Lower Urinary Tract Trauma: Bladder, Urethra,

Genitalia
Editors:
Andrew J. Cohen, MD
Authors:
Lindsey Hartsell, MD; John Barnard, MD
Last Updated:
Wednesday, February 22, 2023

Keywords:
bladder trauma, urethral trauma, genital trauma, penile trauma, scrotal trauma, testicular trauma

Summary
In this chapter of the AUA core curriculum, we describe common trauma to the lower genitourinary
system. We divide the particular inciting trauma into penetrating and blunt. We explore the severity
grading of each trauma and the most common evaluation techniques. Once a diagnosis is
formulated, discuss various surgical and non-surgical options for management of lower
genitourinary trauma. We provide pictures, resources and links to anatomic overviews to assist the
reader in accessing information about this acute setting.

1. Bladder Trauma
See Core Curriculum section Bladder

1.1 Introduction
The bladder is the second most commonly injured organ in the genitourinary system after the
kidney. Overall, bladder trauma accounts for 10% of all genitourinary injuries. 1,2 Broadly, bladder
injuries result from blunt or penetrating trauma with most bladder injuries caused by blunt force
injury. Pelvic fractures are commonly associated with bladder injury due to their proximity. Those
bladder injuries associated with bladder wall disruption are categorized based on the location of
urine extravasation, which could be extraperitoneal, intraperitoneal, or combined.

1.2 Definition
Bladder injuries result from multiple types of trauma; however, the underlying principle of blunt
trauma is that the source of motion transfers its kinetic energy to the bladder. The amount of
energy at impact relates to the significance of the resultant injury. The impact, complications,
and management of bladder injuries are highly variable and greatly dependent on the
mechanism, involvement of surrounding structures, and severity.

a. Blunt injuries: Contusions, lacerations, and rupture

b. Penetrating injuries: Lacerations and rupture
c. Iatrogenic injuries: Partial and full thickness lacerations and penetrations

1.3 Anatomy
See Core Curriculum section Anatomy & Physiology Bladder
The bladder sits deep in the pelvis and is protected from injury by the pelvic ring. Retropubic
and perivesical fat surround the bladder anteriorly and laterally.3 The anterior and lateral anatomic
arrangements create the space of Retzius. Posteriorly, the anatomic relationships of the bladder
differ in the male and female. In men, the posterior bladder is in approximation to the peritoneal
covering of the rectum’s anterior surface (rectovesical space). In the female, the posterior bladder
is in approximation to the anterior vaginal wall and uterus. When full, the bladder projects
superiorly out of the true pelvis and loses the surrounding protection. Furthermore, the urachus and
remnant tissue attach the bladder to the anterior abdominal wall. The weakest point of the bladder
is the attachment of the urachus to the lumen. 3
The bladder’s blood supply arises from multiple laterally based arteries from the internal iliac
(hypogastric) artery. The primary arteries that supply the bladder are the superior and inferior
vesical arteries. Due to collateral blood flow within the bladder wall, the internal iliac artery can be
unilaterally ligated without compromising blood supply to the bladder. 3 Venous drainage of the
bladder parallels the arterial supply. 3
The innervation of the bladder is diffuse and arises from parasympathetic, sympathetic,
and somatic nerves.4 The parasympathetic nerves arise in the sacral spinal cord and travel
anteriorly to the bladder. 4 The primary action of parasympathetic nerves on the bladder is
excitatory. The sympathetic nerves originate in the lumbar chain and travel anteriorly to the bladder
innervating the bladder’s anterior and posterior aspects. 3 The actions of the sympathetic nerves on
the bladder are both excitatory and inhibitory. The somatic innervation of the bladder arises from
the pudendal nerves and has afferent and efferent sensory function. 3 The primary action of the
pudendal nerves is on the external urinary sphincter.

1.4 Etiology
Blunt: Blunt mechanisms cause the majority of traumatic bladder injuries (80-85%) and
usually are accompanied by pelvic fracture (83-95%).5 The most common sources include
motor vehicle collisions, falls, and industrial injuries. As previously noted, most bladder injuries
occur in association with a pelvic fracture, but few (2-11%) of pelvic fractures are associated with
bladder injury. 5 Other causes of blunt bladder trauma include direct blows to the lower abdomen.
Penetrating: Penetrating injuries to the bladder are rare, due to the protected nature of the bladder
within the pelvis, but can occur from multiple mechanisms, of which gunshot wound is the most
6
common. 6 These injuries most often involve an entry and exit wound in the bladder and are often
accompanied by injuries to the surrounding structures, including vascular, intestines, and rectum.
Iatrogenic: Iatrogenic bladder injuries are also common. Most iatrogenic injuries result from surgical
dissection of organs surrounding the bladder with loss of the anatomic planes. Abdominal
surgeries that are the most common causes of bladder injury are hysterectomy, followed by
Cesarean section and general surgical procedures in the pelvis. 6 Rarely inguinoscrotal hernias will
contain the bladder. Since these are frequently asymptomatic, they may be discovered
intraoperatively. The risk of bladder injury in these cases is reported to be as high as 12%. Risk
factors for bladder involvement in inguinal hernias include: obesity, age over 50, and urinary
obstruction. Bladder injuries can result in urine leak or fistula formation if not recognized. In
high-risk patients a thorough preoperative workup should be undertaken. 7

1.5 Presentation
Most bladder injuries resulting from an external etiology present in the context of multisystem
trauma. As bladder injuries are not immediately life-threatening, evaluation and resuscitation follow
standard trauma protocols. The initial steps in the evaluation include the ABCs - airway, breathing,
and circulation.
In the setting of multisystem trauma, providers cannot always obtain information from the patient.
However, it is essential to identify the mechanism of injury (blunt versus penetrating) and critical
details about the mechanism, e.g., high-speed motor vehicle collision. Physical exam findings are
nonspecific and not always helpful in diagnosing a bladder injury, particularly in patients with
impaired sensorium, neurologic deficits, or prior lower urinary tract surgery. Nonetheless, a careful
abdominal, genital, digital rectal, and vaginal exam are essential to assess for concomitant injuries.
Gross hematuria is the hallmark sign of injury to the bladder. In patients with sustained blunt
force trauma, the combination of pelvic fracture and gross hematuria is associated with a
bladder injury in 16-27% of cases.8 Bladder rupture in patients with microscopic hematuria and
no other overt signs of lower urinary tract injury after blunt trauma is unlikely, so cystogram should
not be routinely performed in these patients.9,10 Penetrating injuries to the bladder do not always
produce gross hematuria and need to be evaluated based on the injury’s suspected trajectory. 6

1.6 Diagnosis and Imaging Studies

 Figure A: CT Cystogram demonstrating active intraperitoneal
extravasation of contrast material. Courtesy of Dr. Faris.

Bladder injury can be diagnosed with imaging or intraoperative evaluation. When performed
properly, a stress cystogram is the most accurate test for bladder rupture. Techniques using plain
film and computed tomography (CT) are acceptable.9 At a minimum, three images of the
anterior/posterior pelvis are necessary: views with a scout, when the bladder is filled, and
post-drainage. A critical step in performing cystography is adequate distention of the
bladder with 300-400 cc of contrast and obtaining images following retrograde contrast
administration. Ideally, patients should have lateral/oblique views of the bladder as well.
A CT cystogram has the same sensitivity as a plain film cystogram when appropriately
performed.10 In a CT cystogram, the bladder is filled with 300-400 cc of dilute contrast, and the
Foley catheter is clamped while a CT scan of the pelvis is performed. It is important to note that
CT scans without active distension of the bladder with the retrograde instillation of contrast
do not have adequate sensitivity or specificity to diagnose bladder trauma .11
Intraoperative exploration is appropriate and utilized during damage control surgery in
hemodynamically unstable trauma patients taken directly to the operating room without imaging.
Exploration mainly serves to diagnose intraperitoneal injuries at the dome and superior
bladder. Surgical exploration of the space of Retzius or the deep pelvic retroperitoneum is
not advisable immediately after severe blunt force pelvic trauma due to the risk of
exsanguination from myriad pelvic veins .
Another diagnostic test that can be helpful in the intraoperative evaluation of bladder injury is
cystoscopy. Direct visualization of the bladder lumen reveals subtle tears or the presence of a
foreign body like a bullet or penetrating bone fragments. In some circumstances, retrograde
pyelograms may be indicated to evaluate for ureteral injury, especially with penetrating injuries to
the bladder base.
Furthermore, in patients with anterior pelvic ring fractures, such as inferior rami and pubic
symphysis diastasis, one should consider evaluation of the urethra with a retrograde urethrogram
to diagnose unrecognized urethral injury in a patient with hematuria and no evidence of bladder
injury on diagnostic imaging.

