To cite this guideline:
Morey AF, Brandes S, Dugi DD 3rd et al: Urotrauma: AUA guideline. J Urol 2014, 192: 327.

Published 2014; Amended 2017, 2020

This clinical guideline on Urotrama discusses diagnosis and management of genitourinary injuries, including renal, ureteral, bladder, urethral, and genital trauma.

Guideline as it appears in The Journal of Urology® [pdf]

Unabridged version of this Guideline [pdf]

Allen F. Morey, MD; Steve Brandes, MD; Daniel David Dugi III, MD; John H. Armstrong, MD; Benjamin N. Breyer, MD; Joshua A. Broghammer, MD; Bradley A. Erickson, MD; Jeff Holzbeierlein, MD; Steven J. Hudak, MD; Stuart Mirvis, MD; Jeffrey H. Pruitt, MD; James T. Reston, PhD, MPH; Richard A. Santucci, MD; Thomas G. Smith III, MD; Hunter Wessells, MD. The Practice Guidelines Committee would like to acknowledge the contributions of Drs. Courtney M.P. Hollowell, MD and Maxim J. McKibben, MD to the 2020 Guideline Amendment.

Purpose

The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries.

Methods

A systematic review of the literature using the MEDLINE® and EMBASE databases (search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria. These publications were used to inform the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

In April 2017, the Urotrauma guideline underwent an amendment based on an additional literature search, which retrieved additional studies published between original publication and December 2016. Forty-one studies from this search provided data relevant to the management and treatment of urotrauma.

In April of 2020, the Urotrauma guideline underwent an additional amendment based on a current literature search. This literature search retrieved additional studies published between January 2017 to February 2020. Eighty- three studies were identified from this search to provide data relevant to the management and treatment of urotrauma.

Guideline Statements

Renal Trauma

1. Clinicians should perform diagnostic imaging with intravenous (IV) contrast enhanced computed tomography (CT) in stable blunt trauma patients with gross hematuria or microscopic hematuria and systolic blood pressure < 90mmHG. (Standard; Evidence Strength: Grade B)

2. Clinicians should perform diagnostic imaging with IV contrast enhanced CT in stable trauma patients with mechanism of injury or physical exam findings concerning for renal injury (e.g., rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest). (Recommendation; Evidence Strength: Grade C)

3. Clinicians should perform IV contrast enhanced abdominal/pelvic CT with immediate and delayed images when there is suspicion of renal injury. (Clinical Principle)

4. In hemodynamically stable patients with renal injury, clinicians should use non-invasive management strategies. (Standard; Evidence Strength: Grade B)

5a. In hemodynamically unstable patients with no or transient response to resuscitation, the surgical team must perform immediate intervention (surgery or angioembolization in selected situations). (Standard; Evidence Strength: Grade B)

5b. For hemodynamically unstable patients with radiographic findings of large perirenal hematoma (> 4 cm) and/or vascular contrast extravasation in the setting of deep or complex renal laceration (AAST Grade 3-5), surgeons should perform immediate intervention (angioembolization or surgery). (Recommendation; Evidence Strength; Grade C)

6. Clinicians may initially observe patients with renal parenchymal injury and urinary extravasation. (Clinical Principle)

7. Clinicians should perform follow-up CT imaging for renal trauma patients having either (a) deep lacerations (AAST Grade IV-V) or (b) clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention). (Recommendation; Evidence Strength: Grade C)

8. Clinicians should perform urinary drainage in the presence of complications such as enlarging urinoma, fever, increasing pain, ileus, fistula or infection. (Recommendation; Evidence Strength: Grade C) Drainage should be achieved via ureteral stent and may be augmented by percutaneous urinoma drain, percutaneous nephrostomy or both. (Expert Opinion)

Ureteral Trauma

9a. Clinicians should perform IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram) for stable trauma patients with suspected ureteral injuries. (Recommendation; Evidence Strength: Grade C)

9b. Clinicians should directly inspect the ureters during laparotomy in patients with suspected ureteral injury who have not had preoperative imaging. (Clinical Principle)

10a. Surgeons should repair traumatic ureteral lacerations at the time of laparotomy in stable patients. (Recommendation; Evidence Strength: Grade C)

10b. Surgeons may manage ureteral injuries in unstable patients with temporary urinary drainage followed by delayed definitive management. (Clinical Principle)

10c. Surgeons should manage traumatic ureteral contusions at the time of laparotomy with ureteral stenting or resection and primary repair depending on ureteral viability and clinical scenario. (Expert Opinion)

