Clinical Approach

The overall approach to trauma is discussed in Chap...243. Only issues specific to genitourinary trauma are discussed here.

Renal system injuries rarely require immediate intervention. Investigation of renal injuries should not supercede evaluation of more life-threatening injuries. For example, with a pelvic fracture, determining the need for pelvic angiography is more important than determining whether a urethral injury exists. The patient may well die from a sheared major artery, whereas an injured urethra will never require immediate attention. The retrograde introduction of dye will render subsequent pelvic angiography very difficult, if not impossible.

During the detailed secondary survey, a concerted effort should be made to closely inspect the perineum. Blood on the underwear is an important finding. In both male and female patients, the folds of the buttocks should be spread in search of perineal lacerations, which often denote an open pelvic fracture. Such lacerations should not be probed lest a clot be disrupted and exsanguinating hemorrhage result. During the rectal examination, sphincter tone, the position of the prostate gland, and presence of any blood should be noted. If the prostate is riding high or feels boggy, there has been a disruption of the membranous urethra. Next, the scrotum is palpated and inspected for ecchymoses, laceration, and testicular disruption. Simultaneously, the length of the penis is palpated to inspect for blood at the meatus. In females, the labia are inspected for lacerations and hematomas. If there is any evidence of likelihood of trauma in this area, a bimanual vaginal examination is required. If there is blood in the vagina, a speculum examination is necessary to rule out vaginal laceration.

During the secondary survey, the trauma series x-rays are obtained and often include an anteroposterior view of the pelvis. The presence of a pelvic fracture has important implications in the workup of genitourinary injuries.

Generally, no urinary catheter should be introduced until the urine can be evaluated for hematuria. However, the placement of a urinary catheter for monitoring of urine output may be required in severely injured patients who cannot void. If there is doubt and placement of a catheter is urgent, a suprapubic approach may be the most prudent. In menstruating women, a specimen obtained with a catheter is likely to offer more accurate urinalysis than a spontaneously voided specimen.

The standard serologic and blood specimen results are generally not helpful in determining the presence or degree of renal injury in the acute setting.

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