EAU GUIDELINES ON

UROLOGICAL TRAUMA

(Text update March 2019)

N.D. Kitrey (Chair), N. Djakovic, P. Hallscheidt, F.E. Kuehhas,

N. Lumen, E. Serafetinidis, D.M. Sharma.
Guidelines Associates: Y. Abu-Ghanem, A. Sujenthiran,
M. Waterloos

Introduction
Traumatic injuries are classified according to the basic
mechanism of the injury into penetrating and blunt injuries.
Penetrating trauma is further classified according to the
velocity of the projectile into high- and medium-velocity
projectiles (e.g. rifle and handgun bullets, respectively), and
low-velocity items (e.g. knife stab). High-velocity weapons
inflict greater damage due to a temporary expansive
cavitation that causes destruction in a much larger area than
the projectile tract itself. In lower velocity injuries, the damage
is usually confined to the projectile tract. Blast injury is a
complex cause of trauma which includes blunt and
penetrating trauma and burns.

Urological trauma is often associated with significant injuries

in the polytraumatised patient. Advances in trauma care
include the widespread acceptance of damage control
principles and trauma centralisation to major trauma centres
staffed by dedicated trauma teams. Urologists increasingly
understand their role in the context of polytrauma with the
ultimate aims of improving survivability and decreasing
morbidity in these patients.

358 Urological Trauma

Renal Trauma
Renal trauma is present in to up 5% of all trauma cases. It is
most common in young males and has an overall population
incidence of 4.9 per 100,000. Most injuries can be managed
non-operatively with successful organ preservation. The most
commonly used classification system is that of the American
Association for the Surgery of Trauma. It is validated and
predicts morbidity and the need for intervention.

Recommendations for evaluation and management of renal

trauma

Recommendations Strength rating

Evaluation
Assess haemodynamic stability upon Strong
admission.
Record past renal surgery, and known Strong
pre-existing renal abnormalities
(ureteropelvic junction obstruction, solitary
kidney, lithiasis).
Test for haematuria in a patient with Strong
suspected renal injury.
Perform a multiphase computed Strong
tomography scan in trauma patients with:
• visible haematuria;
• non-visible haematuria and one episode
of hypotension;
• a history of rapid deceleration injury
and/or significant associated injuries;
• penetrating trauma;
• clinical signs suggesting renal trauma
e.g. flank pain, abrasions, fractured ribs,
abdominal distension and/or a mass
and tenderness.

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 Management
Manage stable patients with blunt renal Strong
trauma non-operatively with close
monitoring and re-imaging as required.
Manage isolated Grade 1-4 stab and low- Strong
velocity gunshot wounds in stable patients
non-operatively.
Use selective angioembolisation for active Strong
renal bleeding if there are no other
indications for immediate surgical
exploration.
Proceed with renal exploration in the Strong
presence of:
• persistent haemodynamic instability;
• Grade 5 vascular or penetrating injury;
• expanding or pulsatile peri-renal
haematoma.
Attempt renal reconstruction if Weak
haemorrhage is controlled and there is
sufficient viable renal parenchyma.
Repeat imaging in high-grade injuries and in Strong
cases of fever, worsening flank pain, or
falling haematocrit.
Follow-up approximately three months Weak
after major renal injury with:
• physical examination;
• urinalysis;
• individualised radiological investigation
including nuclear scintigraphy;
• blood pressure measurement;
• renal function tests.
Measure blood pressure annually to Strong
diagnose renovascular hypertension.

360 Urological Trauma

 Suspected adult

** A
renal trauma

Determine haemodynamic
Stable stability Unstable
after primary resuscitation

injuries.
Ongoing resuscitation, Failure
Emergency
Non-visible haematuria Visible haematuria multiphase CT, & laparotomy
angioembolisation

angioembolisation.
Rapid deceleration Renal injury
Multiphase CT scan with
Observation injury or major (pulsatile
delayed images
associated injuries or expanding
haematoma)

Grade 5
No active bleeding Active bleeding/blush
(penetrating)

--- If haemodynamically unstable.

Grade 1-3 Grade 4-5*

* Excluding Grade 5 penetrating injuries.

Angiography SAE unavailable
Observation, and selective Renal exploration (reconstruction or
Observation,
bed rest, serial angioembolisation nephrectomy)
bed rest, serial
Ht according to (repeat if Failure
Ht, antibiotics
severity** unsuccessful
Figure 1: Evaluation of blunt renal trauma in adults

Repeat Imaging

Persistant

 ntibiotics should for administered for all penetrating

urinary leak

JJ stent or drain

CT = computed tomography; Ht = haematocrit; SAE = selective

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 Ureteral Trauma
Ureteral injuries are quite rare - most are iatrogenic. They are
often missed intra-operatively, usually involve the lower ureter,
and may result in severe sequelae. Overall, ureteral trauma
accounts for 1-2.5% of urinary tract trauma. Ureteral injury
should be suspected in all cases of penetrating abdominal
injury, especially gunshot wounds, as it occurs in 2-3% of
cases. It should also be suspected in blunt trauma with a
deceleration mechanism, as the renal pelvis can be torn away
from the ureter.