11a. Surgeons should attempt ureteral stent placement in patients with incomplete ureteral injuries diagnosed postoperatively or in a delayed setting. (Recommendation; Evidence Strength: Grade C)

11b. Surgeons should perform percutaneous nephrostomy with delayed repair as needed in patients when stent placement is unsuccessful or not possible. (Recommendation; Evidence Strength: Grade C)

11c.Clinicians should initially manage patients with ureterovaginal fistula using stent placement when possible. In the event of stent failure, clinicians may pursue additional surgical intervention. (Recommendation; Evidence Strength; Grade C)

12a. Surgeons should repair ureteral injuries located proximal to the iliac vessels with primary repair over a ureteral stent, when possible. (Recommendation; Evidence Strength: Grade C)

12b. Surgeons should repair ureteral injuries located distal to the iliac vessels with ureteral reimplantation or primary repair over a ureteral stent, when possible. (Recommendation; Evidence Strength: Grade C)

13a. Surgeons should manage endoscopic ureteral injuries with a ureteral stent and/or percutaneous nephrostomy tube, when possible. (Recommendation; Evidence Strength: Grade C)

13b. Surgeons may manage endoscopic ureteral injuries with open repair when endoscopic or percutaneous procedures are not possible or fail to adequately divert the urine. (Expert Opinion)

Bladder Trauma

14a. Clinicians must perform retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture. (Standard; Evidence Strength: Grade B)

14b. Clinicians should perform retrograde cystography in stable patients with gross hematuria and a mechanism concerning for bladder injury, or in those with pelvic ring fractures and clinical indicators of bladder rupture. (Recommendation; Evidence Strength: Grade C)

15. Surgeons must perform surgical repair of intraperitoneal bladder rupture in the setting of blunt or penetrating external trauma. (Standard; Evidence Strength: Grade B)

16. Clinicians should perform catheter drainage as treatment for patients with uncomplicated extraperitoneal bladder injuries. (Recommendation; Evidence Strength: Grade C)

17. Surgeons should perform surgical repair in patients with complicated extraperitoneal bladder injury. (Recommendation; Evidence Strength: Grade C)

18. Clinicians should perform urethral catheter drainage without suprapubic (SP) cystostomy in patients following surgical repair of bladder injuries. (Standard; Evidence Strength: Grade B)

Urethral Trauma

19. Clinicians should perform retrograde urethrography in patients with blood at the urethral meatus after pelvic trauma. (Recommendation; Evidence Strength: Grade C)

20a. Clinicians should establish prompt urinary drainage in patients with pelvic fracture associated urethral injury. (Recommendation; Evidence Strength: Grade C)

20b. Clinicians should perform percutaneous or open suprapubic tube placement as preferred initial management for most pelvic fracture urethral injury (PFUI) cases. (Recommendation; Evidence Strength: Grade C)

21. Surgeons may place suprapubic tubes (SPTs) in patients undergoing open reduction internal fixation (ORIF) for pelvic fracture. (Expert Opinion)

22. Clinicians may perform primary realignment (PR) in hemodynamically stable patients with pelvic fracture associated urethral injury. (Option; Evidence Strength: Grade C) Clinicians should not perform prolonged attempts at endoscopic realignment in patients with pelvic fracture associated urethral injury. (Clinical Principle)

23. Clinicians should monitor patients for complications (e.g., stricture formation, erectile dysfunction, incontinence) for at least one year following urethral injury. (Recommendation; Evidence Strength: Grade C)

24. Surgeons should perform prompt surgical repair in patients with uncomplicated penetrating trauma of the anterior urethra. (Expert Opinion)

25. Clinicians should establish prompt urinary drainage in patients with straddle injury to the anterior urethra. (Recommendation; Evidence Strength: Grade C)

Genital Trauma

26. Clinicians must suspect penile fracture when a patient presents with penile ecchymosis, swelling, pain cracking or snapping sound during intercourse or manipulation and immediate detumescence. (Standard; Evidence Strength: Grade B)

27. Surgeons should perform prompt surgical exploration and repair in patients with acute signs and symptoms of penile fracture. (Standard; Evidence Strength: Grade B)

28. Clinicians may perform ultrasound in patients with equivocal signs and symptoms of penile fracture. (Recommendation; Evidence Strength: Grade C)

29. Clinicians must perform evaluation for concomitant urethral injury in patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria or inability to void. (Standard; Evidence Strength: Grade B)

30a. For blunt scrotal injuries, clinicians should perform scrotal ultrasonography for most patients having physical findings suggestive of testis rupture. (Recommendation; Evidence Strength: Grade C)