1.7 Management
See Reference 12
General Concepts:
Extraperitoneal injuries are the most common, occurring approximately 63% of the time,
followed by intraperitoneal in 32% of cases. Combination injuries are seen in 4.2% of
cases.13
Intraperitoneal injuries: Intraperitoneal injuries that result from external trauma need to be
surgically repaired as soon as feasible.
Extraperitoneal Injuries: Extraperitoneal injuries, in contrast, can often be managed conservatively
by catheter drainage. Smaller extraperitoneal injuries heal rapidly with catheter drainage. Due to
the invariable bacterial colonization that will occur with an indwelling catheter, surgeons should
provide antibiotics with gram-negative coverage.14
However, not all extraperitoneal bladder injuries should be managed conservatively.
Complications are most likely to develop for those ruptures managed conservatively with
concomitant urethral or bladder neck injury.15 Therefore, contra-indications to
non-operative management of extraperitoneal bladder rupture include inadequate catheter
drainage (e.g., clots, persistent leak), vaginal or rectal injury, and bladder neck or urethral
injury.9,16 Ongoing hematuria can lack adequate drainage of the bladder due to obstructing clots
and poor wound healing. Concomitant rectal or vaginal injury can result in a vesicle fistula with
long term sequelae. Massive pelvic trauma with extensive bladder injuries can result in urinary
extravasation into perineal injuries or the medial thigh. Again, these injuries may fistulize outside
the body, and initial repair is advisable at the time of the injury or shortly after. 16 There are a variety
of ways the bladder neck can be lacerated ranging from a simple linear laceration through the
bladder neck and prostate to complete avulsion of the bladder neck. Bladder neck involvement
can result in bladder neck incompetence causing persistent incontinence or internal
fistulae; thus repair is warranted.17 A formal bladder repair is warranted when extraperitoneal
bladder injuries are associated with protruding pelvic bone fragments or an intraluminal foreign
body (bullet or shrapnel). These findings will compromise the healing of the bladder. A repeat
bladder repair is warranted when patients have persistent urinary extravasation from the original
bladder repair. The decision to re-operate depends upon the degree of persistent extravasation,
the possibility of an unrecognized injury, and the patient’s clinical state.
Penetrating injuries, such as gunshot wounds, are explored and repaired immediately due to the
high likelihood of injury to surrounding structures. These indications include: the need for accurate
assessment of the ureters, treatment of both the entry and exit wound, and evaluation and repair of
injuries to the rectum, bowel, or named vascular structures. 6 The recent WSES-AAST Kidney and
Urotrauma Guidelines state that some uncomplicated penetrating extraperitoneal bladder injuries
may be managed conservatively. 18
Relative indications for bladder repair are patients undergoing laparotomy for other reasons or
orthopedic hardware placement into the pelvis in areas of bladder injury. The latter is essential due
to the disruption of the space of Retzius from pelvic injury and poor containment of urinary leak or
the potential for contamination of the pelvic hardware.
Operative repair of bladder injury:
The lower abdominal midline approach is the preferred operative approach to intraperitoneal and
extraperitoneal bladder injuries. Intraperitoneal injuries should be readily apparent along the
peritoneal surface of the bladder at the bladder dome. In patients with concomitant pelvic
fracture, it is crucial to open the intraperitoneal injury wide enough to confirm that there are
no concomitant extraperitoneal injuries that require repair . Combined intraperitoneal and
extraperitoneal injuries can occur in severe pelvic trauma. 19 The safest approach to repairing
extraperitoneal injuries in patients with pelvic fracture is transvesical or through the bladder
lumen. The surgeon can accomplish the exposure by creating a sizeable anterior cystotomy along
the bladder’s peritoneal surface that allows visualization of the bladder’s entire lumen.20 The
ureteral orifices can then be visualized and if there is concern for ureteral injury, ureteral stents can
be placed or a retrograde imaging can be performed.
In this fashion, the pelvic hematoma is left undisturbed lessening the chance of severe and
uncontrollable bleeding. It is advisable to wait in hemodynamically unstable patients until the
patient is fully resuscitated to repair these injuries. 21
Most surgeons will close the bladder in multiple layers using absorbable suture to prevent calculi
formation on permanent suture exposed to urine. The surgeon may also use a flap of peritoneum
or omentum as an adjunct to tenuous repairs or if the repair is near another injured organ to aid in
wound healing and avoid fistulization by providing a well-vascularized tissue layer. After closure, a
closed suction drain should be left in the perivesical space to alert the surgeon to continued urinary
extravasation and delayed infection risk. A suprapubic cystotomy tube is usually not needed for
uncomplicated repairs to the bladder. 9,22 Suprapubic tubes should be considered in patients with
complicated repairs, significant hematuria, or in patients who are likely to need prolonged9
catheterization. Surgeons may utilize additional antibiotic therapy after bladder repair, given the
inherent contamination associated with an indwelling catheter.
Follow up imaging of bladder injury:
Radiologic follow-up confirms that a bladder injury has healed regardless of whether the bladder
injury was repaired or managed conservatively. Imaging is typically done in 10-14 days but can
be extended to 3 weeks for severe injuries .23 Post-injury testing or imaging can include a
cystogram, a CT cystogram or cystoscopy.24 Cystoscopy may be the least sensitive for small leaks
along a suture line.

1.8 Complications
The most common complication of bladder injury is persistent urinary extravasation usually due to
poor wound healing, technical error in bladder repair, or unsuccessful conservative management
( Table 1). Often, small persistent leaks will heal through additional catheter drainage without
sequelae. 19 Severe long-term complications may result from persistent urinary extravasation and
ultimately can require urinary diversion in rare cases. 25 When the surgeon identifies persistent
urinary extravasation, they should further investigate for bony spicules or a foreign body within the
bladder. Unrepaired urine leaks can result in communication of the surgical site containing pelvic
orthopedic hardware or fistulization to the bowel, vagina, or skin.
Table 1: Extraperitoneal injuries and the rate of conservative management and
the associated complications

Studies Total Conservative Complications Major

Complications

Wirth et 22 10 (45%) 2 (20%) Osteomyelitis and

26
al, leak (1)
Persistent leak and
hematuria (1)

Kotkin et 36 29 (81%) 7 (26%) Persistent urinary

25
al, extravasation (4)
Vesico-cutaneous
fistula (2)
Infected pelvic
hematoma (1)

Cass et 87 34 (40%) 2 (6%) Persistent urinary

27
al, extravasation (2)

Corriere 62 41 (66%) 5 (12%) Persistent urinary

23
et al, extravasation (5)

Total 203 114 (56%) 16 (14%)

Other complications can include urinary incontinence or neurogenic bladder from pelvic nerve
injury. Bladder dynamics mirror those in pelvic nerve injury from cauda equina or after low
colorectal surgery. In these patients, the bladder becomes non-compliant or fibrotic and the urinary
sphincter may either be dyssynergic or incompetent. Overall mortality rate for bladder rupture is
8%.
Long-term complications include pelvic pain, hematuria, or infections due to eventual erosion of
pelvic hardware or bony callous into the bladder. Patients may present many years or even
decades after pelvic fracture and require surgical management for correction.

2. Urethra Trauma
2.1 Introduction
The urethra is not commonly injured from external violence and accounts for 4% of all
genitourinary trauma.28 The vast majority of urethral injuries are the result of blunt force trauma;
however, a minority of injuries do result from penetrating trauma. 29 For anatomic categorization in
instances of injury, the urethra is divided into the anterior and posterior segments at the level of the
genitourinary diaphragm. 29 Due to anatomic location, each segment has very different
sources of injury and initial treatment options. Most urethral injuries occur in men due to the
longer overall urethral length and higher incidence of traumatic injuries in men. 9 Based on single
center series, common mechanisms of blunt urethral trauma are motorcycle crash and sexual
injury with a majority of men presenting with concomitant scrotal injury.30

2.2 Definition
Urethral injuries result from many different trauma sources, and some are unique to this segment
of the lower urinary system. These injuries are dependent on the anatomic location (anterior
versus posterior), etiology, and severity of the traumatic injury. The impact, complications, and
management of urethral injuries are highly variable and greatly dependent on the
mechanism, involvement of surrounding structures, and severity.

a. Blunt injuries: Contusion, and avulsions.

b. Penetrating injuries: Laceration, transection, and blast injury with delayed stenosis.
c. Iatrogenic: Result from endoscopic injuries and instrumentation. These range from minor
mucosal abrasions to lacerations and penetrations, and thermal injury.