Diagnostic evaluation
• A high index of suspicion of ureteral injury should be
maintained as the majority of cases are diagnosed late,
predisposing the patient to pain, infection, and renal
function impairment.
• Haematuria is an unreliable indicator.
• Extravasation of contrast material in computed
tomography (CT) is the hallmark sign of ureteral trauma.
• In unclear cases, a retrograde or antegrade urography is
required for confirmation.

Management of ureteral trauma

Recommendations Strength rating

Visually identify the ureters to prevent Strong
ureteral trauma during abdominal and
pelvic surgery.
Beware of concomitant ureteral injury in Strong
all abdominal penetrating trauma, and in
deceleration-type blunt trauma.
Use pre-operative prophylactic stents in Strong
high-risk cases.

362 Urological Trauma

Repair iatrogenic ureteral injuries Strong
recognised during surgery immediately.
Treat iatrogenic ureteral injuries with Strong
delayed diagnosis by nephrostomy tube/JJ
stent urinary diversion.
Manage ureteral strictures by ureteral Strong
reconstruction according to the location
and length of the affected segment.

Urological Trauma 363

 Figure 2: Management of ureteric injuries

Ureteric Injury

Immediate diagnosis Delayed diagnosis

Stable Unstable

Damage control
Immediate repair* Nephrostomy /JJ-stent
nephrostomy

Follow up

Stricture

Endo-urologic dilation

Yes No

Upper 1/3: Mid 1/3:

Lower 1/3: Long segment:
• end-to-end • end-to-end
• Psoas hitch • Graft
• Transuretero- • Transuretero-
ureteroplasty
ureterostomy ureterostomy
• Intestinal
• Uretero- • Boari
interposition
calycostomy
• Auto-
transplant
Failure

364 Urological Trauma

Bladder Trauma
Bladder trauma is primarily classified according to the
location of the injury: intraperitoneal, extraperitoneal, and
combined intra-extraperitoneal as it guides further manage-
ment. Bladder trauma is categorised by aetiology: non-
iatrogenic (blunt and penetrating) and iatrogenic (external
and internal). Extraperitoneal injury is almost always
associated with pelvic fractures. Intraperitoneal injury is
caused by a sudden rise in intravesical pressure of a distended
bladder, secondary to a blow to the pelvis or lower abdomen.

Diagnostic evaluation
The principal sign of bladder injury is visible haematuria.
Absolute indications for bladder imaging include: visible
haematuria and a pelvic fracture or non-visible haematuria
combined with high-risk pelvic fracture or posterior urethral
injury. In the absence of these absolute indications, further
imaging is based on clinical signs and symptoms including:
• inability to void or inadequate urine output;
• abdominal tenderness or distension due to urinary ascites,
or signs of urinary ascites in abdominal imaging;
• uraemia and elevated creatinine level due to intra-
peritoneal re-absorption;
• entry/exit wounds at lower abdomen, perineum or buttocks
in penetrating injuries.

Intra-operative signs of external iatrogenic bladder injury

include: extravasation of urine, visible laceration, visible
bladder catheter, and blood and/or gas in the urine bag during
laparoscopy. Internal bladder injury is recognised by cysto-
scopic identification of fatty tissue, dark space, or bowel.

Imaging – Cystography and Cystoscopy

Cystography is the preferred diagnostic modality for non-
iatrogenic bladder injury and for a suspected iatrogenic

Urological Trauma 365

 bladder trauma in the post-operative setting. Intraperitoneal
extravasation is visualised by free contrast medium in the
abdomen outlining bowel loops or abdominal viscera.
Extraperitoneal bladder injury is typically diagnosed by flame-
shaped areas of contrast extravasation in the peri-vesical soft
tissues. Cystoscopy is the preferred method for detection of
intra-operative bladder injuries as it may directly visualise the
laceration and can localise the lesion in relation to the
position of the trigone and ureteral orifices.

Management of bladder trauma

Recommendations Strength rating

Perform cystography in the presence of Strong
visible haematuria and pelvic fracture.
Perform cystography in case of suspected Strong
iatrogenic bladder injury in the post-
operative setting.
Perform cystography with active retrograde Strong
filling of the bladder with dilute contrast
(300-350 mL).
Perform cystoscopy to rule out bladder Strong
injury during retropubic sub-urethral sling
procedures.
Manage uncomplicated blunt extra- Weak
peritoneal bladder injuries conservatively.
Manage blunt extraperitoneal bladder Strong
injuries operatively in cases of bladder neck
involvement and/or associated injuries that
require surgical Intervention.
Manage blunt intraperitoneal injuries by Strong
surgical exploration and repair.