30b. For most penetrating scrotal injuries, clinicians should perform prompt surgical exploration with repair or orchiectomy (when non-salvageable) given the high rate of testicular injury and limited sensitivity of ultrasound in this setting. (Recommendation; Evidence Strength: Grade C)

30c. In patients with suspected testicular rupture, surgeons should perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvagable). (Standard; Evidence Strength: Grade B)

31. Surgeons should perform exploration and limited debridement of non-viable tissue in patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical). (Standard; Evidence Strength: Grade B)

32. Surgeons should perform prompt penile replantation in patients with traumatic penile amputation, with the amputated appendage wrapped in saline-soaked gauze, in a plastic bag and placed on ice during transport. (Clinical Principle)

33. Clinicians should initiate ancillary psychological, interpersonal, and/or reproductive counseling and therapy for patients with genital trauma when loss of sexual, urinary, and/or reproductive function is anticipated. (Expert Opinion)

Purpose

Urologic injury often occurs in the context of severe multisystem trauma that requires close cooperation with trauma surgeons. The urologist remains an important consultant to the trauma team, helping to ensure that the radiographic evaluation of urogenital structures is performed efficiently and accurately, and that the function of the genitourinary system is preserved whenever possible. Immediate interventions for acute urologic injuries often require flexibility in accordance with damage control principles in critically ill patients. In treating urotrauma patients, urologists must be familiar with both open surgical techniques and minimally invasive techniques for achieving hemostasis and/or urinary drainage. The Panel’s purpose is to review the existing literature pertaining to the acute care of urologic injuries in an effort to develop effective guidelines for appropriate diagnosis and intervention strategies in the setting of urotrauma.

Methodology

A comprehensive search of the literature targeted the five main urotrauma topics within the scope of this guideline. The search used an extensive list of keywords related to renal, ureteral, bladder, urethral, and genital trauma. A full list of keywords and the search strategy are available on request. This search covered articles published between January 1990 and September 2012. Study designs consisting of randomized controlled trials (RCTs), controlled clinical trials (CCTs), and observational studies (diagnostic accuracy studies, cohort with and without comparison group, case-control, case series) were included. Systematic reviews were included if they performed a quantitative analysis of data that did not overlap with data from other included studies; otherwise they were retrieved only for hand-searches of their bibliographies.

The following publications and study types were excluded: preclinical studies (e.g., animal models), meeting abstracts, commentary, editorials, non-English language studies, pediatric studies (except for specific key questions associated with renal trauma, ureteropelvic junction [UPJ] trauma and bladder neck/urethral trauma), and studies of urethral and genital injuries that did not separately analyze data from males and females. Studies with less than 10 patients were excluded from further evaluation and thus data extraction given the unreliability of the statistical estimates and conclusions that could be derived from them. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria.

In April 2017, the Urotrauma guideline was updated through the AUA amendment process in which newly published literature is reviewed and integrated into previously published guidelines in an effort to maintain currency. The amendment allowed for the incorporation of additional literature released since the initial publication of this guideline in 2014. Comprehensive searches of several databases from original publication to December 2016 were conducted. The search strategy was designed and conducted by an experienced librarian with input from the study's principle investigator. Controlled vocabulary supplemented with keywords was used to search for studies on treatment and management of urotrauma.

The search yielded 3,976 references, of which 3,657 were excluded after duplicate abstract and title review. A second pass of the abstracts and titles excluded an additional 278 studies. Eventually, 41 studies provided relevant data on the specific treatment for urotrauma.

In April 2020, the Urotrauma guideline was updated through the AUA amendment process in which newly published literature is reviewed and integrated into previously published guidelines in an effort to maintain currency. The amendment allowed for the incorporation of additional literature released since the initial publication of this guideline in 2014 and built on the updated literature review conducted in 2017. Comprehensive searches of several databases from August 2016 to February 2020 were conducted. The search strategy was designed and conducted by an experienced librarian with input from the study's principle investigator. Controlled vocabulary supplemented with keywords was used to search for studies on treatment and management of urotrauma.

The search yielded 6,241 references, of which 5,670 were excluded after a first pass abstract and title review. A second pass of the abstracts and titles excluded an additional 490 studies. Eventually, 81 studies provided relevant data on the specific treatment for urotrauma. Based on these 81 studies plus 41 studies identified by the amendment process in 2017, seven proposed recommendation changes were further investigated. Full text review was conducted on 84 studies that potentially informed on the seven statement changes. Following review, the evidence base consisted of 31 studies, which underwent quality assessment using validated study-type specific risk of bias tools (systematic reviews, AMSTAR¹; cohort studies, ROBINS-I²). The certainty of the evidence base informing each statement alteration was assessed using GRADE and then translated into the AUA 3-tiered strength of evidence grading system.

