria with a pelvic fracture or trauma to the genitals or pelvis, a urethral injury must be on your differential, even if the patient is admitted and cannot have the definitive test before going upstairs. Depending on the institution, this can mean a RUG performed downstairs, a discussion with trauma surgery/ admitting service, or a urology consult.

6. “I just assumed he couldn’t urinate because he was anxious after his car crash and because we gave him fentanyl.”

Inability to void is common in the setting or lower urinary tract injury. In a setting of abdominal or pelvic trauma, this complaint must be investigated with bladder ultrasound to look for retention and appropriate additional imaging (CT cystogram, RUG, etc) to ensure the inability to void is not masking serious injury. Missed bladder and urethral injury can cause significant lifelong morbidity.

7. “His scrotum was so swollen and he had so many other injuries from his motorcycle crash, I couldn’t have possibly caught his traumatic testicular torsion.”

Renal and GU trauma is rarely the “main event” in the sick polytrauma patient. ATLS guidelines, with good reason, mandate dealing with the life-threatening injuries first. However, genital trauma with marked physical examination abnormalities can and should be addressed on secondary or tertiary examination, with a plan in place for additional imaging, such as ultrasound, and appropriate subspecialty consultation. The time-sensitive nature of some genital trauma makes this especially important.

8. “I assumed he had a penile fracture, but he was able to void, so I sent him home with pain medicine and a plan to see urology in the clinic in 1 to 2 days.”

Penile fracture, most commonly caused by trauma sustained during sexual intercourse, is a surgical emergency no matter how severe it appears on physical examination or the patient’s ability to void. Although urethral injury is a concern, repairing the underlying defect in the tunica albuginea is also essential for future sexual function and cosmesis.

9. “We got a stat CT of the abdomen and pelvis when we saw the flank bullet exit wound, but we missed the ureteral injury because of how we ordered it.”

Ureteral injuries are uncommon in general, but they are most commonly seen in penetrating trauma. A regular CT of the abdomen with IV contrast is not timed to catch most ureteral injuries. When the path of the projectile or stabbing implement, based on history or physical examination, is near a ureter or the kidney, delayed excretory images performed roughly 10 minutes after contrast administration are required.

10. “We called trauma when we saw the shattered kidney. When her FAST was positive and her pressure dropped, she went straight upstairs. Urology complained the next day.”

Although in most institutions the management of critically ill trauma patients is primarily dictated by the ED and their trauma surgery consultants, any high-grade renal or GU injury benefits from early involvement of a urologist. Ideally, they are involved in the initial operative intervention to help with urinary diversion and lend their expertise in renal salvage.