366 Urological Trauma

Manage small uncomplicated intra- Weak
peritoneal bladder injuries during
endoscopic procedures conservatively.
Perform cystography to assess bladder wall Strong
healing after repair of a complex injury or in
case of risk factors for wound healing.

Urethral Trauma
• Injuries to the anterior urethra (AU) are caused by straddle
injuries, trauma during sexual intercourse (associated with
penile fracture), penetrating trauma and from iatrogenic
trauma e.g. endoscopic instruments, catheterisation.
• Pelvic fractures are the predominant cause of male
posterior and female urethral injury.
• Pelvic fracture and penetrating urethral injuries have a high
likelihood of life-threatening concomitant injuries.
• Female urethral injuries are often associated with vaginal
injuries.
• Insertion of a synthetic sub-urethral sling for the treatment
of stress urinary incontinence is an important cause of
iatrogenic female urethral injury.

Diagnostic evaluation
• Blood at the external urethral meatus is the most common
clinical sign, and indicates the need for further diagnostic
work up.
• Inability to void is usually a sign of a complete injury.
• Incomplete injuries are associated with pain on urination
and haematuria in the majority of cases.
• Blood at the vaginal introitus is present in the majority of
female patients with pelvic fractures and co-existing
urethral injuries.
• Rectal examination may reveal a “high-riding” prostate.
However, this is an unreliable finding. Blood on the
examination finger is suggestive of a rectal injury

Urological Trauma 367

 associated with pelvic fracture.
• Urethral bleeding or urinary extravasation can cause penile
and scrotal swelling and haematoma, but these findings
are usually delayed (> 1 hr).
• Retrograde urethrography is the standard in the early
evaluation of a male urethral injury, except for penile
fracture related injuries for which cysto-urethroscopy is
preferred.
• Cysto-urethroscopy combined with vaginoscopy is the
preferred diagnostic modality in case of suspected female
urethral injury.

Management
Male urethral injuries
• The management of male anterior and posterior urethral
injuries are summarised in Figures 3 and 4, respectively.

Female urethal injuries

• In case of hemodynamic instability, provide urinary
diversion by suprapubic catherisation or a single attempt
of urethral catheterisation.
• Early repair within seven days has the highest succes
rate and the lowest complication rate in comparison with
delayed repair or early endoscopic re-aligment.

Management of urethral trauma

Recommendations Strength rating

Provide appropriate training to reduce the Strong
risk of traumatic catheterisation.
Evaluate male urethral injuries with flexible Strong
cysto-urethroscopy and/or retrograde
urethrography.

368 Urological Trauma

Evaluate female urethral injuries with cysto- Strong
urethroscopy and vaginoscopy.
Treat iatrogenic anterior urethral injuries by Strong
transurethral or suprapubic urinary
diversion.
Treat blunt anterior urethral injuries in Weak
males by suprapubic diversion.
Treat pelvic fracture urethral injuries Strong
(PFUIs) in hemodynamically unstable
patients by transurethral or suprapubic
catheterisation initially.
Perform early endoscopic re-alignment in Weak
male PFUIs when feasible.
Do not repeat endoscopic treatments after Strong
failed re-alignment for male PFUI.
Treat partial posterior urethral injuries by Strong
suprapubic or transurethral catheter.
Do not perform immediate urethroplasty Strong
(< 48 hours) in male PFUIs.
Perform early urethroplasty (two days to six Weak
weeks) for male PFUIs with complete
disruption in selected patients (stable,
short gap, soft perineum, lithotomy
position possible).
Manage complete posterior urethral Strong
disruption in male PFUIs with suprapubic
diversion and deferred (at least three
months) urethroplasty.
Perform early repair (within seven days) for Strong
female PFUIs (not delayed repair or early
re-alignment).