Quality of Studies and Determination of Evidence Strength. Quality of individual studies was rated as high, moderate, or low based on instruments tailored to specific study designs. RCTs were assessed using the Cochrane Risk of Bias tool.⁴ Conventional diagnostic cohort studies, diagnostic case-control studies, or diagnostic case series that presented data on diagnostic test characteristics were assessed using the QUADAS-2 tool⁵ that evaluates the quality of diagnostic accuracy studies. Cohort studies with a comparison of interest were evaluated with the Drug Effectiveness Review Project instrument.⁶ There is no widely agreed upon quality assessment tool for case series that do not present data on diagnostic test characteristics, thus the quality of individual case series was not formally assessed with an instrument. Instead, these studies were labeled as low quality due to their study design.

The categorization of evidence strength is conceptually distinct from the quality of individual studies. Evidence strength refers to the body of evidence available for a particular question and includes consideration of study design, individual study quality, consistency of findings across studies, adequacy of sample sizes, and generalizability of samples, settings, and treatments for the purposes of the guideline. The AUA categorizes body of evidence strength as Grade A (well-conducted RCTs or exceptionally strong observational studies), Grade B (RCTs with some weaknesses of procedure or generalizability or generally strong observational studies), or Grade C (observational studies that are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data). Because most of the available evidence consisted of low quality case series, the majority of evidence was considered Grade C.

AUA Nomenclature: Linking Statement Type to Evidence Strength. The AUA nomenclature system explicitly links statement type to body of evidence strength and the Panel’s judgment regarding the balance between benefits and risks/burdens.⁷Standards are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken based on Grade A or Grade B evidence. Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken based on Grade C evidence. Options are non-directive statements that leave the decision to take an action up to the individual clinician and patient because the balance between benefits and risks/burdens appears relatively equal or appears unclear; the decision is based on full consideration of the patient’s prior clinical history, current quality of life, preferences and values. Options may be supported by Grade A, B, or C evidence.

In some instances, the review revealed insufficient publications to address certain questions from an evidence basis; therefore, some statements are provided as Clinical Principles or Expert Opinions with consensus achieved using a modified Delphi technique if differences of opinion emerged.⁸ A Clinical Principle is a statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members’ clinical training, experience, knowledge, and judgment for which there is no evidence.

Limitations of the Literature. The Panel proceeded with full awareness of the limitations of the urotrauma literature. These limitations include heterogeneous patient groups, small sample sizes, lack of studies with diagnostic accuracy data, lack of RCTs or controlled studies with patient outcome data, and use of a variety of outcome measures. Overall, these difficulties precluded use of meta-analytic procedures or other quantitative analyses. Instead, narrative syntheses were used to summarize the evidence for the questions of interest.

Panel Selection and Peer Review Process. The Panel was created by the American Urological Association Education and Research, Inc. (AUA). The Practice Guidelines Committee (PGC) of the AUA selected the Panel Chair and Vice Chair who in turn appointed the additional panel members, all of whom have specific expertise with regard to the guideline subject. Once nominated, panel members are asked to record their conflict of interest (COI) statements, providing specific details on the AUA interactive web site. These details are first reviewed by the Guidelines Oversight Committee (GOC), a member sub-committee from the PGC consisting of the Vice Chair of the PGC and two other members. The GOC determines whether the individual has potential conflicts related to the guideline. If there are no conflicts, then the nominee’s COI is reviewed and approved by the AUA Judicial and Ethics (J&E) committee. A majority of panel members may not have relationships relevant to the guideline topic.

The AUA conducted an extensive peer review process. The initial draft of this Guideline was distributed to 69 peer reviewers of varying backgrounds; 35 responded with comments. The panel reviewed and discussed all submitted comments and revised the draft as needed.

Once finalized, the Guideline was submitted for approval to the PGC. It was then submitted to the AUA Board of Directors for final approval. Funding of the panel was provided by the AUA. Panel members received no remuneration for their work.

Trauma refers to injury caused by external force from a variety of mechanisms, including traffic- or transportation-related injuries, falls, assault (e.g., blunt weapon, stabbing, gunshot), explosions, etc. Injuries are frequently referred to as being either blunt or penetrating injuries as these different basic mechanisms have implications for management and outcomes. Blast injuries may have features of both penetrating and blunt trauma, and are most common in settings of war or violent conflict.