Tables and Figures

Table 1. Potential Sequelae of Renal and Genitourinary Injuries

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Yeung LL, Brandes SB. Contemporary management of renal trauma: differences between urologists and trauma surgeons. J Trauma Acute Care Surg. 2012;72(1):68-75. (Survey study; 156 participants)
  2. Kuy S, Codner PA, Guralnick M, et al. Combined rectovesicular injuries from low velocity penetrating trauma in an adult. WMJ. 2013;112(1):32-34. (Case report and review article)
  3. * McGeady JB, Breyer BN. Current epidemiology of genitourinary trauma. Urol Clin North Am. 2013;40(3):323-334. (Review article)
  4. Lynch TH, Martínez-Piñeiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol. 2005;47(1):1-15. (Review article)
  5. Cinman NM, McAninch JW, Porten SP, et al. Gunshot wounds to the lower urinary tract: a single-institution experience. J Trauma Acute Care Surg. 2013;74(3):725-730. (Prospective analysis; 50 patients)
  6. Nnamani NS, Janak JC, Hudak SJ, et al. Genitourinary injuries and extremity amputation in Operations Enduring and Iraqi Freedom: early findings from the Trauma Outcomes and Urogenital Health (TOUGH) project. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S95-S99. (Retrospective; 1367 patients)
  7. Srinivasa RN, Akbar SA, Jafri SZ, et al. Genitourinary trauma: a pictorial essay. Emerg Radiol. 2009;16(1):21-33. (Review article)
  8. Baverstock R, Simons R, McLoughlin M. Severe blunt renal trauma: a 7-year retrospective review from a provincial trauma centre. Can J Urol. 2001;8(5):1372-1376. (Retrospective; 227 patients)
  9. Kansas BT, Eddy MJ, Mydlo JH, et al. Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center. J Urol. 2004;172(4 I):1355-1360. (Retrospective; 123 patients)
  10. Hsieh CH, Chen RJ, Fang JF, et al. Diagnosis and management of bladder injury by trauma surgeons. Am J Surg. 2002;184(2):143-147. (Retrospective; 51 patients)
  11. Lückhoff C, Mitra B, Cameron PA, et al. The diagnosis of acute urethral trauma. Injury. 2011;42(9):913-916. (Retrospective; 223 patients)
  12. Ziran BH, Chamberlin E, Shuler FD, et al. Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J Trauma. 2005;58(3):533-537. (Retrospective; 43 patients)
  13. Bjurlin MA, Fantus RJ, Mellett MM, et al. Genitourinary injuries in pelvic fracture morbidity and mortality using the national trauma data bank. J Trauma. 2009;67(5):1033-1039. (Retrospective; 1444 patients)
  14. Matlock KA, Tyroch AH, Kronfol ZN, et al. Blunt traumatic bladder rupture: a 10-year perspective. Am Surg. 2013;79(6):589-593. (Retrospective; 54 patients)
  15. Harpole BG, Wibbenmeyer LA, Erickson BA. Genital burns in the national burn repository: incidence, etiology, and impact on morbidity and mortality. Urology. 2014;83(2):298-302. (Retrospective; 1245 patients)
  16. Ter-Grigorian AA, Kasyan GR, Pushkar DY. Urogenital disorders after pelvic ring injuries. Cent European J Urol. 2013;66(3):352-356. (Review article)
  17. Vanni AJ, Hotaling J, Hamlat C, et al. Do inclusive trauma systems improve outcomes after renal trauma? J Trauma Acute Care Surg. 2012;72(2):385-389. (Retrospective; 14,590 patients)
  18. Dunfee BL, Lucey BC, Soto JA. Development of renal scars on CT after abdominal trauma: does grade of injury matter? AJR Am J Roentgenol. 2008;190(5):1174-1179. (Retrospective; 54 patients)
  19. Tasian GE, Aaronson DS, McAninch JW. Evaluation of renal function after major renal injury: correlation with the American Association for the Surgery of Trauma Injury Scale. J Urol. 2010;183(1):196-200. (Retrospective; 67 patients)
  20. Shoobridge JJ, Corcoran NM, Martin KA, et al. Contemporary management of renal trauma. Rev Urol. 2011;13(2):65-72. (Review article)
  21. Gomez RG, Mundy T, Dubey D, et al. SIU/ICUD consultation on urethral strictures: pelvic fracture urethral injuries. Urology. 2014;83(3 Suppl):S48-S58. (Consensus statement)
