This document was updated in January 2026 to reflect changes in literature since it was originally released for publication in August 2017 and amended in November 2022.  This document will continue to be periodically updated to reflect the growing body of literature related to this topic.

Key Words: Obstructive uropathy, priapism, Fournier’s gangrene, paraphimosis, trauma, testicular torsion

Learning Objectives

At the end of medical school, the medical student will be able to:

1. Describe the most frequent conditions that are considered urologic emergencies requiring immediate recognition and management
2. Distinguish, through patient history and physical examination, the key features of urinary obstruction, obstructive pyelonephritis, gross hematuria with clot retention, priapism, penile fracture, Fournier’s gangrene, and paraphimosis
3. Order appropriate imaging studies and lab tests to help evaluate the patient presenting with a urologic emergency
4. Formulate a treatment plan for the most common urologic emergencies

Introduction

Emergencies are medical conditions requiring prompt treatment to minimize the likelihood of loss of organ structure or function, and in rare cases, of the patient’s life. Although urologic emergencies are rare, it is incumbent on providers to recognize the often-subtle clinical presentations of these conditions. After completing this module, students should be confident in their ability to diagnose and formulate a treatment plan for the most common urologic emergency conditions.

Lower Urinary Tract Obstruction

Acute urinary retention (AUR), or the involuntary inability to pass urine from the bladder, is the most common reason for emergent urologic care, ¹ with 10% of men aged 70-79 and 30% of men aged 80-89 having at least one episode. ² AUR (the passage of no minimal amounts of urine) may result from blockage of urine outflow or from inability of the bladder to contract. Lower urinary tract outflow obstruction may be secondary to blockage of the bladder neck, urethra, or urethral meatus, from strictures (scar tissue), stones, tumors, blood clots, prostate enlargement, local edema, or phimosis. Additionally, women may experience bladder outlet obstruction from significant pelvic organ prolapse, an obstructing urethral diverticulum, or failure of the pelvic floor or external sphincter to relax.^{2, 3} Abnormalities in bladder contractility can arise from medications or neurologic conditions. For example, anticholinergic drugs may decrease bladder contractility, while sympathomimetic drugs may prevent sufficient relaxation of the bladder neck. Additionally, patients may experience acute urinary retention after surgery, which is often due at least in part to anesthesia (general or regional, including epidural), drugs (including narcotic pain medications), constipation, and decreased mobility. ⁴

Patients with significant urinary retention often have discomfort and may have a palpable bladder (Figure 1).  Imaging, including bedside ultrasound, can also confirm the presence of a large volume of urine in the bladder.  Initial treatment of AUR consists of decompression of the bladder, typically with the placement of a urethral catheter.If a catheter cannot be placed to decompress the bladder, a short-term intervention includes needle decompression of the bladder to empty some of the retained urine. This allows additional time to prepare for interventions (example: procedures in the operating room) without imminent threat of bladder rupture. Additionally, a suprapubic tube can be placed percutaneously under local analgesia. 

Any patient with complete urinary obstruction should be monitored after bladder decompression for the development of postobstructive diuresis.  Postobstructive diuresis is diagnosed when the urine output exceeds 200 cc/hour for two consecutive hours, or more than three liters in 24 hours.⁵ While the incidence of postobstructive diuresis is widely variable, ⁶ a high index of suspicion for its development must be maintained in the first 24 hours after decompression, as solute loss accompanying the diuresis may be associated with severe electrolyte derangements as well as hypovolemia.

Gross Hematuria with Clot Retention

Gross hematuria is the presence of visible blood in the urine and may occur from renal or urologic pathology.  True hematuria (the presence of red blood cells in the urine) should be distinguished from other causes of reddish urine, including myoglobinuria, hemoglobinuria, and drugs (e.g. rifampin) or dietary causes (e.g. beets).  In children, renal causes of hematuria predominate.⁷ While true gross hematuria necessitates a prompt evaluation, clot retention, or the inability to urinate owing to the volume of blood clot in the bladder, is a urologic emergency.

Urinary clots develop when the amount of blood in the bladder exceeds the ability of the urinary urokinase to prevent clot formation. Retention of urine associated with blood clots in the urine can occur when the clots physically block the urethra or bladder neck (see Figure 2). Thus, treatment of clot retention has two goals: to relieve the outflow blockage and to prevent new clot formation. ^{8, 9} In patients who are unable to void because of clots, placement of a large urethral catheter (usually at least 22 Fr, and often larger), and irrigation with 0.9% normal saline via a catheter-tipped syringe is often sufficient to remove the intravesical clots and re-establish spontaneous bladder drainage. Hematuria catheters, which have large drainage holes at the tip of the catheter and which are often reinforced so as not to collapse with withdrawal of fluid, are helpful when irrigating. If a three-way catheter is used, it is important to remember that the lumen of the drainage port is smaller than in a two-way catheter of similar external (French) size. Patients in whom clots cannot be cleared using hand irrigation may require cystoscopy and clot evacuation in the operative setting,=. In the OR, intravesical clots can be removed with assistance of various tools include Ellik evacuators, resectoscopes, and other endoscopic tools. Additionally, actively hemorrhaging sites can be fulgurated. Once the urine has been successfully cleared of clots, continuous bladder irrigation (CBI) with 0.9% normal saline through a three-way catheter is typically used to prevent further clotting in the immediate postprocedure period. The irrigation rate is titrated to the minimal amount needed to achieve clear or very light pink urine. CBI should always be performed with the irrigant infused via gravity (never on a pump), to minimize the risk of bladder perforation. Patients with clot retention should be evaluated and treated for underlying causes of bleeding (e.g. bladder cancer, coagulopathy).