Traumatic injuries are the leading cause of death in the United States for people ages 1-44 years, and a significant cause of morbidity and loss of productive life across all ages.⁹ Worldwide, traumatic injuries are the sixth leading cause of death and the fifth leading cause of moderate and severe disability.¹⁰ Young males ages 15-24 have the greatest burden of injury.¹¹ Isolated urologic injuries are uncommon in major trauma as the kidneys, ureters, and bladder are well protected within the abdomen and pelvis, and the penis and testes are physically mobile. Urologic injuries are more common in the multiply-injured patient, and urologic organs are involved in approximately 10% of abdominal traumas.¹²

Renal Injuries. The kidneys are the most commonly injured genitourinary organ. Civilian renal injury occurs in up to 5% of trauma victims,^13,14 and accounts for 24% of traumatic abdominal solid organ injuries.¹⁵ The kidney is particularly vulnerable to deceleration injuries (e.g., falls, motor vehicle collisions) because it is fixed in space only by the renal pelvis and the vascular pedicle. Flank ecchymosis and broken ribs are signs suggestive of renal injury. Computed tomography (CT) scan with intravenous (IV) contrast enhancement including delayed imaging remains the most common method of evaluating for extravasation of urine from the collecting system.

Over the past few decades, management of traumatic renal injuries has changed from operative exploration to non-operative management in the vast majority of cases. Much of the impetus for this change comes from the recognition that, in many cases, urgent surgical exploration of renal injuries leads to nephrectomy for the injured kidney.¹⁴ Percutaneous angioembolization is increasingly accepted for treating ongoing bleeding without surgical exploration.^16,17 While non-operative management of the vast majority of blunt renal injuries is now firmly established, non-operative management of penetrating and high-grade renal injuries continues to inspire debate.¹⁸

Ureteral Injuries. Ureteral injuries are rare, accounting for 1% of urologic injuries. Distinct from other urologic organs, ureteral injuries tend to be iatrogenic, occurring during gynecologic, urologic, or colorectal surgery.¹⁹ The majority of ureteral injuries originating outside of the operating room are a result of penetrating trauma. Injuries may not be recognized early unless they are specifically investigated. Treatment may include placement of a ureteral stent or surgical repair, depending on the severity and location of injury.

Bladder Injuries. Bladder injuries occur in approximately 1.6% of blunt abdominal trauma victims.²⁰ Because the bladder is well protected within the pelvis, the vast majority of injuries are associated with pelvic fractures. The bladder rupture can occur into the peritoneal cavity (intraperitoneal bladder rupture) or outside the peritoneal cavity (extraperitoneal rupture). Bladder injuries are extraperitoneal in approximately 60%, intraperitoneal in approximately 30%, and the remaining injuries are both intraperitoneal and extraperitoneal ruptures.²¹ Gross hematuria is the most common sign, present in 77-100% of injuries.²² Retrograde cystography (CT or conventional) is critical as it can determine the presence of an injury and whether it is intraperitoneal or extraperitoneal. Since the 1980s, clinicians manage most extraperitoneal bladder ruptures non-operatively with catheter drainage, while intraperitoneal ruptures are surgically repaired.²⁰

Urethral Injuries. Injuries to the male urethra are divided into injuries to the posterior urethra (at or above the membranous urethra) or anterior urethra (penile or bulbar urethra). Posterior urethral injuries are almost exclusively associated with pelvic fractures and occur between 1.5 and 10% of pelvic fractures; concomitant bladder injuries are present in 15% of such urethral injuries.^21,23 Urethral injuries may be partial or complete disruption of the urethra. Anterior urethral injures may be blunt (e.g., straddle injuries, where the urethra is crushed between the pubic bones and a fixed object) or penetrating, and the urethra may be lacerated, crushed, or disrupted. Blood at the urethral meatus is the most common finding, although highly variable, present in 37-93%.²⁴ Other clinical findings include inability to urinate, perineal/genital ecchymosis, and/or a high-riding prostate on physical exam. Diagnosis is made by retrograde urethrography. Immediate surgical closure of urethral injuries is recommended primarily in penetrating injuries of the anterior urethra. Straddle injuries of the anterior urethra are initially treated with suprapubic (SP) or urethral urinary drainage and are at high risk for delayed stricture formation. Attempts at immediate sutured repair of posterior urethral injury are associated with unacceptably high rates of erectile dysfunction and urinary incontinence.²⁵ Regardless of the type of injury, securing catheter drainage of the bladder is the immediate goal of treatment. In females, urethral injuries occur almost exclusively as a result of pelvic fracture and should be suspected in patients having labial edema and/or blood in the vaginal vault during pelvic exam.