2.3 Anatomy
See Core Curriculum section: Anatomy & Physiology Penis, Female, Urethra
The male urethra is anatomically divided into two areas: anterior and posterior. As both the
anterior and posterior segments are attached to the genitourinary diaphragm, this is the point of
anatomic differentiation. 31 The anterior urethra, from distal to proximal, is comprised of the fossa
navicularis, penile or pendulous, and bulbar segments. The penile urethra and fossa navicularis
comprise slightly more than half of the distal anterior urethra and are external to the body in the
penis. This location limits injury to this segment of the urethra. The posterior urethra is composed
of two segments, membranous and prostatic. These segments are intimately related to the bony
pelvis and are injured more frequently in pelvic fractures. 31
The blood supply to the urethra arises proximally from the internal pudendal artery.3 This artery
becomes the common penile artery that terminates into the bulbourethral artery. The common
penile and bulbourethral arteries are the main blood supply to the urethra. The bulbourethral
arteries arborize in the glans of the penis to provide retrograde perfusion of the urethra
when the bulbar arteries are transected. The urethra is further supplied by small perforating
arteries that pass through the corporal bodies and enter the dorsal urethra at its attachment along
the dorsum or inferior aspect of the corporal bodies. The venous outflow of the urethra parallels the
arterial supply.

2.4 Etiology
Blunt: The majority of urethral injuries are the result of blunt force trauma. The anterior
urethral segment most commonly injured is the bulbar urethra, which occurs in 85% of
anterior urethral injuries.29,31 Typically, these injuries result from a straddle type fall or direct blow
to the perineum and are usually isolated injuries. During a penile fracture, the force tearing the
corporal body could injure the pendulous urethra's corpus spongiosum. Posterior urethral injuries
due to blunt mechanisms are almost uniformly associated with pelvic fracture. Approximately
3-6% of male and female patients with pelvic fracture have associated posterior urethral
injuries .24 This injury results from stretching and shearing forces at the level of the membranous
urethra resulting in bulbomembranous disruption. 32,33 Patients that sustain a urethral injury after
blunt pelvic fracture are often severely traumatized suffering multi-system trauma and having high
injury severity scores. 34,35 These patients can have a high mortality rate in the acute trauma
setting.35
Penetrating: Most penetrating injuries to the male anterior urethra result from gunshot wounds or
stab wounds. Approximately 3% of gunshot wounds to the genitourinary system involve the
anterior urethra. 36 Additionally, 40-50% of patients with penetrating wounds to the penis
have concomitant injuries to the urethra.37 Penetrating posterior urethral injuries have a similar
mechanism to anterior, although impalement injuries can occur in this area. Furthermore,
penetrating injuries in this location are associated with injuries to surrounding structures such as
the rectum and pelvic vasculature.
Iatrogenic: Injuries to the male anterior urethra and female urethra often are the result of urethral
catheter placement. No true incidence is known but analysis have shown an incidence of 3.2 per
1000 patients. 28 Male posterior urethral injuries are more often related to instrumentation of the
urethra during primarily endoscopic surgical procedures. 31

2.5 Presentation
 Figure 1: Inadvertent placement of Foley catheter into pelvic
hematoma

Based on the anatomic differentiation of the male urethra, urethral injuries have a variable
presentation.
Anterior: Blunt urethral injuries secondary to straddle injuries or direct blows to the perineum may
present as isolated injuries, and these patients relate a history of perineal trauma. Most of these
injuries are located in the mid-perineum, where the urethra is crushed against the pubic
arch. A subset of these injuries result when the penis is crushed against the pubic symphysis
causing a distal pendulous urethral injury. Penetrating injuries present with obvious wounds to the
perineum or penis.
Posterior: Posterior urethral injuries from external violence present in the context of severe
multisystem trauma. Urethral injuries are not immediately life-threatening and patient evaluation
should follow AAST (American Association for the Surgery of Trauma). The initial steps in the
evaluation include the ABCs - airway, breathing, and circulation. Although patients may not be
directly interviewed, providers should obtain information concerning mechanism of injury, blunt
versus penetrating, and details of that mechanism, i.e. high speed motor vehicle collision or high
velocity missile injury. Physical examination of these patients is difficult, especially in blunt trauma,
as posterior urethral injuries are highly associated with pelvic fracture, and up to 15% of these
have associated bladder injury. 9 Patients with the combination of blood at the urethral
meatus, inability to void, and pelvic fracture should be presumed to have a posterior
urethral injury.
Female: Female urethral injuries are associated with 0-6% of patients with pelvic fracture.14
Females with urethral injury may have hematuria or vaginal lacerations. Other associated findings
may include labial edema or urethrorrhagia. 29
Physical Exam Findings:
The classic triad of blood at the urethral meatus, inability to void, and a palpably distended
bladder is uncommon in clinical practice. Blood at the urethral meatus is variable in
presentation and occurs in 37-93% of patients.38 However, in those patients who do present
with blood at the urethral meatus, especially in pelvic trauma, evaluation of the urethra is
mandatory. 9 Patients with bulbar urethral injuries may present with a perineal hematoma. This
hematoma is confined by Colles’ fascia, which is continuous with Scarpa’s fascia and contiguous
with the dartos fascial layers. 39 The hematoma can have a classic appearance of a butterfly
within the perineum, due to rupture of Buck’s fascia, and can spread into the scrotum or up
the abdomen along the layers of Dartos and Scarpa’s fascia. Patients with posterior urethral
injuries may have a “high-riding” or ballotable prostate on exam if the apical prostate has been
detached from the genitourinary diaphragm from severe pelvic trauma.
The inability to pass a catheter following pelvic trauma can be a hallmark of a severe urethral
injury. In this instance, the catheter is passed inadvertently into the pelvic hematoma before the
urethral injury is recognized. (Figure 1)

2.6 Diagnosis and Imaging Studies

 Figure 2: A full transection of the posterior urethral from pelvic
fracture

Imaging:40,41
Male urethral injury, both anterior and posterior, is typically assessed with radiologic imaging.
When a urethral injury is suspected, a retrograde urethrogram is performed. This studies key
element is the placement of the patient in a 30-45% lateral decubitus position to ensure adequate
visualization of the entire urethra.29 Partial injuries to the urethral lumen will reveal some contrast
extravasation coupled with the passage of a variable amount of contrast into the bladder’s lumen.
There is a dramatic bloom of urinary contrast extravasation at either the bulbomembranous
junction or the prostatic apex in patients with complete urethral transection. ( Figure 2)
Another key consideration in urethral injury imaging is the pattern of pelvic fracture. In its simplest
form, pelvic fractures that produce urethral injury involve the anterior arch of the pubis. The
anterior pelvic arch can be disrupted in various combinations, either involving the diastasis of the
symphysis pubis, fracture of the rami of the anterior pubic arch, or a combination of both. 42
Specific fractures associated with a greater risk of urethral injury are pubis symphysis
diastasis and inferior pubic rami fracture, especially in the medial aspect of the rami .43,44
Recognizing these high-risk fractures can help in raising the suspicion of injury, along with the
other signs of urethral injury.
In patients with a urethral injury accompanied by a pelvic fracture, it is essential to evaluate for a
concomitant bladder injury. Combined bladder and urethral injury is found in 10-29% of
patients with bladder injury and pelvic fracture.45 Providers should evaluate patients with
persistent gross hematuria following catheter or suprapubic tube placement with plain film or CT
cystogram.
Diagnostic testing:
Cystoscopy may also diagnose a urethral injury. If a patient is hemodynamically unstable or has
penetrating trauma and is taken directly to the operating room, limited cystoscopy can be
performed to inspect the urethra. 39 In patients with partial urethral injury, cystoscopy may also
facilitate Foley catheter placement.
Surgeons should consider a concomitant rectal injury in patients with penetrating injuries
to the posterior urethra. Anoscopy is often performed to rule out a rectal injury in this
circumstance. In female patients with pelvic fracture, surgeons should include examination and
evaluation for a urethral injury. In this patient population, retrograde urethrogram is not technically
feasible for assessing the urethra in pelvic trauma. The best diagnostic test is a direct
examination by cystoscopy using either a flexible cystoscope or specialized rigid scope
without a cutback beak .46