  22. Mundy AR, Andrich DE. Urethral trauma. Part II: types of injury and their management. BJU Int. 2011;108(5):630-650. (Review article)
  23. Brandes SB, McAninch JW. Renal trauma: a practical guide to evaluation and management. ScientificWorldJournal. 2004;4 Suppl 1:31-40. (Review article)
  24. Shewakramani S, Reed KC. Genitourinary trauma. Emerg Med Clin North Am. 2011;29(3):501-518. (Review article)
  25. Pontes JE, Pierce JM Jr. Anterior urethral injuries: four years of experience at the Detroit General Hospital. J Urol. 1978;120(5):563-564. (Retrospective; 19 patients)
  26. Black PC, Miller EA, Porter JR, et al. Urethral and bladder neck injury associated with pelvic fracture in 25 female patients. J Urol. 2006;175(6):2140-2144. (Retrospective; 25 patients)
  27. Bryk DJ, Zhao LC. Guideline of guidelines: a review of urological trauma guidelines. BJU Int. 2016;117(2):226-234. (Review article)
  28. Santucci RA, Wessells H, Bartsch G, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int. 2004;93(7):937-954. (Consensus statement)
  29. Mundy AR, Andrich DE. Urethral trauma. Part I: introduction, history, anatomy, pathology, assessment and emergency management. BJU Int. 2011;108(3):310-327. (Review article)
  30. * Sheth S, Casalino D, Remer E, et al. American College of Radiology Appropriateness Criteria®: renal trauma. [Consensus Guideline]. 2012. Available at: https://acsearch.acr.org/docs/69373/Narrative/. Accessed July 10, 2017. (Consensus guideline)
  31. Lockhart M, Remer E, Leyendecker J, et al. American College of Radiology Appropriateness Criteria®: suspected lower urinary tract trauma. [Consensus Guideline]. 2013. Available at: https://acsearch.acr.org/docs/69376/Narrative/. Accessed July 10, 2017. (Consensus guideline)
  32. * Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335. (Practice guideline)
  33. * Holevar M, DiGiacomo C, Ebert J, et al. Practice management guidelines for the evaluation of genitourinary trauma. [Literature review and consensus guideline]. 2003. Available at: https://www.east.org/education/practice-management-guidelines/genitourinary-trauma-diagnostic-evaluation-of. Accessed July 10, 2017. (Consensus guideline)
  34. * Kitrey N, Djakovic N, European Association of Urology (EAU) Guidelines Group for Urological Trauma, et al. Guidelines on urological trauma: 2016 update. [European Association of Urology Guidelines]. 2016. Available at: http://uroweb.org/guideline/urological-trauma/. Accessed July 10, 2017. (Practice guideline)
  35. Wessells H, Suh D, Porter JR, et al. Renal injury and operative management in the United States: results of a population-based study. J Trauma. 2003;54(3):423-430. (Retrospective; 6231 patients)
  36. Bagga HS, Fisher PB, Tasian GE, et al. Sports-related genitourinary injuries presenting to United States emergency departments. Urology. 2015;85(1):239-244. (Retrospective review; 13,851 observations)
  37. Shnorhavorian M, Hidalgo-Tamola J, Koyle MA, et al. Unintentional and sexual abuse-related pediatric female genital trauma: a multiinstitutional study of free-standing pediatric hospitals in the United States. Urology. 2012;80(2):417-422. (Retrospective; 5664 patients)
  38. Cutinha P, Venugopal S, Salim F. Genitourinary trauma. Surgery (Oxford). 2013;31(7):362-370. (Review article)
  39. Siram SM, Gerald SZ, Greene WR, et al. Ureteral trauma: patterns and mechanisms of injury of an uncommon condition. Am J Surg. 2010;199(4):566-570. (Retrospective; 582 patients)
  40. Lehnert BE, Sadro C, Monroe E, et al. Lower male genitourinary trauma: a pictorial review. Emerg Radiol. 2014;21(1):67-74. (Review article)
  41. Figler BD, Hoffler CE, Reisman W, et al. Multi-disciplinary update on pelvic fracture associated bladder and urethral injuries. Injury. 2012;43(8):1242-1249. (Review article)
  42. Swanson DE, Polackwich AS, Helfand BT, et al. Penile fracture: outcomes of early surgical intervention. Urology. 2014;84(5):1117-1121. (Retrospective analysis; 30 cases)