Figure 2: Bladder distension due to clot retention; the heterogeneous nature of the intravesical fluid reflects mixing of clot and urine.

Ureteral Obstruction

Ureteral obstruction, in which the antegrade flow of urine from the kidney to the bladder is blocked, can occur in either or both kidneys.  Urgent or emergent intervention is needed when obstruction affects all renal units, , there is evidence of infection, or in the presence of acute worsening of renal function.  It is important to emergently intervene if a patient has a solitary kidney or a functionally solitary kidney.  Causes of ureteral obstruction may be intrinsic (including stones, ureteropelvic junction obstruction, ureteral polyps or tumors, blood clots, or ureteroceles), or extrinsic (including crossing blood vessels or external masses such as tumors, retroperitoneal fibrosis).  Stones (Figure 3) are the most common cause of ureteral obstruction, with an 11% lifetime risk of nephrolithiasis, and can be diagnosed using ultrasound or CT scans.¹⁰ Figure 4 shows an obstructing ureterocele..

Figure 3: Left ureteral stone with associated collecting system dilatation.

Figure 4: An obstructing ureterocele containing purulent urine.

In patients in whom adequate pain control can be achieved, in whom there is no evidence of immunosuppression (e.g. diabetes, pregnancy, immunosuppressive medications such as chemotherapy or antirejection medications) or infection (e.g. fever, urinalysis suggestive of infection), and in whom serum creatinine is not significantly elevated from baseline, non-urgent management based on the underlying etiology of the obstruction may be considered.^11,12  In patients with obstruction of both kidneys or of a solitary functioning kidney, or in whom there is worsening of renal function from baseline, urgent endoscopic drainage with a ureteral stent or percutaneous drainage with a nephrostomy tube should be considered.  Patients with fevers or significant pain that cannot be controlled with oral medications should undergo drainage as well. While both endoscopic (stent) and percutaneous (nephrostomy tube usually placed by Interventional Radiology) approaches may be considered in these cases, patients with sepsis associated with ureteral obstruction may benefit from percutaneous rather than endoscopic drainage.  Culture of the urine proximal to the source of obstruction should be performed once drainage has been achieved, and the patient’s antibiotic regimen should be tailored to the culture and sensitivity results. In pregnant patients, ultrasound guidance may be preferred over fluoroscopy  to define anatomy during drainage procedures. fetal monitoring should be employed intra- and perioperatively.¹³

In general, definitive treatment of ureteral obstruction should not be undertaken concurrently with urgent or emergent upper tract decompression. This is especially true when the patient has evidence of infection.  Endoscopic management of intraluminal causes such as stones and polyps can often be scheduled on an outpatient basis, while extrinsic causes such as abdominal masses should typically prompt more urgent evaluation once decompression has even achieved.

Priapism

The American Urologic Association has published a Guideline on the Management of Priapism:Acute Ischemic Priapism: an AUA/SMSNA Guideline - American Urological Association (auanet.org), ¹⁴ which contrasts the pathophysiology and management of ischemic and nonischemic priapism.  Priapism is defined as a persistent (four or more hours) penile erection in the absence of or persisting beyond sexual stimulation. The incidence of priapism is low; one study reported 1.5 cases per 100,000 men per year with the incidence in men aged 40 and older being 2.9 cases per 100,000 men per year.¹⁵  However, more recent research suggests that the incidence of this condition is higher (5.34 cases per 100,000 men annually),¹⁶ particularly in men with sickle cell anemia or trait.¹⁷  Almost three-quarters of patients with sickle cell anemia may have at least one episode of priapism.¹⁸  Patients may seek care for priapism more frequently in the summer than in the winter.¹⁶

Priapism can occur as ischemic priapism (most common presentation), nonischemic priapism, and stuttering priapism. The precise etiology of ischemic priapism is often unknown or multifactorial, but generally results in the inflow of blood to the corpus cavernosum exceeding the outflow.  Obstruction to outflow of cavernosal blood can occur when the cavernosal smooth muscle fails to relax or when there is physical blockage of the venous drainage (e.g. sickle cell anemia, pelvic mass).  Ischemic priapism develops when the increased intracavernosal pressure generated by impaired drainage results in an effective penile compartment system, causing damage to local tissues and decreasing arterial inflow.  The resulting hypoxia and acidosis can further damage the tissue.  Non-ischemic priapism typically results when the arterial inflow exceeds the venous outflow; because arterial blood is being supplied to the tissues and there is some venous drainage, there is little risk of tissue death.