Immediate management of posterior urethral injuries remains controversial. Traditional management of PFUI is placement of a suprapubic tube (SPT) and delayed urethroplasty to reconnect the ruptured urethra. As endoscopic equipment and techniques have improved over the past two decades, primary realignment (PR) of posterior urethral ruptures has become more common. Primary realignment refers to advancing a urinary catheter across the ruptured urethra. The goal of PR is to allow a partial urethral injury to heal while diverting the urine via the catheter, or to align both ends of the disrupted urethra so that they heal in the correct position as the pelvic hematoma is reabsorbed. Review of the literature of the incidence of urethral stenosis after primary realignment is variable, ranging from 14 to 100%.^26-28 Concern surrounding primary realignment centers on problems with the definition of success and whether patients in these studies have had appropriate follow-up evaluation, as most eventually require repeated instrumentation and/or formal urethroplasty to maintain patency.²⁹

Genital Injuries. Genital injuries are a heterogeneous group of injuries, including blunt injuries, penetrating, amputation, bite, burn, or avulsion injuries to the penis, scrotum, or testicles in males and the vulva in females. There is little epidemiologic data for genital injuries, although one-half to two-thirds of penetrating genitourinary injuries involve the external genitalia.³⁰ The most commonly encountered injuries are penile fracture, testicular rupture, and penetrating penile injuries.

Penile fracture refers to a rupture of the tunica albuginea of the penis as a result of forceful bending of the erect penis, most commonly during sexual intercourse in the United States. It may be associated with urethral injury in 10-22% of cases.³¹ Diagnosis is usually confirmed by clinical history of forceful bending of the erect penis, an audible “pop” or “snap,” rapid detumescence, and penile ecchymosis. In equivocal cases, ultrasound or magnetic resonance imaging (MRI) may clarify the diagnosis. Surgical exploration and repair is associated with lower risk of erectile dysfunction and penile curvature.³²

Blunt scrotal trauma may lead to rupture of the tunica albuginea of the testicle in 50% of cases presenting for evaluation.³³ Ultrasound may confirm or imply testicular rupture, which should prompt exploration and attempt at repair. Early exploration is associated with higher testicular salvage rates.³³ Penetrating injuries to the scrotum should undergo surgical exploration as over 50% will have testicular rupture.³⁴

Penetrating penile injuries may be associated with concomitant urethral injuries in 11-29% of cases.³⁴ All but the most superficial injuries should be evaluated for urethral injury, explored, and repaired. Penile amputation is a rare injury that is usually self-inflicted and associated with extreme mental illness.³⁵ Replantation can be successful with prompt treatment, especially with microvascular repair.

Clinicians should perform diagnostic imaging with intravenous (IV) contrast enhanced computed tomography (CT) in stable blunt trauma patients with gross hematuria or microscopic hematuria and systolic blood pressure < 90mmHG. (Standard; Evidence Strength: Grade B)

Clinicians should perform diagnostic imaging with IV contrast enhanced CT in stable trauma patients with mechanism of injury or physical exam findings concerning for renal injury (e.g., rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest). (Recommendation; Evidence Strength: Grade C)

Clinicians should perform IV contrast enhanced abdominal/pelvic CT with immediate and delayed images when there is suspicion of renal injury. (Clinical Principle)

In hemodynamically stable patients with renal injury, clinicians should use non-invasive management strategies. (Standard; Evidence Strength: Grade B)

In hemodynamically unstable patients with no or transient response to resuscitation, the surgical team must perform immediate intervention (surgery or angioembolization in selected situations). (Standard; Evidence Strength: Grade B)

For hemodynamically unstable patients with radiographic findings of large perirenal hematoma (> 4 cm) and/or vascular contrast extravasation in the setting of deep or complex renal laceration (AAST Grade 3-5), surgeons should perform immediate intervention (angioembolization or surgery). (Recommendation; Evidence Strength; Grade C)

Clinicians may initially observe patients with renal parenchymal injury and urinary extravasation. (Clinical Principle)

Clinicians should perform follow-up CT imaging for renal trauma patients having either (a) deep lacerations (AAST Grade IV-V) or (b) clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention). (Recommendation; Evidence Strength: Grade C)

Clinicians should perform urinary drainage in the presence of complications such as enlarging urinoma, fever, increasing pain, ileus, fistula or infection. (Recommendation; Evidence Strength: Grade C) Drainage should be achieved via ureteral stent and may be augmented by percutaneous urinoma drain, percutaneous nephrostomy or both. (Expert Opinion)