  43. Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989;29(12):1664-1666. (Practice guideline)
  44. Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling. III: chest wall, abdominal vascular, ureter, bladder, and urethra. J Trauma. 1992;33(3):337-339. (Practice guideline)
  45. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207(5):646-655. (Retrospective; 54,148 patients)
  46. Scott I, Porter K, Laird C, et al. The prehospital management of pelvic fractures: initial consensus statement. Emerg Med J. 2013;30(12):1070-1072. (Consensus statement)
  47. Bjurlin MA, Fantus RJ, Fantus RJ, et al. The impact of seat belts and airbags on high grade renal injuries and nephrectomy rate in motor vehicle collisions. J Urol. 2014;192(4):1131-1136. (Retrospective; 3846 patients)
  48. Fanning DM, Forde JC, Mohan P. A simple football injury leading to a grade 4 renal trauma. BMJ Case Rep. 2012 Mar 8;2012. (Case report)
  49. Schmidlin FR, Iselin CE, Naimi A, et al. The higher injury risk of abnormal kidneys in blunt renal trauma. Scand J Urol Nephrol. 1998;32(6):388-392. (Retrospective; 120 patients)
  50. Morey AF, Iverson AJ, Swan A, et al. Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma. 2001;51(4):683-686. (Practice guideline)
  51. Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int. 2004;94(1):27-32. (Consensus statement)
  52. Yamacake KG, Lucon M, Lucon AM, et al. Renal artery pseudoaneurysm after blunt renal trauma: report on three cases and review of the literature. Sao Paulo Med J. 2013;131(5):356-362. (Case report)
  53. Goldman HB, Idom CB, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol. 1998;159(3):956-959. (Retrospective; 20 patients)
  54. Pereira BM, de Campos CC, Calderan TR, et al. Bladder injuries after external trauma: 20 years experience report in a population-based cross-sectional view. World J Urol. 2013;31(4):913-917. (Retrospective; 111 patients)
  55. Pichler R, Fritsch H, Skradski V, et al. Diagnosis and management of pediatric urethral injuries. Urol Int. 2012;89(2):136-142. (Review article)
  56. Docimo S Jr , Diggs L, Crankshaw L, et al. No evidence supporting the routine use of digital rectal examinations in trauma patients. Indian J Surg. 2015;77(4):265-269. (Retrospective; 111 patients)
  57. Ball CG, Jafri SM, Kirkpatrick AW, et al. Traumatic urethral injuries: Does the digital rectal examination really help us? Injury. 2009;40(9):984-986. (Retrospective; 41 patients)
  58. Bocchi F, Benecchi L, Russo F, et al. Early exploratory intervention in scrotal trauma. Urologia. 2013;80(2):140-144. (Retrospective; 43 patients)
  59. Hartman RJ Jr. Penile fracture. N Engl J Med. 2015;372(11): 1055. (Case report)
  60. Iqbal CW, Jrebi NY, Zielinski MD, et al. Patterns of accidental genital trauma in young girls and indications for operative management. J Pediatr Surg. 2010;45(5):930-933. (Retrospective; 167 patients)
  61. Santucci RA, McAninch JW, Safir M, et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma. 2001;50(2):195-200. (Retrospective; 2467 patients)
  62. Daum GS, Krolikowski FJ, Reuter KL, et al. Dipstick evaluation of hematuria in abdominal trauma. Am J Clin Pathol. 1988;89(4):538-542. (Prospective; 178 patients)
  63. Mee SL, McAninch JW, Robinson AL, et al. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. J Urol. 1989;141(5):1095-1098. (Prospective; 1146 patients)
  64. Hardeman SW, Husmann DA, Chinn HK, et al. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. J Urol. 1987;138(1):99-101. (Prospective: 506 patients)
  65. Herschorn S, Radomski SB, Shoskes DA, et al. Evaluation and treatment of blunt renal trauma. J Urol. 1991;146(2):274-276. (Retrospective; 126 patients)
  66. Nicolaisen GS, McAninch JW, Marshall GA, et al. Renal trauma: re-evaluation of the indications for radiographic assessment. J Urol. 1985;133(2):183-187. (Prospective; 359 patients)