Clinical Presentation

The classic presentation of ischemic priapism is as a “rock hard” erection that is painful.  On examination, the corpora cavernosa are erect while the glans and corpus spongiosum are spared.  The most common causes are sickle cell disease, malignancy (leukemia/lymphoma, primary or metastatic penile cancer, or pelvic mass), and drugs (most commonly agents used to treat erectile dysfunction, such as PDE-5 inhibitors and intracavernosal injections, but also including trazodone, cocaine, alpha blockers and total parenteral nutrition).^19,20  Some products purchased over the counter that are marketed for sexual health can contain ingredients that can lead to priapism, thus it is important to specifically ask about “supplements” or over the counter products that have been consumed.

The table below, from the AUA Guidelines, lists some of the medications associated with priapism.

Unlike ischemic priapism, nonischemic priapism is not a surgical emergency. It is often the result of a trauma, in many cases a straddle injury which then results in an arteriovenous fistula.

Diagnosis

The prompt diagnosis and initiation of definitive treatment is paramount to minimizing the risk of permanent tissue damage and erectile dysfunction: 50% patients with resolution of the priapism within 24 hours will retain erectile function, compared with almost none of patients after 36 hours.²¹ A thorough history and physical examination is critical. A history of trauma should prompt consideration for a non-ischemic aneurysm. The diagnosis can be confirmed with a penile blood gas, which often shows signs of abnormal tissue perfusion (pO2<30, pCO₂>60, pH<7.25).^22,23  The Table below, from the AUA Core Curriculum outlines the findings on blood gas in the setting of ischemic and non-ischemic priapism. (https://university.auanet.org/core/consults-emergencies/consults-and-emergencies-priapism/index.cfm?&AUAID=00720185) Doppler ultrasonography will demonstrate poor intracavernosal arterial inflow, and is useful for confirming successful treatment.^24,25  However, delaying treatment in favor of imaging should be approached with caution since erectile function is closely tied to duration of priapism. A complete blood count can be performed to evaluate for hematologic or malignant disease, with hemoglobin electrophoresis considered in patients at risk for sickle cell disease.

Management

Treatment of ischemic priapism centers on removing the blood from the corpora in order to allow arterial inflow. Patient counseling is critical, as both the priapism itself as well as the treatment of priapism can impact erectile function. Historically, a number of conservative options have been offered to patients, including masturbation, use of pseudoephedrine, warm baths or compresses, but there is little data to support the efficacy of these treatments, and their use should not delay standard of care interventions for ischemic priapism.

Initial treatment includes aspiration and irrigation of the corpora with normal saline; this is most successful early in the priapism episode, often before most patients have presented for medical care. Irrigation will help evacuate clotted blood that is contributing to the pathophysiology of the priapism.  Intracorporal injection of 1 cc of 1 mg/1mL phenylephrine, diluted in 19 cc of 0.9% normal saline (20 cc total) can be performed every three to five minutes until detumescence is achieved.  Vital signs (heart rate and blood pressure) should be monitored during sympathomimetic injection. Administration of alpha agonists can lead to hypertension and reflex bradycardia. 

If injection is unsuccessful, surgical intervention is necessary.  Distal shunts (Ebbehoj, Winter, and Al-Ghorab) involve creation of a communication between the distal corpora cavernosa and the corpus spongiosum of the glans, while proximal shunts (Quackels or Sacher and Grayhack or Barry) involve drainage of the proximal corporal cavernosa into the corpus spongiosum or veins (saphenous or deep dorsal) vein, respectively.²⁶  Scalpel based shunts are recommended over needle shunts due to efficacy. If a distal shunt fails, the AUA Guidelines recommend corporal tunneling, which is use of dilators to evacuate the clotted blood proximally towards the crus. Historically, if a distal shunt fails, Urologists often consider a proximal shunt. However, more recent data and experience suggests that proximal shunts are rarely indicated and effective, and tunneling in the setting of failed distal shunts is now advised. In patients who present with untreated ischemic priapism, and in those who have failed distal shunting with or without tunneling, placement of a penile prosthesis can be considered. There are a number of nuanced factors to take into consideration when counseling the patient on this option.

Although the immediate care of a patient with ischemic priapism centers on the return of blood flow to the penis, comprehensive evaluation of the patient to identify contributing factors should be performed.  In addition to bloodwork, imaging of the pelvis may be appropriate if a local malignancy is suspected.  Patients with drug-related priapism may benefit from discontinuation of that drug when feasible.