2.7 Management
See Reference 47,48
Anterior urethra: The initial management of anterior urethral injuries varies based on mechanism.
In blunt urethral injuries, the primary objective is a urinary diversion performed using either urethral
Foley catheter placement or suprapubic cystostomy tube placement. 9,49 Often, catheter placement
requires cystoscopic guidance or realignment.
Penetrating injuries should have an immediate operative intervention. Patients with limited
tissue loss and injury from either a low-velocity gunshot or stab wound, primary surgical repair are
indicated.9,49 Surgeons repair penetrating injuries by creating a spatulated primary repair using
absorbable suture. For injuries with significant tissue loss, urinary diversion only is performed. 50
Furthermore, hemodynamically unstable patients should be fully fluid resuscitated prior to surgical
intervention for urethral injuries.
Posterior urethra: The location of pelvic fracture urethral injuries can vary within the posterior
urethra. These injuries occur distally beyond the external sphincter or can involve the prostatic
apex, just proximal to the external sphincter.51,32 he location of the injuries is mainly dependent
upon the nature and location of the pelvic fracture and the ligamentous attachments to the
prostate. 17 The immediate goal in the management of complete urethral disruption is to obtain
urinary drainage, usually with suprapubic tube placement. 9 Although controversial, some advocate
endoscopic realignment of the urethra when stable from their pelvic injury.9 Primary realignment
may decrease the risk of stricture formation, but It is unclear if there is significant benefit and
experts do not recommend prolonged efforts to accomplish realignment.52 If realignment is
experts do not recommend prolonged efforts to accomplish realignment.52 If realignment is
attempted, it may require the use of both retrograde and antegrade endoscopy. 53 Indeed,
urotrauma guidelines recommend clinicians perform percutaneous or open suprapubic
tube (SPT) placement as initial management for most pelvic fracture urethral injury (PFUI)
cases.54 Given the high rate of stricture formation even when primary realignment is performed,
continued suprapubic catheter for a time period after the foley is removed should be considered.
Immediate operative repair of posterior urethral injuries is not indicated. Posterior urethral injuries
are well suited to “damage control” maneuvers, and many adjunct and reconstructive procedures
are well-described options. 21 Most experts agree that immediate repair of these injuries can be
dangerous and leads to an unacceptably high restenosis rate. 14 Exceptions to this are bladder
neck injuries or extension of a bladder or bladder neck injury into prostatic urethra’s anterior
portion within the pelvis. 55
Surgical technique
Given the complexity of repair of a pelvic fracture urethral injury, this should be undertaken by an
experienced surgeon in a high-volume center. Urethroplasty should be delayed for at least 6 to 12
weeks to allow for decrease in inflammation. A perineal approach is normally sufficient, but
occasionally abdominal access is also required. Depending on the length of the defect there are
several additional maneuvers that can be utilized including: urethral mobilization, coporal splitting,
pubectomy, and urethral rerouting. These are employed in a stepwise fashion depending on the
additional length needed. Using this approach success rates of over 90% can be achieved.56
Female urethra: Due to frequent association with vaginal lacerations, female urethral injuries are
repaired at the time of presentation unless the patient is hemodynamically unstable. Repair is
recommended during the initial hospital course to minimize the chance of post-injury
urinary incontinence or the development of a urethrovaginal fistula.57 Injuries of the distal
female urethra may be managed expectantly or formalized and made hypospadiac as the
continence mechanism is usually spared.

2.8 Complications and Long-term Outcomes

Podcast: AUA 2019 Crossfire Controversies in Urology Primary Bulbar Stricture DVIU
Urethral: Serious long-term sequelae often accompany traumatic urethral injury. Although some
injuries, especially partial urethral injuries, can heal without subsequent scarring, most urethral
injuries are associated with dense fibrosis in the intervening gap created by transection.
Urethroplasty is the most appropriate therapy to reestablish a patent urethra after traumatic
injury. 34,56,58,59 The outcomes of posterior urethroplasty are excellent with an average success rate
of approximately 89%. (Table 2)
Other complications include formation of a diverticulum, infected urinoma or fistulization to the
perineum or rectum.
Table 2: Outcomes posterior urethroplasty after pelvic fracture.

Study N Follow-up (mean) Strict Success

Johnsen, et al, 2019 122 7 months 91%

34
Cooperberg, et al, 2007 134 2.75 years 86%

58
Kizer, et al, 2007 142 > 1 year 92%

59
Koraitim 2005 155 13 years 90%

56
Flynn, et al, 2003 122 5.3 years 89%

60
Corriere 2001 63 63%

61
Ennemoser, et al, 1997 31 9.2 years 100%

62
Mundy 1996 82 > 5 years 88%

63
Webster, et al,1991 74 96%

Total 803 89%

The overall success of the operations was greater as men with recurrent strictures
were often treated successfully with endoscopic treatments or re-do urethroplasty.

View Image.
Erectile dysfunction: Erectile dysfunction is common after pelvic fracture associated urethral injury,
but the published incidence varies considerably, and likely reflects differences in patient
populations and definitions of erectile dysfunction ( Table 3).64,65,66 Typically, erectile dysfunction
after pelvic fracture is attributed to injury to the parasympathetic nerves as they travel along the
lateral border of the prostate. Rarely, erectile dysfunction in these patients is purely arteriogenic,
resulting from damage to the internal pudendal artery from trauma or embolization. 67 It is important
to identify these patients, as they are at a higher risk of failure after urethroplasty. Erectile
dysfunction may recover over time but can take up to 2 years to occur. 68
Table 3: Percentage of men with erectile dysfunction after posterior urethral
injury and recovery of erectile function post operatively

Study N Total Pre-op ED Post-op recovery

59
Koraitim 2005 110 44 (40%) 29/44 (66%)

56
Flynn, et al, 2003 117 65 (56%) 6/65 (9%)

60
Corriere 2001 60 29 (48%) 9/29 (31%)

69
Morey, et al, 1997 82 44 (52%) 15/44 (34%)

63
Webster, et al, 1991 52 33 (63%) 3/33 (9%)

Total 421 215 (51%) 62/215 (29%)

View Image.
Incontinence: Incontinence is a rare consequence of urethral injury. While the external urinary
sphincter is damaged in nearly all cases – because of the initial trauma or the urethroplasty – the
bladder neck is typically intact. However, if there is an initial concomitant bladder neck or serious
pelvic nerve injury, incontinence can occur after posterior urethroplasty for pelvic fracture-related
urethral injury.70 Close attention to the pre-operative voiding cystogram may reveal an incompetent
bladder neck and predict this problem pre-operatively.

3. Genitalia
3.1 Introduction
Genital trauma encompasses a wide variety of injuries making it difficult to classify and standardize
treatment. Genitourinary trauma includes blunt and penetrating sources. Examples of genitourinary
trauma include burns, bites, and avulsions involving the penis, testicles, scrotum, and perineum in
the male and vulva in the female. Few epidemiologic studies exist to determine the incidence of
genital trauma, and the incidence varies widely. Approximately 28-68% of patients with injuries to
the genitourinary system have injuries the external genitalia. 28 The majority of external genital
trauma is blunt; however, 40-60% of penetrating injuries to the genitourinary system involves the
external genitalia. 71 While these injuries are rarely life-threatening, the long-term sequelae of
the injuries – impaired fertility, decreased sexual function, physiologic endocrine changes,
and psychiatric – in a predominately young population require prompt treatment and close
follow-up.

3.2 Definition
As noted above, external genital injuries encompass a wide spectrum of types, etiologies and
severity of injuries. The impact, complications, and management of external genital injuries
are highly variable and greatly dependent on the mechanism, involved structure or organ,
and severity.

a. Blunt injuries: Contusion, avulsion, and burns

b. Penetrating injuries: Laceration, amputation, and bites

3.3 Anatomy
See Core Curriculum Anatomy & Physiology Testis, Epididymis, Vas Deferens
The male external genital structures lie external and inferior to the bony pelvis. The male
genital structures are connected to the body through the anterior perineum, specifically the male
genitourinary triangle. The scrotum is attached to the anterior apex of the triangle and overlies
Colles’ fascia. The root of the penis, consisting of the paired corporal bodies and the corpus
spongiosum, attaches medially to Colles’ fascia. The testes lie within the scrotum and are
suspended by the spermatic cords, which enter the groin from the inguinal rings bilaterally. The
epididymis is a paired structure lying posterolateral on the testis and has an internal structure of a
tubule or duct that coalesces to become the vas deferens.
The internal iliac artery provides the majority of the blood supply to the perineum through
the primary feeding branch is the internal pudendal artery. The venous drainage mirrors the
arterial inflow. The exception is the blood supply to the testicles and adjacent structures,
which are supplied by the testicular arteries that branch directly off the aorta in the
retroperitoneum.
Innervation of the genitalia is more complex, reflecting the overlapping nature of the nervous
system. The majority of nervous supply arises in the lumbosacral plexus. The perineum,
posterior scrotum, and penis are innervated by the pudendal nerve branching from the sacral
plexus. The sensory input from the anterior scrotum and tunica vaginalis is supplied by the
genitofemoral nerve arising from the lumbar plexus. The visceral nerve supply to the testes and
epididymii arise from the aortic and renal plexuses or the pelvic plexus which supplies the vas
deferens.