Clinicians should perform IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram) for stable trauma patients with suspected ureteral injuries. (Recommendation; Evidence Strength: Grade C)

Clinicians should directly inspect the ureters during laparotomy in patients with suspected ureteral injury who have not had preoperative imaging. (Clinical Principle)

Surgeons should repair traumatic ureteral lacerations at the time of laparotomy in stable patients. (Recommendation; Evidence Strength: Grade C)

Surgeons may manage ureteral injuries in unstable patients with temporary urinary drainage followed by delayed definitive management. (Clinical Principle)

Surgeons should manage traumatic ureteral contusions at the time of laparotomy with ureteral stenting or resection and primary repair depending on ureteral viability and clinical scenario. (Expert Opinion)

Surgeons should attempt ureteral stent placement in patients with incomplete ureteral injuries diagnosed postoperatively or in a delayed setting. (Recommendation; Evidence Strength: Grade C)

Surgeons should perform percutaneous nephrostomy with delayed repair as needed in patients when stent placement is unsuccessful or not possible. (Recommendation; Evidence Strength: Grade C)

Clinicians should initially manage patients with ureterovaginal fistula using stent placement when possible. In the event of stent failure, clinicians may pursue additional surgical intervention. (Recommendation; Evidence Strength; Grade C)

Surgeons should repair ureteral injuries located proximal to the iliac vessels with primary repair over a ureteral stent, when possible. (Recommendation; Evidence Strength: Grade C)

Surgeons should repair ureteral injuries located distal to the iliac vessels with ureteral reimplantation or primary repair over a ureteral stent, when possible. (Recommendation; Evidence Strength: Grade C)

Surgeons should manage endoscopic ureteral injuries with a ureteral stent and/or percutaneous nephrostomy tube, when possible. (Recommendation; Evidence Strength: Grade C)

Surgeons may manage endoscopic ureteral injuries with open repair when endoscopic or percutaneous procedures are not possible or fail to adequately divert the urine. (Expert Opinion)

Clinicians must perform retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture. (Standard; Evidence Strength: Grade B)

Clinicians should perform retrograde cystography in stable patients with gross hematuria and a mechanism concerning for bladder injury, or in those with pelvic ring fractures and clinical indicators of bladder rupture. (Recommendation; Evidence Strength: Grade C)

Surgeons must perform surgical repair of intraperitoneal bladder rupture in the setting of blunt or penetrating external trauma. (Standard; Evidence Strength: Grade B)

Clinicians should perform catheter drainage as treatment for patients with uncomplicated extraperitoneal bladder injuries. (Recommendation; Evidence Strength: Grade C)

Surgeons should perform surgical repair in patients with complicated extraperitoneal bladder injury. (Recommendation; Evidence Strength: Grade C)

Clinicians should perform urethral catheter drainage without suprapubic (SP) cystostomy in patients following surgical repair of bladder injuries. (Standard; Evidence Strength: Grade B)

Clinicians should perform retrograde urethrography in patients with blood at the urethral meatus after pelvic trauma. (Recommendation; Evidence Strength: Grade C)

Clinicians should establish prompt urinary drainage in patients with pelvic fracture associated urethral injury. (Recommendation; Evidence Strength: Grade C)

Clinicians should perform percutaneous or open suprapubic tube placement as preferred initial management for most PFUI cases. (Recommendation; Evidence Strength: Grade C)

Surgeons may place suprapubic tubes (SPTs) in patients undergoing open reduction internal fixation (ORIF) for pelvic fracture. (Expert Opinion)

Clinicians may perform primary realignment (PR) in hemodynamically stable patients with pelvic fracture associated urethral injury. (Option; Evidence Strength: Grade C) Clinicians should not perform prolonged attempts at endoscopic realignment in patients with pelvic fracture associated urethral injury. (Clinical Principle)

Clinicians should monitor patients for complications (e.g., stricture formation, erectile dysfunction, incontinence) for at least one year following urethral injury. (Recommendation; Evidence Strength: Grade C)

Surgeons should perform prompt surgical repair in patients with uncomplicated penetrating trauma of the anterior urethra. (Expert Opinion)

Clinicians should establish prompt urinary drainage in patients with straddle injury to the anterior urethra. (Recommendation; Evidence Strength: Grade C)

Clinicians must suspect penile fracture when a patient presents with penile ecchymosis, swelling, pain, cracking or snapping sound during intercourse or manipulation and immediate detumescence. (Standard; Evidence Strength: Grade B)