In contrast to ischemia priapism, non-ischemic (or “high-flow”) priapism typically develops in the setting of a local vascular malformation or after surgical or accidental trauma, although malignancies have also been reported.²⁷ Because blood flow to the corpora is preserved, nonischemic priapism is not an emergency and may resolve independently (in 60% of cases).²⁸ Patients with nonischemic priapism have a persistent, partial, and painless erection.  Penile blood gases in patients with nonischemic priapism show high oxygen levels and no acidosis (pO₂>90, pCO₂<40, pH ~7.40).²⁸ Doppler ultrasonography may show arteriosinusoidal flow.²⁹ In patients with persistent nonischemic priapism, selective embolization is often successful.^{30, 31}

Key Points

• Priapism is most often ischemic and can be caused by a number of factors. In some cases it is idiopathic.
• The duration of priapism is directly related to subsequent erectile dysfunction and thus urgent intervention is warranted
• The evaluation includes a thorough history and physical, and careful investigation into any medications and supplements the patient may be taking
• Treatment is initiated with corporal irrigation with saline, followed by injection of phenylephrine. If this fails, a distal shunt with or without tunneling can be performed. Proximal shunts are performed infrequently and are not standard of care.
• Refractory cases of priapism can be considered for placement of penile prosthesis

Fournier's Gangrene

Fournier’s gangrene is a life threatening, necrotizing infection of the soft tissue of the perineum. Fournier’s gangrene is uncommon, with a prevalence of 1.6 per 100,000 men per year, ³⁶ and less common in women (23% of patients in one series), ³⁷ usually aged 50 and older. While men and women are similar demographically with regard to age and comorbidities, with the exception of obesity (women tend to have a BMI that is, on average, ten points higher than that of men), ^37,38 although women may fare worse clinically. ³⁹ Risk factors include diabetes mellitus, obesity, immunosuppression (e.g. HIV infection), malignancy, alcoholism, smoking, and renal failure. ⁴⁰ The infection is typically polymicrobial, with mixed aerobic and anaerobic bacteria ( E. coli, Klebsiella, enterococci, Bacteroides, Fusobacterium, Clostridium) and rarely fungi. ^41,42

In the early stages, necrotizing soft tissue infections may appear unimpressive, but as the bacterial infection spreads along fascial planes with accompanying vascular thrombosis, the patient’s condition can deteriorate quickly (Figure 5).

Clinical Presentation

The classic presentation of a necrotizing soft tissue infection is of a patient presenting with pain out of proportion to the accompanying physical findings. Depending on the progression of the disease at the time of evaluation, patients may have a spectrum of local findings or may have apparent systemic disease. Early on, patients may simply have exquisite tenderness without other outward findings; later in the disease there may be changes in the skin and soft tissue overlying the infection (e.g. edema, bullae, blisters, crepitus, and local anesthesia). Severely ill patients may have abnormal vital signs such as tachycardia, tachypnea, hypotension, and hyper- or hypothermia, in some cases presenting in florid septic shock. ⁴³ Clinicians must maintain a high index of suspicion for the disease in order to make a prompt diagnosis in the early stages, as case fatality rate is approximately 6-7%. ^36,37

Figure 5: Fournier’s gangrene of the scrotum. Note necrotic, black patch of scrotal skin with large ulceration. (From: Aho T et al. (2006) Fournier's gangrene Nat Clin Pract Urol 3: 54–57)

Diagnosis

Diagnosis is often based on clinical examination as noted above. In addition, it can be helpful to obtain cross sectional imaging, which can demonstrate fluid or air in the tissues (Figure 6). The extent of involvement is not always clear on imaging, but can lead the surgeon to pursue surgical debridement of areas that may not have been evident on examination. In addition, imaging can suggest involvement of other nearby organs that necessitate and multi-disciplinary operative approach (example: perirectal involvement with combined surgical approach with General Surgery or Colorectal Surgery).

Laboratory studies as noted above can augment the diagnostic algorithm, but physical examination is the mainstay of diagnosis.

Management

Immediate treatment consists of aggressive surgical debridement, combined with broad-spectrum intravenous antibiotics. Because the extent of tissue involvement is often not apparent at initial debridement, patients should undergo “second look” procedures, with additional debridement if necessary. Coordination with general surgery colleagues is critical as perirectal tissue can be involved and in some cases, may be the source of the infection. Excision of affected tissue is a necessary component of treatment; treatment with antibiotics alone typically has a 100% mortality. After surviving the initial infection, many patients will need multiple reconstructive procedures. Wound management techniques include wound wet to dry dressings, wound vac devices, and in very select cases, primary closure of the wound. Treatment with hyperbaric oxygen may preserve healthy tissue and reduce the amount of debridement necessary. ⁴⁴

Key Points

• Fournier’s gangrene presents as a rapidly progressive necrotizing infection of genital and perineal tissue.
• Multi-disciplinary care, early surgical debridement, broad spectrum antibiotics, and often multiple operative evaluations is mainstay of treatment

Figure 6: Air seen on sagittal CT imaging in a patient with Fournier’s gangrene and a suprapubic tube, as indicated by the orange arrow.

