Urotrauma
Publication Date: August 1, 2014
Last Updated: March 14, 2022
Guideline Statements
Renal Trauma
Clinicians should perform diagnostic imaging with intravenous contrast enhanced computerized tomography in stable blunt trauma patients with gross hematuria or microscopic hematuria and systolic blood pressure <90 mmHg. (Strong, B)
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Clinicians should perform diagnostic imaging with IV contrast enhanced CT in stable trauma patients with mechanism of injury or physical exam findings concerning for renal injury (e.g., rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest). (Moderate, C)
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Clinicians should perform IV contrast enhanced abdominal/pelvic CT with immediate and delayed images when there is suspicion of renal injury. (Clinical Principle)
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Clinicians should use non-invasive management strategies in hemodynamically stable patients with renal injury. (Strong, B)
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The surgical team must perform immediate intervention (surgery or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation. (Strong, B)
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Clinicians may initially observe patients with renal parenchymal injury and urinary extravasation. (Clinical Principle)
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Clinicians should perform follow-up CT imaging for renal trauma patients having either:
- (a) deep lacerations (AAST Grade IV-V) or
- (b) clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention).
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Clinicians should perform urinary drainage in the presence of complications, such as enlarging urinoma, fever, increasing pain, ileus, fistula or infection. (Moderate, C)
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Drainage should be achieved via ureteral stent and may be augmented by percutaneous urinoma drain, percutaneous nephrostomy or both. (Expert Opinion)
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Ureteral Trauma
Clinicians should perform IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram) for stable trauma patients with suspected ureteral injuries. (Moderate, C)
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Clinicians should directly inspect the ureters during laparotomy in patients with suspected ureteral injury who have not had preoperative imaging. (Clinical Principle)
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Surgeons should repair traumatic ureteral lacerations at the time of laparotomy in stable patients. (Moderate, C)
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Surgeons may manage ureteral injuries in unstable patients with temporary urinary drainage followed by delayed definitive management. (Clinical Principle)
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Surgeons should manage traumatic ureteral contusions at the time of laparotomy with ureteral stenting or resection and primary repair depending on ureteral viability and clinical scenario. (Expert Opinion)
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Surgeons should attempt ureteral stent placement in patients with incomplete ureteral injuries diagnosed postoperatively or in a delayed setting. (Moderate, C)
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Surgeons should perform percutaneous nephrostomy with delayed repair as needed in patients when stent placement is unsuccessful or not possible. (Moderate, C)
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Surgeons should repair ureteral injuries located proximal to the iliac vessels with primary repair over a ureteral stent, when possible. (Moderate, C)
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Surgeons should repair ureteral injuries located distal to the iliac vessels with ureteral reimplantation or primary repair over a ureteral stent, when possible. (Moderate, C)
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Surgeons should manage endoscopic ureteral injuries with a ureteral stent and/or percutaneous nephrostomy tube, when possible. (Moderate, C)
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Surgeons may manage endoscopic ureteral injuries with open repair when endoscopic or percutaneous procedures are not possible or fail to adequately divert the urine. (Expert Opinion)
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Bladder Trauma
Clinicians must perform retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture. (Strong, B)
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Clinicians should perform retrograde cystography in stable patients with gross hematuria and a mechanism concerning for bladder injury, or in those with pelvic ring fractures and clinical indicators of bladder rupture. (Strong, B)
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Surgeons must perform surgical repair of intraperitoneal bladder rupture in the setting of blunt or penetrating external trauma. (Strong, B)
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Clinicians should perform catheter drainage as treatment for patients with uncomplicated extraperitoneal bladder injuries. (Moderate, C)
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Surgeons should perform surgical repair in patients with complicated extraperitoneal bladder injury. (Moderate, C)
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Clinicians should perform urethral catheter drainage without suprapubic (SP) cystostomy in patients following surgical repair of bladder injuries. (Strong, B)
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Urethral Trauma
Clinicians should perform retrograde urethrography in patients with blood at the urethral meatus after pelvic trauma. (Moderate, C)
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Clinicians should establish prompt urinary drainage in patients with pelvic fracture associated urethral injury. (Moderate, C)
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Surgeons may place suprapubic tubes in patients undergoing open reduction internal fixation for pelvic fracture. (Expert Opinion)
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Clinicians may perform primary realignment (PR) in hemodynamically stable patients with pelvic fracture associated urethral injury. (Conditional, C)
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Clinicians should not perform prolonged attempts at endoscopic realignment in patients with pelvic fracture associated urethral injury. (Clinical Principle)
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Clinicians should monitor patients for complications (e.g., stricture formation, erectile dysfunction, incontinence) for at least one year following urethral injury. (Moderate, C)
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Surgeons should perform prompt surgical repair in patients with uncomplicated penetrating trauma of the anterior urethra. (Expert Opinion)
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Clinicians should establish prompt urinary drainage in patients with straddle injury to the anterior urethra. (Moderate, C)
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Genital Trauma
Clinicians must suspect penile fracture when a patient presents with penile ecchymosis, swelling, cracking or snapping sound during intercourse or manipulation and immediate detumescence. (Strong, B)
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Surgeons should perform prompt surgical exploration and repair in patients with acute signs and symptoms of penile fracture. (Strong, B)
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Clinicians may perform ultrasound in patients with equivocal signs and symptoms of penile fracture.
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Clinicians must perform evaluation for concomitant urethral injury in patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria or inability to void. (Strong, B)
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Surgeons should perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvagable) in patients with suspected testicular rupture. (Strong, B)
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Surgeons should perform exploration and limited debridement of non-viable tissue in patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical). (Strong, B)
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Surgeons should perform prompt penile replantation in patients with traumatic penile amputation, with the amputated appendage wrapped in saline-soaked gauze, in a plastic bag and placed on ice during transport. (Clinical Principle)
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Recommendation Grading
Overview
Title
Urotrauma
Authoring Organization
American Urological Association
Publication Month/Year
August 1, 2014
Last Updated Month/Year
June 27, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries.
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Infant
Health Care Settings
Emergency care, Hospital, Outpatient, Radiology services
Intended Users
Radiology technologist, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Management, Treatment
Diseases/Conditions (MeSH)
D014572 - Urology
Keywords
Urotrauma, genitourinary injuries.
Supplemental Methodology Resources
Methodology
Number of Source Documents
219
Literature Search Start Date
January 1, 1990
Literature Search End Date
September 19, 2012