3.4 Etiology
See Reference 72,73
Penis:
Penile injury is uncommon due to the flaccid and mobile nature of the penis and scrotum. Penile
injuries fall into one of three categories: blunt, penetrating, or amputation.
Blunt: Blunt injury to the erect penis may result in penile fracture or tear of the corpora cavernosa,
which is the most common form of penile injury requiring surgical intervention. Many fractures
result from the erect penis striking the pubic bone or perineum during sexual intercourse. 14 Another
well-described injury occurs during “taghaandan”, in which detumescence is achieved by forcibly
pushing the erect penis down. 74 There has been an increase in penile fractures in patients who
have undergone treatment with Collagenase Clostridium Histolyticum for Peyronie’s disease.
Corporal fractures can be seen in 0.5-4.9% of patients after injection. 75
Penetrating: Penetrating injuries to the penis most commonly result from gunshot wounds, though
stab wounds comprise more than 40% of penile injuries in some series. In a civilian environment,
most gunshot wound injuries result from low-velocity missiles, which impart less kinetic energy
transfer. The majority of these patients have associated non-urologic injuries, 54-80%. 37,71
Amputation: Amputation injuries are usually self-inflicted and associated with severe, untreated
mental illness.9
Testis:
The testes are protected from trauma by the scrotum’s mobility, a dense surrounding sheath
(tunica albuginea), and the retractile nature of the cremasteric muscles. 76 Nonetheless, testicular
injury can result in loss of fertility and sexual function if not treated promptly. The diagnosis and
management of suspected testicular trauma vary depending on the type of trauma.
Blunt: Testis injuries are usually the result of blunt trauma and can involve a spectrum from a
Blunt: Testis injuries are usually the result of blunt trauma and can involve a spectrum from a
contusion to total parenchymal loss. Blunt trauma accounts for 50-85% of testicular injuries, and
many injuries are the result of sports and athletic activities. 9,76
Penetrating: Although less common, penetrating testicular injuries are often more severe,
associated with bilateral injuries in up to 30% of patients and non-genital associated injuries in up
to 80% of patients.14,77 Blast trauma is an uncommon cause of penetrating testicular injury in the
civilian setting, but accounts for up to 10% of injuries in combat environments and often involves
both testicles. 28
Scrotum:
Genital and scrotal skin injuries are typically the result of either mechanical shearing injury or burn
injury. A burn injury can be the result of thermal, chemical, or electrical injury. In combat
environments, significant blast and penetrating injuries can result in skin loss.
Blunt: Blunt injuries to the scrotum are often the result of direct impact during athletic activities.76
More significant skin injuries can result from severe motor vehicle collisions or industrial
accidents.78
Penetrating: Scrotal trauma from penetrating injuries can result from gunshots, stab wounds or
other projected missiles. Due to the scrotum’s external location, a unique penetrating injury to the
genitalia are bite injuries from both human and animal sources with resultant skin loss. 71,79,80 In a
military setting, the nature of injuries has changed due to the increased use of improvised explosive
devices (IED’s). Military medical professionals more commonly evaluate injuries from projectile
fragments, rather than bullets, or other fired missiles. 81,82
Burns/Infection: As the scrotum is an externalized structure covered with hair-bearing skin, the
scrotum is susceptible to the same burn injuries elsewhere on the body, including thermal,
chemical, and electrical. Furthermore, progressive infections of the skin and subcutaneous tissues
can result in significant skin loss.
Perineum:
Blunt: The perineum is susceptible to the same injuries and mechanisms as scrotal trauma.
However, due to the location of the perineum, isolated avulsion and shearing injuries of the
perineum are uncommon.
Penetrating: Perineal injuries are very rare and usually involve penetrating mechanisms, most
commonly gunshot wounds. Due to the size and location of the perineum, these injuries often
involve surrounding structures. 83 The most common associated injuries are to the anus and
rectum. 84

3.5 Presentation
 Figure C: Penile injury involving wood shard. Courtesy of Dr. Faris

Figure B: Classic eggplant deformity associated with penile

fracture. Courtesy of Dr. Faris

See Reference 85
See AUA Update Series: Diagnosis and Management of the Acute Scrotum85
Penis:
Blunt: The classic patient history of a penile fracture includes the description of popping or
cracking sound followed by rapid detumescence, pain and penile swelling The classic
physical exam appearance is referred to as an “eggplant” deformity because of the severe swelling
physical exam appearance is referred to as an “eggplant” deformity because of the severe swelling
and ecchymosis that invariably occurs deep to Buck’s fascia after a penile fracture. In cases where
the urethra is also injured, there may be blood at the urethral meatus or inability to urinate.
Penetrating: Penetrating trauma may involve surrounding structures. This is most commonly the
soft tissues of the thigh, although urethral and scrotal structures may be involved. Up to 40-60%
of penetrating injuries to the genitourinary system involves the external genitalia. Providers
should evaluate for urethral injury in patients who present with blood at the urethral meatus or the
inability to urinate.
Testis:
Blunt: Blunt trauma directly to the scrotum can present with scrotal ecchymosis, swelling, and
potentially hematoma. The historical details usually reveal a significant strike to the scrotum
directly, or glancing blows from the thigh or groin. Industrial or shearing injuries present with
significant genital skin loss and exposed testes either with or without intact tunica vaginalis.
Penetrating: Civilian penetrating injuries typically present with focal scrotal tissue damage and
similar physical findings of scrotal ecchymosis, swelling, and potentially hematoma. When
surgeons explore a penetrating scrotal wound, 40-60% of patients also have a penetrating
injury to the testis.9
Scrotum:
Scrotal injuries have a very similar presentation to blunt and penetrating testicular injury. Patients
who have burn injuries should be evaluated as a patient sustaining a thermal, electrical, or
chemical burn. Scrotal and genital skin loss is usually dramatic and often associated with
significant multisystem trauma.
Perineum:
We divide perineal injuries into blunt and penetrating mechanisms. Blunt perineal injuries usually
present similarly to scrotal injuries and involve significant trauma with skin loss. Isolated burns to
the perineum are rare and usually present in association with larger body surface area burns. 78
More frequently (although still uncommon), perineal injuries result from penetrating trauma and
result from missiles or impalement of the perineum.