Paraphimosis

Paraphimosis occurs when the foreskin becomes trapped behind the penile corona. Figure 6. Subsequent obstruction to venous and lymphatic outflow results in increasing preputial and glanular edema; in extreme cases, the increased pressure generated by the edema and the venous congestion will decrease arterial inflow, resulting in ischemia and tissue death.⁴⁵

Paraphimosis occurs when the foreskin is pulled back behind the glans, but is not replaced in anatomic position. ⁴⁶ Failure to replace the foreskin after cleaning the penis, after voiding, or after other manipulation of the prepuce may result in paraphimosis. Importantly, paraphimosis can be iatrogenic, occurring when the foreskin is manipulated in a medical setting but not reduced to the anatomic position. Contributing factors include pre-existing phimosis and abnormal skin quality (e.g. inflammation, decreased elasticity). ⁴⁷ 

Clinical Presentation

Patients typically present with pain, preputial and glanular edema, and an apparent transition point just proximal to the edema; patients who are obtunded or otherwise unable to describe pain may have solely physical findings. In some cases, it can be challenging to determine whether a patient has balanitis or penile edema from other causes (total body fluid edema/anasarca) – asking the patient whether they are circumcised often helps with the diagnosis, if patients are able to provide this information. Patients with urethral compression may be unable to void normally. Tissue constriction from external materials (e.g. hair) should be excluded, as similar presentations can occur with externally applied materials. ^{48, 49}

Management

The initial treatment of paraphimosis is to relieve the obstruction.  Initial efforts should center on reduction of the foreskin.  (Figure 7) After placement of a penile block, decompression of the distal glanular edema, followed by firmly pulling (not pushing) the foreskin over the glans, is typically successful (Figure 8).  In some cases, the edema is so substantial that compression for several minutes with gentle compression using gauze is necessary.  Placement of water-based lubricant on the glans often facilitates reduction.^50-52 If this is not successful, emergent dorsal slit (incision of the dorsal foreskin) should be performed, and the foreskin then reduced.  Patients with a history of paraphimosis should be counseled on operative intervention with a formal dorsal slit or circumcision to prevent future occurrences. Some patients with phimosis that led to paraphimosis can also be managed with steroid topical cream.

Figure 6: Paraphimosis, notice the tight ring behind the coronal margin.

Figure 7: Reduction of the paraphimosis, with a rolling action of the tight foreskin over the glans penis. Often, there is edema associated with the foreskin that requires compression to reduce the edema to permit the foreskin to slide over the glans penis.

Key Points

• Paraphimosis occurs when the foreskin in an uncircumcised patient is not returned over the glans and forms a tight, constricting ring
• Reduction of paraphimosis is the primary treatment, and if unsuccessful, a dorsal slit may be necessary

Testicular Torsion

See Testicular Torsion sub-section within “Acute Scrotum” on the AUA Medical Student Curriculum page: http://www.auanet.org/education/educational-programs/medical-student-education/medical-student-curriculum/acute-scrotum

Penile Trauma

Penile trauma is addressed in detail in the AUA Guidelines “Urotrauma” revised in 2020, Urotrauma Guideline - American Urological Association (auanet.org).

Penile fractures occur when application of force to the erect penis results in rupture of the tunica albuginea, often during sexual activity.  It is considered a surgical urgency.

Clinical Presentation

The diagnosis of a penile fracture is suggested by a “popping” sound or sensation, accompanied by development of pain and spontaneous detumescence accompanied by significant penile bruising.  Some patients may have blood at the meatus, which should raise suspicion for a coexisting urethral injury.  Penetrating trauma to the penis is uncommon but can occur from the same mechanisms that cause injury to the bladder. Penile amputation presents as either a partial or complete transection.

Finally, penile trauma can occur from erosion of a malleable or inflatable penile prosthesis. The patient may present with extrusion of a cylinder from the urethra or can present simply with tender and signs and symptoms of infection associated with components of the device.

Diagnosis

The diagnosis of penile fracture is primarily clinical, although the use of MRI and ultrasound have been reported, and retrograde urethrogram should be considered in patients with potential urethral injury.  False negative (plaque rupture) or delayed penile fractures have been reported in patients after collagenase injection for penile plaques.^{32, 33}

The diagnosis of a penile penetrating injury or amputation is clearly evident on examination. In the setting of penetrating trauma from a gun shot wound, the clinician should suspect damage to nearby structures – injury to the urethra is discussed separately.

Management

Immediate repair of penile fractures is associated with a lower incidence of complications, including erectile dysfunction and development of chordee. ³⁴ A circumcising incision and complete penile degloving is recommended in order to facilitate visual inspection of the entire penis for multiple injuries (Figure 9). Alternatively, a penoscrotal incision can sometimes provide exposure in the setting of an uncircumcised phallus with phimosis.

Primary repair with debridement of vascularized tissue can be performed. In cases of penile amputation, the phallus (if recovered) can be reimplanted. The severed penis should be placed in a bag inside a bag of ice. After debridement of devascularized tissue, corpora cavernosal, and urethral continuity is re-established, and the dorsal arteries, vein, and nerve are re-anastomosed. ³⁵

Urethral injury should be considered in all patients with penile trauma, and consideration should be given to suprapubic urinary diversion to minimize tension on surgical repairs.

In the setting of a traumatic penile amputation, prompt reattachment is indicated, ideally by a surgeon with microsurgical expertise. The amputated tissue should be transported with the patient in saline soaked gauze in a bag of ice but should never be placed directly on ice.

Patients presenting with either extrusion or infection of components of either malleable or inflatable penile prostheses should be taken to the operating room expeditiously for explant of the device. Progressive infection leading to a Fournier’s gangrene can result if infected components are not explanted soon after presentation.