  67. Brandes SB, McAninch JW. Urban free falls and patterns of renal injury: a 20-year experience with 396 cases. J Trauma. 1999;47(4):643-649. (Retrospective; 423 patients)
  68. Knudson MM, Harrison PB, Hoyt DB, et al. Outcome after major renovascular injuries: a Western Trauma Association multicenter report. J Trauma. 2000;49(6):1116-1122. (Retrospective; 89 patients)
  69. Boone TB, Gilling PJ, Husmann DA. Ureteropelvic junction disruption following blunt abdominal trauma. J Urol. 1993;150(1):33-36. (Retrospective; 8 patients)
  70. Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol. 2003;170(4 I):1213-1216. (Review article)
  71. Voelzke BB, McAninch JW. Renal gunshot wounds: clinical management and outcome. J Trauma. 2009;66(3):593-601. (Prospective; 201 patients)
  72. McAninch JW. Urotrauma guidelines. J Urol. 2014;192(2):336. (Commentary)
  73. Brown SL, Hoffman DM, Spirnak JP. Limitations of routine spiral computerized tomography in the evaluation of blunt renal trauma. J Urol. 1998;160(6 Pt 1):1979-1981. (Retrospective; 35 patients)
  74. Mulligan JM, Cagiannos I, Collins JP, et al. Ureteropelvic junction disruption secondary to blunt trauma: excretory phase imaging (delayed films) should help prevent a missed diagnosis. J Urol. 1998;159(1):67-70. (Retrospective; 5 patients)
  75. Hardee MJ, Lowrance W, Brant WO, et al. High grade renal injuries: application of Parkland Hospital predictors of intervention for renal hemorrhage. J Urol. 2013;189(5):1771-1776. (Retrospective; 147 patients)
  76. Ortega SJ, Netto FS, Hamilton P, et al. CT scanning for diagnosing blunt ureteral and ureteropelvic junction injuries. BMC Urology. 2008;8:3. (Retrospective; 8 patients)
  77. Mee SL, McAninch JW, Federle MP. Computerized tomography in bladder rupture: diagnostic limitations. J Urol. 1987;137(2):207-209. (Prospective; 4 patients)
  78. Avery LL, Scheinfeld MH. Imaging of male pelvic trauma. Radiol Clin North Am. 2012;50(6):1201-1217. (Review article)
  79. Ramchandani P, Buckler PM. Imaging of genitourinary trauma. AJR Am J Roentgenol. 2009;192(6):1514-1523. (Review article)
  80. Harper K, Shah KH. Renal trauma after blunt abdominal injury. J Emerg Med. 2013;45(3):400-404. (Case report)
  81. Hong LW, Chun YX, Hong HW, et al. Emergency transcatheter arterial embolization for acute renal hemorrhage. Medicine. 2015;94(42):1-7. (Retrospective; 83 patients)
  82. Lin WC, Lin CH, Chen JH, et al. Computed tomographic imaging in determining the need of embolization for high-grade blunt renal injury. J Trauma Acute Care Surg. 2013;74(1):230-235. (Retrospective; 137 patients)
  83. Bent C, Iyngkaran T, Power N, et al. Urological injuries following trauma. Clin Radiol. 2008;63(12):1361-1371. (Review article)
  84. Ingram MD, Watson SG, Skippage PL, et al. Urethral injuries after pelvic trauma: evaluation with urethrography 1. Radiographics. 2008;28(6):1631-1643. (Review article)
  85. Wu TS, Pearson TC, Meiners S, et al. Bedside ultrasound diagnosis of a traumatic bladder rupture. J Emerg Med. 2011;41(5):520-523. (Case report)
  86. Nicola R, Carson N, Dogra VS. Imaging of traumatic injuries to the scrotum and penis. AJR Am J Roentgenol. 2014;202(6):W512-W520. (Review article)
  87. Shlamovitz GZ, McCullough L. Blind urethral catheterization in trauma patients suffering from lower urinary tract injuries. J Trauma. 2007;62(2):330-335. (Retrospective; 46 patients)
  88. Parry NG, Rozycki GS, Feliciano DV, et al. Traumatic rupture of the urinary bladder: is the suprapubic tube necessary? J Trauma. 2003;54(3):431-436. (Retrospective; 51 patients)
  89. Martinez-Pineiro L, Djakovic N, Plas E, et al. EAU guidelines on urethral trauma. Eur Urol. 2010;57(5):791-803. (Consensus statement)
  90. Haidari M, Azargoon A, Mahmoudvand H, et al. Complications of primary realignment of posterior urethral disruption after pelvic trauma. Trauma Mon. 2014;19(2):e13523. (Retrospective; 24 patients)
