The genitourinary tract, or simply the

urinary tract The human urinary system, also known as the urinary tract or renal system, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressu ...

, consists of the kidneys, ureters, bladder, and the urethra. The

kidney In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organ (anatomy), organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and rig ...

is the most frequently injured.{{Cite book, title=Smith & Tanagho's General Urology, last=McAnich, first=Jack, last2=Lue, first2=Tom, publisher=Lange, year=2013, isbn=, location=, pages=Chapter 18 Injuries to the kidney commonly occur after automobile or

sports Sport is a physical activity or game, often competitive and organized, that maintains or improves physical ability and skills. Sport may provide enjoyment to participants and entertainment to spectators. The number of participants in ...

-related accidents. A blunt force is involved in 80-85% of injuries. Major decelerations can result in vascular injuries near the kidney's hilum. Gunshots and knife wounds and fractured ribs can result in penetrating injuries to the kidney. Pelvic fractures can damage the

urethra The urethra (: urethras or urethrae) is the tube that connects the urinary bladder to the urinary meatus, through which Placentalia, placental mammals Urination, urinate and Ejaculation, ejaculate. The external urethral sphincter is a striated ...

and bladder.

Presentation

Comorbidity

In 90% of bladder injuries, there is a concurrent pelvic fracture. Pelvic bone fragments penetrate and perforate the bladder. Perforations can be either extraperitoneal or

intraperitoneal The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesothe ...

. Intraperitoneal perforations allow for urine to enter the

peritoneal cavity The peritoneal cavity is a potential space located between the two layers of the peritoneum—the parietal peritoneum, the serous membrane that lines the abdominal wall, and visceral peritoneum, which surrounds the internal organs. While situated ...

. Symptoms typically develop immediately if the urine is infected. Otherwise sterile urine may take days to cause symptoms.

Diagnosis

Hematuria Hematuria or haematuria is defined as the presence of blood or red blood cells in the urine. "Gross hematuria" occurs when urine appears red, brown, or tea-colored due to the presence of blood. Hematuria may also be subtle and only detectable with ...
in patients presenting after trauma

Blood in the urine after abdominal trauma suggests a urinary tract injury. Renal injuries are suggested by lower rib fractures. Bladder and urethral injuries are suggested by pelvic fractures.

Foley catheter

The

urethral meatus The urinary meatus (, ; : meati or meatuses), also known as the external urethral orifice, is the opening of the penis or vulva where urine exits the urethra during urination. It is also where semen exits during male ejaculation, and other fluids ...

should be examined after trauma. Blood at the

l meatus precludes insertion of a

foley catheter In urology, a Foley catheter is one of many types of urinary catheters (UC). The Foley UC was named after Frederic Foley, who produced the original design in 1929. Foleys are indwelling UC, often referred to as an IDCs (sometimes IDUCs). This dif ...

into the bladder. Erroneously placing a foley in this situation can result in infections of periprostatic and perivesical

hematoma A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is ...

s or conversion of a partial transection to a complete urethral transections. Blood at the urethral meatus suggests an injury to the urethra. Otherwise a foley catheter can be placed into the bladder and hematuria can be assessed for.

Abdominal imaging

Hemodynamically stable individuals should undergo further

radiographic Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical ("diagnostic" radiography and "therapeu ...

assessment. Abdominal

computed tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

(CT) with contrast can detect retroperitoneal hematomas, renal lacerations, urinary extravasation, and renal arterial and venous injuries. A repeat scan ten minutes after the first is recommended.

Retrograde urethrography (RUG)

The purpose of this study is to identify and characterize injuries to the urethra. The tip of a small (12F) foley catheter is placed in the urethral meatus. The catheter remains fixed after 3 mL of water are instilled into the foley catheter's balloon. Radiographic films are taken as 20 mL of water-soluble contrast material are injected This outlines the urethra from the

to the

bladder neck The bladder () is a hollow organ in humans and other vertebrates that stores urine from the kidneys. In placental mammals, urine enters the bladder via the ureters and exits via the urethra during urination. In humans, the bladder is a distensi ...

. If injuries exist, the location can be determined.

Retrograde cystography

The purpose of this study is to identify bladder perforations. The bladder needs to be adequately distended with contrast medium. 300 mL or more are generally recommended. The study has two films. One film is taken when the bladder is adequately distended and filled with contrast. The next film is taken after the bladder is emptied without the assistance of a foley catheter.

Angiography Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. Modern angiography is perfo ...

Helpful in identifying injuries to the kidney's

parenchyma upright=1.6, Lung parenchyma showing damage due to large subpleural bullae. Parenchyma () is the bulk of functional substance in an animal organ such as the brain or lungs, or a structure such as a tumour. In zoology, it is the tissue that ...

and vasculature.

Management

Genitourinary trauma

Urethral injuries

Management depends on what part of the urethra was injured and to what extent. The two broad anatomical separations are the posterior and anterior urethra. The posterior urethra includes the prostatic and membranous urethra. The anterior urethra includes the bulbous and pendulous portion.

= Posterior urethra injuries

= The

membranous urethra The membranous urethra or intermediate part of male urethra is the shortest, least dilatable, and, with the exception of the urinary meatus, the narrowest part of the urethra. It extends from the apex of the prostate proximally to the bulb of ur ...

can be separated from the

prostate The prostate is an male accessory gland, accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found in all male mammals. It differs between species anatomically, chemica ...

's apex after blunt trauma. The urethra should not be catheterized. Initial management should be the creation of a suprapubic cystostomy for urine drainage. The bladder should be opened in the midline so to facilitate inspection of bladder lacerations. Perforations can be closed with absorbable sutures. The suprapubic cystostomy remains in place for three months. Incomplete urethral disruptions heal spontaneously and the suprapubic cystostomy can be removed after three weeks for these injuries. Before removing a cystostomy, a

voiding cystourethrography Urination is the release of urine from the bladder through the urethra in placental mammals, or through the cloaca in other vertebrates. It is the urinary system's form of excretion. It is also known medically as micturition, voiding, ...

should demonstrate no urine extravasation. Delayed urethral reconstruction may be performed within 3 months. This typically entails a direct excision of the now strictured area and anastomosis of the bulbous urethra to the prostate's apex. A urethral catheter and suprapubic cystostomy should be left in place. These are removed within a month.

References

Genitourinary system Injuries