Key Points

• One of the most common penile injuries is a penile fracture, which occurs when the tunica albuginea ruptures
• Prompt repair of a fracture is indicated to optimized long-term outcomes
• In the setting of a penile amputation, microsurgical repair is preferred if possible

Figure 9: Intraoperative photograph of a penile fracture with concurrent urethral injury. This was repaired via a penoscrotal incision.

Bladder Rupture

Bladder rupture occurs when urine leaks from the bladder into surrounding tissues, most often following trauma or iatrogenic injury. Bladder ruptures are divided into extraperitoneal and intraperitoneal types. Extraperitoneal rupture is usually associated with pelvic fractures and blunt trauma. Intraperitoneal rupture often results from a direct trauma to a distended bladder with the rupture occurring at the bladder dome. Iatrogenic injuries occur during cryptoscopic procedures, aggressive catheterizations, and pelvic surgeries.

Clinical Presentation

Patients with bladder rupture present with gross hematuria, abdominal pain, and an inability to void. In trauma patients, the presence of gross hematuria in combination with a pelvic fracture should raise immediate concern for bladder injury. Other findings can include abdominal distension or bruising due to urine extravasation into surrounding tissues. If the injury occurred during a cystoscopic procedure the patient might present with large volume ascites from the procedure irrigating fluid.

Diagnosis

The diagnostic study of choice is retrograde cystogram, performed either with fluoroscopy or CT imaging. The bladder must be filled retrograde with contrast (typically 300 mL in adults) to localize the location of the rupture. Imaging before and during filling and following drainage provides the most definitive assessment. Intraperitoneal rupture (Figure 10) appears as contrast outlining bowel loops, whereas extraperitoneal rupture shows contrast confined to the perivesical space.

Management

Intraperitoneal ruptures often require surgical repair, typically performed with a two-layer watertight closure. A catheter is left in place afterwards to decompress the bladder while the repair heals. In contrast, extraperitoneal ruptures are generally managed nonoperatively with continuous bladder drainage for two to three weeks. If, however, there are other factors that might prevent healing or lead to other complications, surgical repair might be indicated. This includes bone fragments in the bladder from trauma, bladder neck involvement, or concomitant rectal or vaginal injury. A follow-up cystogram should be obtained prior to catheter removal to ensure healing for both intra- and extraperitoneal ruptures.

Key Points

• Bladder rupture should always be considered in any trauma patient with gross hematuria, especially those with pelvic fractures.
• CT cystogram is the gold standard for diagnosis.
• Management depends on rupture type:
  • Intraperitoneal injuries → require surgical repair.
  • Extraperitoneal injuries → typically heal with catheter drainage alone.

Figure 8: Drainage film after a cystogram shows contrast after draining the bladder, confirming bladder rupture obscured during the filling phase. The outline bowel loops indicates an intraperitoneal bladder rupture.

Ureteral Trauma

Urethral trauma is an uncommon injury that can result in long-term complications if not promptly recognized and managed. Injuries are classified in the male patient as anterior (involving the penile or bulbar urethra) or posterior (at or proximal to the membranous urethra). The causes and management of these two types of injuries vary.

Mechanisms of Injury

Posterior urethral injuries almost always occur in the setting of pelvic fractures and are caused by shearing forces that disrupt the membranous urethra. Anterior urethral injuries are more often due to straddle injuries, blunt perineal trauma, or penetrating injuries. Iatrogenic urethral injury can also occur during traumatic catheterizations or instrumentation during a cystoscopic procedure.

Clinical Presentation

The classic signs of urethral injury are blood at the urethral meatus, inability to void, and a palpably distended bladder. Additional findings may include perineal bruising, scrotal or labial swelling, or a “high-riding” prostate on rectal examination. However, these findings are not always present. A urethral injury should always be ruled out in a patient with a pelvic fracture and blood at their urethral meatus.

Diagnosis

If a urethral injury is suspected, retrograde urethrogram (RUG) is the diagnostic. Contrast is instilled into the urethral meatus, and images are obtained to evaluate for contrast extravasation. The urethra should be placed on stretch during this study with contrast instilled just at the meatus and not via a catheter so that the contrast fills the urethra. A complete disruption is indicated by contrast leaking from the urethra without entering the bladder, while partial tears show partial filling of the bladder. Importantly, a catheter should not be placed before imaging, as blind catheterization can worsen the injury. In patients who already have a Foley catheter, a pericatheter RUG can be performed if there is concern for injury.

Management

Initial management focuses on urinary drainage after stabilizing patients hemodynamically. For posterior urethral injuries, primary surgical repair is avoided acutely, as it carries a high risk of incontinence and erectile dysfunction. Instead, suprapubic catheter drainage is established, followed by delayed urethral reconstruction once the patient has recovered. In select cases, endoscopic realignment can be attempted to align the urethral ends and potentially reduce later stricture formation. This is done with cystoscopy to directly visualize the true lumen to the bladder. Anterior urethral injuries, particularly penetrating ones, are typically managed with prompt surgical exploration, debridement of devitalized tissue, and primary repair over a catheter whenever a tension-free closure is possible.