  91. Smith TG 3rd, Coburn M. Damage control maneuvers for urologic trauma. Urol Clin North Am. 2013;40(3):343-350. (Review article)
  92. Dugi DD 3rd, Morey AF, Gupta A, et al. American Association for the Surgery of Trauma grade 4 renal injury substratification into grades 4a (low risk) and 4b (high risk). J Urol. 2010;183(2):592-597. (Retrospective; 102 patients)
  93. * McClung CD, Hotaling JM, Wang J, et al. Contemporary trends in the immediate surgical management of renal trauma using a national database. J Trauma Acute Care Surg. 2013;75(4):602-606. (Retrospective; 9002 patients)
  94. Deibert CM, Spencer BA. The association between operative repair of bladder injury and improved survival: results from the National Trauma Data Bank. J Urol. 2011;186(1):151-155. (Retrospective; 8565 patients)
  95. Barrett K, Braga LH, Farrokhyar F, et al. Primary realignment vs suprapubic cystostomy for the management of pelvic fracture-associated urethral injuries: a systematic review and meta-analysis. Urology. 2014;83(4):924-929. (Meta-analysis; 161 articles)
  96. Swanson DE, Polackwich AS, Helfand BT, et al. Penile fracture: outcomes of early surgical intervention. Urology. 2014;84(5):1117-1121. (Retrospective; 30 patients)
  97. Cubillos J, Reda EF, Gitlin J, et al. A conservative approach to testicular rupture in adolescent boys. J Urol. 2010;184(4 Suppl):1733-1738. (Prospective; 7 patients)
  98. Gomez RG, Storme O, Catalan G, et al. Traumatic testicular dislocation. Int Urol Nephrol. 2014;46(10):1883-1887. (Retrospective; 7 patients)
  99. Mani N, Kim L. The role of interventional radiology in urologic tract trauma. Semin Intervent Radiol. 2011;28(4):415-423. (Review article)
  100. McCombie SP, Thyer I, Corcoran NM, et al. The conservative management of renal trauma: a literature review and practical clinical guideline from Australia and New Zealand. BJU Int. 2014;114 Suppl 1:13-21. (Practice guideline)
  101. Chang AJ, Brandes SB. Advances in diagnosis and management of genital injuries. Urol Clin North Am. 2013;40(3):427-438. (Review article)
  102. Al-Qudah HS, Santucci RA. Complications of renal trauma. Urol Clin North Am. 2006;33(1):41-53, vi. (Practice guideline)
  103. Tank ES, Eraklis AJ, Gross RE. Blunt abdominal trauma in infancy and childhood. J Trauma. 1968;8(3):439-448. (Review article)
  104. Fallat ME, Casale AJ. Practice patterns of pediatric surgeons caring for stable patients with traumatic solid organ injury. J Trauma. 1997;43(5):820-824. (Retrospective; 87 respondents)
  105. Bagga HS, Tasian GE, Fisher PB, et al. Product related adult genitourinary injuries treated at emergency departments in the United States from 2002 to 2010. J Urol. 2013;189(4):1362-1368. (Retrospective; 3545 patients)
  106. Quinlan D, Gearhart J. Blunt renal trauma in childhood. Features indicating severe injury. Br J Urol. 1990;66(5):526-531. (Retrospective; 50 patients)
  107. LeeVan E, Zmora O, Cazzulino F, et al. Management of pediatric blunt renal trauma: a systematic review. J Trauma Acute Care Surg. 2016;80(3):519-528. (Meta-analysis; 32 articles)
  108. Bjurlin MA, Goble SM, Fantus RJ, et al. Outcomes in geriatric genitourinary trauma. J Am Coll Surg. 2011;213(3):415-421. (Retrospective; 9470 patients, 852 elderly)
  109. Ku JH, Jeon YS, Kim ME, et al. Is there a role for magnetic resonance imaging in renal trauma? Int J Urol. 2001;8(6):261-267. (Prospective; 12 patients)
  110. Cagini L, Gravante S, Malaspina CM, et al. Contrast enhanced ultrasound (CEUS) in blunt abdominal trauma. Crit Ultrasound. 2013;5(1):1. (Review article)
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Publication Information
Authors

Whitney K. Bryant, MD, MPH, MEd; Sanjay Shewakramani, MD, FACEP

Publication Date

August 1, 2017

CME Expiration Date

September 1, 2020

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