3.6 Diagnosis and Imaging Studies

See Reference 86,87,88,89,90,91
See AUA Update Series: Genitourinary Trauma, Vol 34, Lesson 18, 2015
See AUA Update Series: Injuries and Wounds of the External Genitalia, Vol 37, Lesson 4,
2018
See AUA Update Series: Lessons Learned in Military Urotrauma, Vol 38, Lesson 24, 2019
Evaluation of the patient sustaining genital trauma should include history and physical examination,
laboratory evaluation (urinalysis), and radiologic imaging (plain films, ultrasonography, and CT
scan) as appropriate. Physical examination of male genitalia following pelvic, perineal, or lower
extremity trauma is the most important aspect of patient evaluation. Key physical findings include
ecchymosis or hematoma of the any of the external genitalia (penis, scrotum, or perineum) and
injury or loss of the overlying skin. It is important to remember that history and physical
examination in trauma patients are guided by ATLS principles, and initial assessment of
airway, breathing, and circulation (ABCs) are paramount. In trauma limited to the external
genitalia, further evaluation is not always indicated .
Specific evaluation of the penis and urethra resulting from a traumatic injury usually are dictated by
history and physical findings. More importantly, however, it is for the treating physician to
remember that in severely injured patients with multisystem trauma, life threatening injuries dictate
evaluation and management.
It is imperative that evaluation of urethral, rectal and bladder injury is performed early in the
patient’s hospital course. Appropriate methods of evaluation for urethral injuries include retrograde
urethrogram and urethroscopy. Rectal and bladder injuries can be evaluated with direct
endoscopic inspection or directed radiographic studies, i.e. cystography for bladder injuries and
contrast enhanced cross sectional imaging for rectal evaluation.
Penis:
Blunt: In those patients with severe discomfort or an equivocal physical examination and history,
ultrasonography or magnetic resonance imaging can assist with diagnosis and evaluation of the
integrity of the corpora cavernosa. In patients with hematuria or inability to void, a qualified
medical professional should perform a urethral evaluation by either retrograde urethrogram
or cystoscopy.
Penetrating: The team should strongly consider a urethral evaluation using retrograde urethrogram
in patients with penetrating penile injuries or those patients with injuries in proximity to the urethra
and inability to void or hematuria. If radiographic imaging will delay treatment in these patients,
cystoscopy in an operative setting can adequately evaluate the urethra’s integrity.
Testis/Scrotal:
Blunt: Initial evaluation of blunt testicular injury should include a detailed history and focused
physical exam, though examination in these patients can be difficult due to scrotal swelling, pain,
and ecchymosis. In these patients, the use of ultrasound provides significant adjunct
findings, including heterogeneous echotexture of the parenchyma, hematocele and
testicular contour loss .9,92 In patients with concerning physical exam findings and equivocal
ultrasound examinations, experts recommend surgical exploration.76
Penetrating: The clinical presentation dictates the evaluation of the patient with penetrating
testicular trauma. Those who are hemodynamically stable can undergo full historical and physical
examination. Hemodynamically unstable patients will require tailored evaluation for life-threatening
injuries. It is imperative that evaluation for urethral, rectal and bladder injury is performed early in
the patient’s hospital course. Ultimately, there is a high rate of testicular injury for penetrative
the patient’s hospital course. Ultimately, there is a high rate of testicular injury for penetrative
trauma and very limited sensitivity of ultrasound. 54

3.7 Management
True penile injuries typically require operative management to improve sexual function outcomes
and cosmesis. 9
Penis:
Blunt: When a penile fracture has been confirmed or cannot be ruled out, a urologist should
perform prompt surgical exploration and repair.9 Conservative management results in an increased
risk of erectile dysfunction, curvature, 93 and painful erections. The surgeon exposes the injured
corpus cavernosum to fully visualize the injury. The exposure is typically attained through a
circumcising or midline ventral scrotal incision that is extended laterally at the distal end of the
incision (“hockey stick”). The latter approach is particularly useful for proximal injuries. Surgeons
repair the corporal injury with slow absorbing suture. If a urethral injury is also present, it should be
repaired with absorbable suture and a catheter left in place. There is debate among experts about
whether surgical repair is needed in penile fractures after injection with Collagenase Clostridium
Histolyticum, with some opting for conservative management. 94
Penetrating: Management of these injuries requires surgical exploration of the wound with
debridement and repair of the associated corpora cavernosal injury and overlying skin. As with
blunt injuries, repair is performed with slow absorbing suture. If repair is not feasible, irrigation,
debridement, and packing the wound with delayed coverage and repair is appropriate.
Amputation: Proper handling of the amputated segment is critical. The amputated appendage
should be wrapped in saline-soaked gauze, in a plastic bag and placed on ice during transport.
The gauze prevents the penis from coming into contact with ice and suffering thermal damage.
Operative management includes careful debridement of the wound, followed by macroscopic repair
of the corpora cavernosa, urethra, and corpus spongiosum. Repair should be performed with slow
absorbing suture. When microsurgical expertise is available, the dorsal vascular and nerve
structures should be re-approximated. This repair should be performed within 24 hours. If the
amputated segment is not available, the wound should be formally closed similar to a partial
penectomy. 9
Testis:
Blunt: In those patients with testicular fracture or large hematoma, scrotal exploration and
repair is performed. Repair of the injury is accomplished with limited debridement of the
seminiferous tubules and closure of the tunica albuginea using absorbable suture. In cases of
significant loss of the tunica albuginea, a tunica vaginalis flap can be used. 14
Penetrating: Due to the frequent involvement of adjacent structures and limitations of non-operative
diagnostic tools, penetrating scrotal and testicular injuries should be managed with surgical
exploration. Urologic surgeons can perform exploration and repair similarly to blunt trauma. In
certain circumstances (pediatric patients and patients with solitary testicles), microscopic repair
and re-anastomosis is possible and may be considered. 80
Scrotum:
Blunt and Penetrating: Blunt and penetrating scrotal wounds are managed similarly. Burn wounds
are managed differently due to the progressive changes and effects to the scrotal skin.
Open wounds should be explored in the operating room with wound cleansing and limited
debridement of grossly non-viable skin. Many scrotal wounds can be closed primarily once the
wound bed is healthy, even with skin loss of up to 60%.95 Electrical burns should be cautiously
debrided as these wounds can evolve. Urinary diversion is rarely required unless the wound
involves the urethra or the burn is full thickness and involves the urethra. Larger wounds and burn
injury should be managed with either regular dressing changes and topical antibiotic (e.g.
Silvadene) or negative pressure dressings. Delayed wound closure with skin grafting or local skin
flaps may be required once the patient is stable and the wound bed healthy.
Split-thickness skin grafts can be used for coverage and usually have good graft take and
satisfactory cosmetic results. 96 Alternatively, if there is extensive skin loss and reconstruction
cannot be performed, the testicles can be placed in thigh pouches.

Key Takeaways
Trauma to the lower urinary tract can be the result of blunt, penetrating, or iatrogenic injuries.
Management depends on the stability of the patient and presence of additional injuries.
In most cases penetrating injuries to the lower urinary tract should undergo immediate
surgical exploration.
Pelvic fracture urethral injuries are complex and should be managed at high-volume centers
with experienced surgeons.
Early repair is recommended in female patients with urethral injuries to decrease the risk of
incontinence or fistula formation.
Imaging has limited utility in penetrating scrotal injuries, and these patients should undergo
surgical exploration.
Penetrating penile injuries and blunt injuries concerning for penile fracture require operative
management to improve sexual function outcomes.

Videos
Penile Entrapment by Metal Ring: A Video Guide to Surgical Removal
Iatrogenic Ureteral Injury Repair: Robotic-Assisted End-to-End Distal Ureteroureterostomy

Presentations
Bladder, Urethra, Genitalia Presentation 1
References

Bariol, S.V., et al., An analysis of urinary tract trauma in Scotland: imnpact on management
1 and resource needs. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh
and Ireland, 2005. 3(1): p. 27-30.

Paparel, P., et al., The epidemiology of trauma of the genitourinary system after traffic
2 accidents: analysis of a register of over 43,000 victims. BJU international, 2006. 97(2): p.
338-41.

Chung, B.I., G. Sommer, and J.D. Brooks, Anatomy of the Lower Urinary Tract and Male
3 Genitalia, in Campbell-Walsh Urology, A.J. Wein, et al., Editors. 2012, Elsevier-Saunders:
Philadelphia, PA. p. 33-71.

Yoshimura, N. and M.B. Chancellor, Physiology and Pharmacology of the Bladder and
4 Urethra, in Campbell-Walsh Urology, A.J. Wein, et al., Editors. 2012, Elsevier-Saunders:
Philadelphia, PA. p. 1786-1833.

Gomez, R.G., et al., Consensus statement on bladder injuries. BJU international, 2004. 94(1):
5
p. 27-32.

Cinman, N.M., et al., Gunshot wounds to the lower urinary tract: a single-institution
6
experience. J Trauma Acute Care Surg, 2013. 74(3): p. 725-30; discussion 730-1.

Catalano O (1997) US evaluation of inguinoscrotal bladder hernias: Report of three cases.

7
Clin Imaging 21:126–128

Brewer, M.E., et al., Prospective comparison of microscopic and gross hematuria as

8
predictors of bladder injury in blunt trauma. Urology, 2007. 69(6): p. 1086-1089.

☆ Morey, A.F., et al., Urotrauma: AUA guideline. The Journal of urology, 2014. 192(2): p.
9
327-35. Amended 2017, 2020.

Quagliano, P.V., S.M. Delair, and A.K. Malhotra, Diagnosis of blunt bladder injury: A
10 prospective comparative study of computed tomography cystography and conventional
retrograde cystography. J Trauma, 2006. 61(2): p. 410-21; discussion 421-2.

☆ Haas, C.A., S.L. Brown, and J.P. Spirnak, Limitations of routine spiral computerized
11
tomography in the evaluation of bladder trauma. J Urol, 1999. 162(1): p. 51-2.