Key Points

• Always suspect urethral injury in pelvic fractures or when blood is present at the meatus.
• Do not insert a Foley catheter until the urethra is evaluated by retrograde urethrogram.
• Posterior injuries: suprapubic drainage and delayed repair.
• Anterior injuries: primary repair if feasible.

Renal Trauma

Renal trauma is the most common genitourinary injury following blunt abdominal trauma and occurs in up to 10% of patients with abdominal or pelvic injury. It can result from motor vehicle accidents, falls, sports injuries, or penetrating trauma such as gunshot or stab wounds.

Mechanisms and Classification

Blunt trauma typically causes renal contusion, hematoma, or laceration, while penetrating trauma is more likely to result in deep parenchymal injury or vascular disruption. The American Association for the Surgery of Trauma (AAST) grading system (Grades I–V) is used to describe injury severity, ranging from minor contusions to complete devascularization or “shattered” kidney (Table XX)

Clinical Presentation

Most patients present with flank pain or tenderness on exam and hematuria. Gross hematuria strongly suggests significant renal injury, although it may be absent even with major vascular injury. Associated findings can include flank ecchymosis, abdominal distension, or signs of hemodynamic shock. Renal trauma often occurs in the context of multi-organ injury.

Diagnosis

The diagnostic test of choice is CT imaging with intravenous contrast, ideally including delayed (excretory) phase images to evaluate for collecting system injury or urinary extravasation. Imaging is indicated for patients with gross hematuria, microscopic hematuria and hypotension, or a mechanism of injury suggestive of renal involvement. These include rapid deceleration, flank impact, or penetrating trauma.

Management

Most renal injuries—especially low-grade (AAST I–III)—are managed nonoperatively with bed rest, serial hemoglobin checks, and close monitoring. Angioembolization may be used for ongoing bleeding from segmental renal vessels in hemodynamically stable patients. Surgical exploration is reserved for patients who remain hemodynamically unstable despite resuscitation, or when there is renal pedicle avulsion or a shattered kidney.
Urinary extravasation without major collecting system disruption can often be observed; however, ureteral stenting or nephrostomy may be required if urine leak persists or symptoms develop (Figure 11). If ureteral stenting is performed, often patients require indwelling bladder catheterization to optimize upper tract decompression. Kidney-sparing approaches are preferred whenever possible.

Key Points

• CT with IV contrast and delayed imaging is essential for diagnosis.
• Nonoperative management is perform in most hemodynamically stable patients.
• Angioembolization can control bleeding in stable patients.
• Surgical repair or nephrectomy is reserved for unstable patients or major vascular injury.

Collecting system injuries are managed with upper tract decompression.

Figure 9: Large urinoma accompanying Grade 4 renal injury.

Ureteral Trauma

Ureteral trauma is uncommon and can result from external injury (such as penetrating trauma) or more often from iatrogenic causes during pelvic, vascular, or urologic surgery. Because the ureters are small, mobile, and protected within the retroperitoneum, isolated ureteral injury is rare; however, prompt recognition can prevent infection, urinoma, and renal functional decline.

Mechanisms of Injury

Penetrating traumas such as gunshot or stab wounds are the most frequent external cause, while blunt trauma can lead to ureteral avulsion, particularly near the ureteropelvic junction. Iatrogenic injuries are more common and may occur during gynecologic procedures, colorectal surgery, or retroperitoneal operations where the ureter is inadvertently transected, ligated, or devascularized. These are often difficult surgeries or those with significant blood loss which obscured ureteral visualization.

Clinical Presentation

Patients may present with flank pain, fever, ileus, or persistent urine leakage after surgery. The latter might present as increase surgical drain outputs. Hematuria is not always present, and its absence does not rule out injury. Suspicions should be high when the surgical field involves the ureter.

Diagnosis

CT urogram with delayed images is the preferred diagnostic test, as it can show urinary extravasation, hydronephrosis, or absence of distal ureteral opacification. Intraoperatively, if injury is suspected, intravenous dye (e.g., indigo carmine or methylene blue) and direct visualization may help identify the site of leakage. Prompt recognition during surgery allows for immediate repair and improved outcomes.

Management

Management depends on the location and extent of injury as well as the patient’s stability. Partial injuries may be treated with ureteral stent placement to allow internal drainage and healing. Retrograde pyelogram at the time of stenting can confirm the location of the injury (Figure 12). If the ureter is exposed during surgery when the injury is identified, oversewing the injury might be appropriate for small injuries.  Complete transections require surgical repair, ensuring a tension-free, well-vascularized anastomosis over a stent. Distal injuries are repaired by ureteroneocystostomy, sometimes with a psoas hitch or Boari flap if additional length is needed. Midureteral injuries may be treated with ureteroureterostomy. Proximal injuries may require transureteroureterostomy, ileal ureter substitution, or autotransplantation in complex cases. If immediate repair is not feasible, temporary urinary diversion with a nephrostomy tube should be performed, followed by delayed reconstructive surgery once inflammation subsides.