Surgeons should perform prompt surgical exploration and repair in patients with acute signs and symptoms of penile fracture. (Standard; Evidence Strength: Grade B)

Clinicians may perform ultrasound in patients with equivocal signs and symptoms of penile fracture. (Recommendation; Evidence Strength: Grade C)

Clinicians must perform evaluation for concomitant urethral injury in patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria or inability to void. (Standard; Evidence Strength: Grade B)

For blunt scrotal injuries, clinicians should perform scrotal ultrasonography for most patients having physical findings suggestive of testicular rupture. (Recommendation; Evidence Strength: Grade C)

For most penetrating scrotal injuries, clinicians should perform prompt surgical exploration with repair or orchiectomy (when non-salvageable) given the high rate of testicular injury and limited sensitivity of ultrasound in this setting (Recommendation; Evidence Strength: Grade C)

Surgeons should perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvageable) in patients with suspected testicular rupture. (Standard; Evidence Strength: Grade B)

Surgeons should perform exploration and limited debridement of non-viable tissue in patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical). (Standard; Evidence Strength: Grade B)

Surgeons should perform prompt penile replantation in patients with traumatic penile amputation, with the amputated appendage wrapped in saline-soaked gauze, in a plastic bag and placed on ice during transport. (Clinical Principle)

Clinicians should initiate ancillary psychological, interpersonal, and/or reproductive counseling and therapy for patients with genital trauma when loss of sexual, urinary, and/or reproductive function is anticipated. (Expert Opinion)

As the field of genitourinary reconstruction continues to evolve, clinicians must strive to approach clinical problems in a creative, multi-disciplinary, evidence-based manner to ensure optimal outcomes. Further research is needed to clarify which radiographic indicators of renal injuries can be used to facilitate selection of appropriate candidates for angiographic embolization. Complex ureteral defects are increasingly amenable to robotic repair, and further study is needed to clarify the role of classic reconstructive techniques, such as Boari flap, ileal ureter, and downward nephropexy in the robotic era. Evaluation of the existing literature does not demonstrate conclusively whether or when PR of urethral disruption injuries is advantageous over initial SP urinary diversion alone followed by definitive delayed urethroplasty. Similarly, the role of SPT placement remains controversial in pelvic fracture urethral injury patients who are candidates for internal pubic fixation procedures. Genital injuries are rarely life threatening, but they often become the male trauma patient’s chief concern once acute issues are resolved. Plastic surgical principles offer an important guide for optimal genital cosmesis and function. Further study is needed in the areas of tissue engineering, tissue glues, and wound healing biology to optimize outcomes.

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This document was written by the Urotrauma Guidelines Panel of the American Urological Association Education and Research, Inc., which was created in 2013. The Practice Guidelines Committee (PGC) of the AUA selected the committee chair. Panel members were selected by the chair. Membership of the committee included urologists and other clinicians with specific expertise on this disorder. The mission of the committee was to develop recommendations that are analysis-based or consensus-based, depending on Panel processes and available data, for optimal clinical practices in the treatment of urotrauma. Funding of the committee was provided by the AUA. Committee members received no remuneration for their work. Each member of the committee provides an ongoing conflict of interest disclosure to the AUA. While these guidelines do not necessarily establish the standard of care, AUA seeks to recommend and to encourage compliance by practitioners with current best practices related to the condition being treated. As medical knowledge expands and technology advances, the guidelines will change. Today these evidence-based guidelines statements represent not absolute mandates but provisional proposals for treatment under the specific conditions described in each document. For all these reasons, the guidelines do not pre-empt physician judgment in individual cases. Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences. Conformance with any clinical guideline does not guarantee a successful outcome. The guideline text may include information or recommendations about certain drug uses ('off label') that are not approved by the Food and Drug Administration (FDA), or about medications or substances not subject to the FDA approval process. AUA urges strict compliance with all government regulations and protocols for prescription and use of these substances. The physician is encouraged to carefully follow all available prescribing information about indications, contraindications, precautions and warnings. These guidelines and best practice statements are not in-tended to provide legal advice about use and misuse of these substances. Although guidelines are intended to encourage best practices and potentially encompass available technologies with sufficient data as of close of the literature review, they are necessarily time-limited. Guidelines cannot include evaluation of all data on emerging technologies or management, including those that are FDA-approved, which may immediately come to represent accepted clinical practices. For this reason, the AUA does not regard technologies or management which are too new to be addressed by this guideline as necessarily experimental or investigational.