☆ AUA update series Acute Management of Bladder and Urethral Trauma, Vol 27,
12
Lesson 24, 2008
 Phillips, B., Holzmer, S., Turco, L. et al. Trauma to the bladder and ureter: a review of
13
diagnosis, management, and prognosis. Eur J Trauma Emerg Surg 43, 763–773 (2017).

Morey, A.F. and D.D. Dugi, Genital and Lower Urinary Tract Trauma, in Campbell-Walsh
14
Urology, A.J. Wein, et al., Editors. 2012, Elsevier-Saunders: Philadelphia, PA. p. 2506-2520.

☆ Anderson RE, et al. Current Management of Extraperitoneal Bladder Injuries: Results
15 from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS). J Urol.
2020;204(3):538-544.

Elliott, S.P. and J.W. McAninch, Extraperitoneal bladder trauma: delayed surgical
16 management can lead to prolonged convalescence. Journal of Trauma and Acute Care
Surgery, 2009. 66(1): p. 274-275.

Mundy, A.R. and D.E. Andrich, Pelvic fracture-related injuries of the bladder neck and
17
prostate: their nature, cause and management. BJU Int, 2010. 105(9): p. 1302-8.

Coccolini F, Moore EE, Kluger Y, Biffl W, Leppaniemi A, Matsumura Y, Kim F, Peitzman AB,
Fraga GP, Sartelli M, Ansaloni L, Augustin G, Kirkpatrick A, Abu-Zidan F, Wani I, Weber D,
Pikoulis E, Larrea M, Arvieux C, Manchev V, Reva V, Coimbra R, Khokha V, Mefire AC,
18
Ordonez C, Chiarugi M, Machado F, Sakakushev B, Matsumoto J, Maier R, di Carlo I, Catena
F; WSES-AAST Expert Panel. Kidney and uro-trauma: WSES-AAST guidelines. World J
Emerg Surg. 2019 Dec 2;14:54.

Myers, J.B., et al., Process improvement in trauma: traumatic bladder injuries and compliance
19
with recommended imaging evaluation. J Trauma Acute Care Surg, 2013. 74(1): p. 264-9.

20 Libertino, J.A., Reconstructive urologic surgery. 3rd ed1998, St. Louis: Mosby. xx, 694 p.

Smith, T.G., 3rd and M. Coburn, Damage control maneuvers for urologic trauma. The
21
Urologic clinics of North America, 2013. 40(3): p. 343-50.

Santucci, R.A., Traumatic rupture of the urinary bladder: is the suprapubic tube necessary?
22
Int Braz J Urol, 2004. 30(4): p. 344-5.

☆ Corriere, J.N., Jr. and C.M. Sandler, Mechanisms of injury, patterns of extravasation
23 and management of extraperitoneal bladder rupture due to blunt trauma. J Urol, 1988. 139(1):
p. 43-4.

☆ Broghammer, J.B. and H. Wessells, Acute Management of Bladder and Urethral
24
Trauma. AUA Update Series, 2008. 27(24): p. 221-232.

Kotkin, L. and M.O. Koch, Morbidity associated with nonoperative management of

25
extraperitoneal bladder injuries. J Trauma, 1995. 38(6): p. 895-8.
 Wirth, G.J., et al., Advances in the management of blunt traumatic bladder rupture:
26
experience with 36 cases. BJU Int, 2010. 106(9): p. 1344-9.

Cass, A.S. and M. Luxenberg, Management of extraperitoneal ruptures of bladder caused by

27
external trauma. Urology, 1989. 33(3): p. 179-83.

McGeady, J.B. and B.N. Breyer, Current epidemiology of genitourinary trauma. The Urologic
28
clinics of North America, 2013. 40(3): p. 323-34.

Rosenstein D, Alsikafi N: Diagnosis and classification of urethral injuries. Urol Clin North Am
29
2006; 33:73-85.

McCormick CS, Dumais MG, Johnsen NV, Voelzke BB, Hagedorn JC. Male genital trauma at
30 a level 1 trauma center. World J Urol. 2020 Dec;38(12):3283-3289. doi:
10.1007/s00345-020-03115-0. Epub 2020 Feb 20. PMID: 32077992.

Chapple, C., et al., Consensus statement on urethral trauma. BJU international, 2004. 93(9):
31
p. 1195-202.

☆ Andrich, D.E. and A.R. Mundy, The nature of urethral injury in cases of pelvic fracture
32
urethral trauma. J Urol, 2001. 165(5): p. 1492-5.

☆ Breaud, J., et al., Posterior urethral injuries associated with pelvic injuries in young
33 adults: computerized finite element model creation and application to improve knowledge and
prevention of these lesions. Surgical and radiologic anatomy : SRA, 2012. 34(4): p. 333-9.

☆ Cooperberg, M.R., et al., Urethral reconstruction for traumatic posterior urethral
34 disruption: outcomes of a 25-year experience. The Journal of urology, 2007. 178(5): p.
2006-10; discussion 2010.

☆ Mouraviev, V.B., M. Coburn, and R.A. Santucci, The treatment of posterior urethral
35 disruption associated with pelvic fractures: comparative experience of early realignment
versus delayed urethroplasty. The Journal of urology, 2005. 173(3): p. 873-6.

Najibi, S., M. Tannast, and J.M. Latini, Civilian gunshot wounds to the genitourinary tract:
36 incidence, anatomic distribution, associated injuries, and outcomes. Urology, 2010. 76(4): p.
977-81; discussion 981.

☆ Tillet, J.W. and K.J. Carney, Gunshot Wounds of the Male External Genitalia. AUA
37
Update Series, 2008. 27(5): p. 41-48.

Lim, P.H. and H.C. Chng, Initial management of acute urethral injuries. British journal of
38
urology, 1989. 64(2): p. 165-8.
 Jordan, G.H., R. Virasoro, and E.A. Eltahawy, Reconstruction and management of posterior
39 urethral and straddle injuries of the urethra. The Urologic clinics of North America, 2006.
33(1): p. 97-109, vii.

☆ Pelvis Fractures: Assessment and Management for the Urologist to AUA update series
40
Pelvis Fractures: Assessment and Management for the Urologist, Vol 23, Lesson 11, 2004

☆ Imaging of the Penis and Male Urethra to AUA update series Imaging of the Penis and
41
Male Urethra, Vol 27, Lesson 23, 2008

Devine, P.C. and C.J. Devine, Jr., Posterior urethral injuries associated with pelvic fractures.
42
Urology, 1982. 20(5): p. 467-70.

Aihara, R., et al., Fracture locations influence the likelihood of rectal and lower urinary tract
43 injuries in patients sustaining pelvic fractures. J Trauma, 2002. 52(2): p. 205-8; discussion
208-9.

☆ Basta, A.M., C.C. Blackmore, and H. Wessells, Predicting urethral injury from pelvic
44
fracture patterns in male patients with blunt trauma. J Urol, 2007. 177(2): p. 571-5.

Cass AS. Diagnostic studies in bladder rupture: indications and techniques. Urol Clin North
45
Am, 1989. 16:267-273.

☆ Black, P.C., et al., Urethral and bladder neck injury associated with pelvic fracture in 25
46
female patients. J Urol, 2006. 175(6): p. 2140-4; discussion 2144.

☆ Primary Realignment of the Traumatic Urethral Distraction to AUA update series
47
Primary Realignment of the Traumatic Urethral Distraction, Vol 24, Lesson 30, 2005

☆ Acute Management of Bladder and Urethral Trauma to AUA update series Acute
48
Management of Bladder and Urethral Trauma, Vol 27, Lesson 24, 2008

Brandes, S., Initial management of anterior and posterior urethral injuries. The Urologic clinics
49
of North America, 2006. 33(1): p. 87-95, vii.

☆ Husmann, D.A., T.B. Boone, and W.T. Wilson, Management of low velocity gunshot
50 wounds to the anterior urethra: the role of primary repair versus urinary diversion alone. The
Journal of urology, 1993. 150(1): p. 70-2.

☆ Whitson, J.M., et al., Mechanism of continence after repair of posterior urethral
51
disruption: evidence of rhabdosphincter activity. J Urol, 2008. 179(3): p. 1035-9.