Figure 12: Retrograde pyelogram demonstrating contrast extravasation from iatrogenic ureteral injury.

Key Points

• Most ureteral injuries are iatrogenic
• CT urogram with delayed images is the best diagnostic test.
• Partial injuries can often be managed with ureteral stenting.
• Complete injuries require surgical repair, tailored to the injury site and length.

Scrotal and Testicular Trauma

Scrotal and testicular injuries are uncommon but are important urologic emergencies, as delayed diagnosis can lead to testicular loss and subsequent long-term impairment of fertility and hormone production. Trauma may be blunt (e.g., from sports, assault, or motor vehicle accidents) or penetrating (e.g., stab or gunshot wounds).

Mechanisms of Injury

Blunt trauma is far more common and typically results from a direct impact to the scrotum, such as from a kick, fall, or high-velocity ball strike. The tunica albuginea, a tough fibrous capsule surrounding the testis, normally protects against rupture, but a sudden compressive force can exceed its strength and cause a tear. Penetrating trauma may cause complex injuries involving the testis and cord structures such as the epididymis, and spermatic cord.

Clinical Presentation

Patients often present with acute scrotal pain, swelling, and ecchymosis. On examination, the scrotum may be enlarged and tender, sometimes making it difficult to distinguish individual structures (Figure 13). Hematocele (blood within the tunica vaginalis) and testicular rupture should be suspected if there is significant swelling, bruising, or loss of normal testicular contour. Because pain and swelling can obscure findings, imaging is essential for diagnosis. In the setting of poly trauma, scrotal trauma may be missed due other, higher priority injuries if missed on initial full body exams.

Diagnosis

Scrotal ultrasound with color Doppler is the imaging modality of choice. It can differentiate between simple hematoma and rupture of the tunica albuginea and can assess testicular perfusion. Findings concerning for rupture include discontinuity of the tunica, heterogeneous echotexture of the testis, and loss of normal blood flow. Penetrating injuries are often directly explored due to the high likelihood of significant damage.

Management

The management of scrotal trauma depends on the severity of injury. Minor contusions or hematomas without rupture can be treated conservatively with ice, scrotal elevation, and analgesia. Testicular rupture is a surgical emergency requiring prompt exploration, evacuation of hematoma, debridement of devitalized tissue, and closure of the tunica albuginea to preserve testicular function. If the testis is nonviable, orchiectomy is performed. This is often judged by the degree of the disruption of the tunica or time since the injury occurred. Longer durations between tunica rupture and intervention leads to lower rates of testicular salvage due to compromised perfusion and seminiferous tubule ischemia. Penetrating injuries are typically managed surgically to assess the extent of damage and prevent infection or necrosis.

Key Points

• Always perform scrotal ultrasound in patients with significant swelling or pain after trauma.
• Testicular rupture requires urgent surgical repair to maximize salvage.
• Early intervention preserves hormonal and reproductive function if the testicle can be salvaged.
• Even with severe trauma, testis-sparing repair should be attempted whenever feasible.

Figure 10: Perineal and scrotal ecchymosis accompanying testicular injury.

Table 1. Grading of Renal Injury

Grade	Description (CT or Operative Findings)	Typical Management
I	Subcapsular hematoma and/or renal parenchymal contusion without laceration or urinary extravasation	Observation, bed rest
II	Perirenal hematoma confined within Gerota’s fascia; renal cortical laceration ≤ 1 cm deep without urinary extravasation	Conservative management
III	Renal cortical laceration > 1 cm deep without collecting-system involvement or urinary extravasation	Conservative management with close monitoring
IV	Parenchymal laceration extending into the collecting system with urinary extravasation or laceration of the renal pelvis or ureteropelvic junction; segmental renal artery or vein injury with contained hemorrhage	Usually non-operative; consider ureteral stent or angioembolization
V	Shattered kidney with loss of normal architecture or main renal artery/vein avulsion or hilar devascularization of the kidney	Surgical repair, revascularization, or nephrectomy depending on stability

Summary

Urologic emergencies are numerous and variable in presentation and can be associated with significant acute and delayed morbidity.  A high index of suspicion as well as a thorough history and physical exam and judicious use of lab studies and imaging are critical to the timely diagnosis and treatment of urologic emergencies.

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Authors

2026

Marisa M. Clifton, MD, FACS
Baltimore, MD

Adam Weiner, MD
Los Angeles, CA

Jennifer Yates, MD
Worcester, MA

2022

Kathleen Kieran, MD, MSc, MME
Seattle, WA

Jennifer Yates, MD
Worcester, MA

2020

Kathleen Kieran, MD, MSc, MME
Seattle Children’s Hospital/University of Washington
Disclosures: Nothing to Disclose

Jennifer Yates, MD
University of Massachusetts Medical School/Medical Center
Disclosures: Nothing to Disclose

2017

Damara Kaplan, PhD MD
Albuquerque, NM
Disclosures: Nothing to disclose 

Taylor Kohn
Baylor College of Medicine, Houston, TX
Disclosures: Nothing to disclose

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