Urological Trauma 369

 Figure 3: Management of anterior urethral injuries in men

Anterior urethral injury

Blunt Iatrogenic Penetrating Penile fracture

Stable

No Yes

Urinary diversion urethral or suprapubic Immediate repair

catheter

Partial 1-2 weeks Complete 3 weeks

Urinary diversion urethral or

Urethrogram suprapubic catheter
(2-3 weeks)

Follow-up

370 Urological Trauma

Figure 4: Management of posterior urethral injuries in men

Male posterior urethral injury

Assess hemodynamic status

Unstable Stable

Resusitation plus Perform RUG/

urinary diversion urethroscopy

Urethral catheter
1 attempt

Failure Partial injury Complete injury

Suprapubic
catheter
Injury to bladder neck and/or
prostate
Early
Suprapubic
endoscopic re-
catheter
alignment Failure
No Yes

Surgery for
associated Early repair
injuries

Yes No Follow up

Early
Suprapubic
Follow up endoscopic re-
catheter
alignment Failure

Assess 2 days-6 weeks

Stricture short, flimsy & • short distraction defect
non-obliterative • soft perineum
• lithotomy positon possible

Yes No No Yes

Delayed
Failure Early
1 DVIU urethroplasty
urethroplasty
(> 3 months)

RUG = retrograde urethrography; DVIU = direct visual internal

urethrotomy.

Urological Trauma 371

 Genital Trauma
Of all urological injuries, 33-66% involve the external genitalia.
Genital trauma is much more common in males than in
females this is due to anatomical differences, increased
frequency of road traffic accidents and increased participa-
tion in physical sports, war and crime. The majority of genital
trauma is caused by blunt injuries (80%).

Diagnostic evaluation
A summary of key points for penile fracture and testicular
trauma are provided in Table 1. Blunt vulvar or perineal trauma
in women may be associated with bleeding, pain and voiding
problems. In genital trauma:
• Urinalysis should be performed.
• Visible haematuria requires a retrograde urethrogram in
males, whilst flexible or rigid cystoscopy is recommended
to exclude urethral and bladder injury in females.
• In women with genital injuries and blood at the vaginal
introitus, further gynaecologic investigation to exclude
vaginal injury is required.

Management
Penetrating penile trauma
• Non-operative management is recommended for small
superficial injuries with intact Buck’s fascia.
• More significant injuries require surgical exploration and
debridement of necrotic tissue.
• Surgical approach depends upon the site and extent of
the injury, but a subcoronal incision with penile degloving
usually gives good exposure. Initially, a defect in the tunica
albuginea should be closed after copious irrigation.
• In penile avulsion injuries acute management involves
resuscitation of the patient, and preparation for surgical re-
implantation of the penis if it has been recovered and is not
too badly damaged.

372 Urological Trauma

Blunt scrotal trauma
• May result in testicular dislocation, haematocoele,
testicular rupture and/or scrotal haematoma.
• Traumatic dislocation of the testis is treated by manual
replacement and secondary orchidopexy. If primary manual
reposition cannot be performed, immediate orchidopexy is
indicated.
• If haematocele is smaller than three times the size of the
contralateral testis – conservative management.
• If large haematocele - explore.
• If testicular rupture is suspected, explore, evacuate clot
and any necrotic testicular tubules and close the tunica
albuginea.

Penetrating scrotal trauma

• Surgical exploration with conservative debridement of
non-viable tissue.
• Primary reconstruction of testis and scrotum can be
performed in most cases.
• In complete disruption of the spermatic cord, re-alignment
without vaso-vasostomy may be considered.
• In extensive destruction of the tunica albuginea,
mobilisation of a free tunica vaginalis flap can be
performed for testicular closure.
• If reconstruction cannot be achieved, orchiectomy is
indicated.
• In improvised explosive device blast injury, the extensive
loss of genital tissue often requires complex and staged
reconstructive surgical procedures.

Urological Trauma 373

 Table 1. Summary of key points for penile fracture and
testicular trauma

Penile fracture
The most common causes of penile fracture are sexual
intercourse, forced flexion, masturbation and rolling over.
Penile fracture is associated with a sudden cracking or
popping sound, pain, immediate detumescence and local
swelling.
Magnetic resonance imaging is superior to all other imaging
techniques in diagnosing penile fracture.
Management of penile fracture is surgical intervention with
closure of the tunica albuginea.
Testicular Trauma
Blunt testicular injury may occur under intense compression
of the testis against the inferior pubic ramus or symphysis,
resulting in a rupture of the tunica albuginea.
Testicular rupture is associated with immediate pain,
nausea, vomiting, and sometimes fainting.
Scrotal ultrasound is the preferred imaging modality for the
diagnosis of testicular trauma.
Surgical exploration in patients with testicular trauma
ensures preservation of viable tissue when possible.

374 Urological Trauma

Recommendations for the management of genital trauma

Recommendations Strength rating

Exclude urethral injury in the case of penile Strong
fracture.
Perform ultrasound (US) for the diagnosis Strong
of testis trauma.
Treat penile fractures surgically, with Strong
closure of tunica albuginea.
Explore the injured testis in all cases of Strong
testicular rupture and in those with
inconclusive US findings.

This short booklet text is based on the more comprehensive

EAU Guidelines (ISBN 978-94-92671-04-2) available to all members
of the European Association of Urology at their website,
http://www.uroweb.org/guidelines.

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