☆ Leddy, L.S., et al., Outcomes of endoscopic realignment of pelvic fracture associated
52
urethral injuries at a level 1 trauma center. J Urol, 2012. 188(1): p. 174-8.
 Rehman, J; Samadi, D; Riccardi, R; Kreutzer, E, Early endoscopic realignment as primary
53 therapy for complete posterior urethral disruptions. Journal of Endourology. 1998, Vol.12(3),
p.283-289

☆ Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma
54 Guideline 2020: AUA Guideline. J Urol. 2021 Jan;205(1):30-35. doi:
10.1097/JU.0000000000001408. Epub 2020 Oct 14. PMID: 33053308.

Figler, B.D., et al., Multi-disciplinary update on pelvic fracture associated bladder and urethral
55
injuries. Injury, 2012. 43(8): p. 1242-9.

☆ Flynn, B.J., F.C. Delvecchio, and G.D. Webster, Perineal repair of pelvic fracture
56 urethral distraction defects: experience in 120 patients during the last 10 years. The Journal
of urology, 2003. 170(5): p. 1877-80.

☆ Perry M, Husmann DA: Urethral injuries in the female following pelvic fractures. J Urol
57
1992; 147:139-143.

☆ Kizer, W.S., et al., Simplified reconstruction of posterior urethral disruption defects:
58 limited role of supracrural rerouting. The Journal of urology, 2007. 177(4): p. 1378-81;
discussion 1381-2.

☆ Koraitim, M.M., On the art of anastomotic posterior urethroplasty: a 27-year

59
experience. The Journal of urology, 2005. 173(1): p. 135-9.

☆ Corriere, J.N., 1-Stage delayed bulboprostatic anastomotic repair of posterior urethral
60
rupture: 60 patients with 1-year followup. The Journal of urology, 2001. 165(2): p. 404-7.

☆ Ennemoser, O., et al., Posttraumatic posterior urethral stricture repair: anatomy,
61
surgical approach and long-term results. The Journal of urology, 1997. 157(2): p. 499-505.

Mundy, A.R., Urethroplasty for posterior urethral strictures. British journal of urology, 1996.
62
78(2): p. 243-7.

☆ Webster, G.D. and J. Ramon, Repair of pelvic fracture posterior urethral defects using
63
an elaborated perineal approach: experience with 74 cases. The Journal of urology, 1991.

☆ Wright, J.L., et al., Specific fracture configurations predict sexual and excretory
64 dysfunction in men and women 1 year after pelvic fracture. The Journal of urology, 2006.
176(4 Pt 1): p. 1540-5; discussion 1545.

☆ Shenfeld, O.Z., et al., The incidence and causes of erectile dysfunction after pelvic
65 fractures associated with posterior urethral disruption. The Journal of urology, 2003. 169(6):
p. 2173-6.
 Johnsen NV, Kaufman MR, Dmochowski RR, et al. Erectile Dysfunction Following Pelvic
66 Fracture Urethral Injury. Sexual Medicine Reviews 2018;6:114–123.
doi:10.1016/j.sxmr.2017.06.004.

Zuckerman, J.M., et al., Outcome of penile revascularization for arteriogenic erectile

67
dysfunction after pelvic fracture urethral injuries. Urology, 2012. 80(6): p. 1369-73.

☆ Shenfeld, O.Z., et al., The role of sildenafil in the treatment of erectile dysfunction in
68 patients with pelvic fracture urethral disruption. The Journal of urology, 2004. 172(6 Pt 1): p.
2350-2.

☆ Morey, A.F. and J.W. McAninch, Reconstruction of posterior urethral disruption injuries:
69
outcome analysis in 82 patients. The Journal of urology, 1997. 157(2): p. 506-10.

☆ Iselin, C.E. and G.D. Webster, The significance of the open bladder neck associated
70 with pelvic fracture urethral distraction defects. The Journal of urology, 1999. 162(2): p.
347-51.

☆ Phonsombat S, Master VA, McAninch JW. Penetrating External Genital Trauma: A
71
30-Year Single Institution Experience. Journal of Urology. 2008 Jul;180(1):192–6.

☆ Gunshot Wounds of the Male External Genitalia to AUA update series Gunshot
72
Wounds of the Male External Genitalia, Vol 27, Lesson 5, 2008

☆ Male External Genital Trauma to AUA update series Male External Genital Trauma, Vol
73
36, Lesson 29, 2017

☆ Zargooshi, J., Penile fracture in Kermanshah, Iran: report of 172 cases. The Journal of
74
urology, 2000. 164(2): p. 364-6.

☆ J. A. Beilan, J.J. Wallen, A.S. Baumgarten, et al. Intralesional injection of collagenase
clostridium histolyticum may increase the risk of late-onset penile fractures. Sex Med Rev, 6
(2)(2018), pp.272-278 Gelbard M, Goldstein I, Hellstrom WJ, et al. Clinical efficacy, safety
75
and tolerability of collagenase clostridium histolyticum for the treatment of Peyronie’s disease
in 2 large double-blind, randomized, placebo controlled phase 3 studies. J Urol.
2013;190(1):199–207 Initial study of CCH treatment leading to FDA approval.

Morey, A.F., et al., Consensus on genitourinary trauma: external genitalia. BJU international,
76
2004. 94(4): p. 507-15

77 Cass, A.S. and M. Luxenberg, Testicular injuries. Urology, 1991. 37(6): p. 528-30.

Wessells, H. and Long, L. Penile and genital injuries. The Urologic clinics of North America,
78
2006. 33(1): p. 117-26, vii.
 ☆ Mohr, A.M., et al., Management of trauma to the male external genitalia: the usefulness
79 of American Association for the Surgery of Trauma organ injury scales. The Journal of
urology, 2003. 170(6 Pt 1): p. 2311-5.

Chang, A.J. and S.B. Brandes, Advances in diagnosis and management of genital injuries.
80
The Urologic clinics of North America, 2013. 40(3): p. 427-38.

Hudak, S.J., et al., Battlefield urogenital injuries: changing patterns during the past century.
81
Urology, 2005. 65(6): p. 1041-6.

Banti M, Walter J, Hudak S, et al. Improvised explosive device-related lower genitourinary

82 trauma in current overseas combat operations. J Trauma Acute Care Surg 2016;80:131–134.
doi:10.1097/TA.0000000000000864

☆ Jordan, J.H., Lower Genitourinary Tract Trauma and Male External Genital Trauma
83 (Nonpenetrating injuries, Penetrating injuries, and Avulsion injuries). AUA Update Series,
2000. 19(11): p. 81-88.

Chong,EY et al. A systematic review of penetrating perineal trauma in a civilian setting.

84
European Journal of Trauma and Emergency Surgery. 2022

☆ Diagnosis and Management of the Acute Scrotum to AUA update series Diagnosis and
85
Management of the Acute Scrotum, Vol 35, Lesson 38, 2016

86 ☆ AUA update series Imaging of the Penis and Urethra, Vol 27, Lesson 23, 2008

87 AUA update series Imaging for Genitourinary Trauma, Vol 25, Lesson 4, 2006

88 AUA update series Genitourinary Trauma, Vol 34, Lesson 18, 2015

☆ AUA Update Series: Lower Genitourinary Tract Trauma and Male External Genital
89 Trauma (Nonpenetrating injuries, Penetrating injuries, and Avulsion injuries), Vol 19, Lesson
11, 2000

☆ AUA update series Injuries and Wounds of the External Genitalia, Vol 37, Lesson 4,
90
2018)

91 ☆ AUA update series Lessons Learned in Military Urotrauma, Vol 38, Lesson 24, 2019

☆ Buckley JC, McAninch JW. Use of Ultrasonography for the Diagnosis of Testicular
92
Injuries in Blunt Scrotal Trauma. Journal of urology. 2006 Jan;175(1):175–8.

T. Amer, R. Wilson, P. Chlosta, et al. Penile Fracture: a meta-analysis Urol Int, 96 (2016),
93
pp. 315-329
 Hughes WM, Natale C, Hellstrom WJG. The Management of Penile Fracture: a Review of the
94 Literature with Special Consideration for Patients Undergoing Collagenase Clostridium
Histolyticum Injection Therapy. Curr Urol Rep. 2021 Jan 20;22(2):13.

95 McAninch, JW. Management of genital skin loss. Urol Clin North Am, 16 (1989)pp. 387-397.

Balakrishnan C. Scrotal Avulsion: A new technique of reconstruction by spilt-skin graft. Br J

96
Plst Surg, 9 (1956),pp 38-42.

Abrams, P., Cardozo, L., Fall, M. et al.: The standardisation of terminology in lower urinary
97 tract function: report from the standardisation sub-committee of the International Continence
Society. Urology, 61: 37, 2003