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Ureteral, Bladder, and Urethral Trauma

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Ovid: 5-Minute Sports Medicine Consult, The


Ureteral, Bladder, and Urethral Trauma
Robert J. Baker
Basics
Description
  • Sports-related trauma to the trunk and/or perineum can result in contusion, laceration, or complete transection of the ureter, bladder, or urethra.
  • Ureteral, bladder, and urethral injuries may be associated with pelvic fractures.
Epidemiology
  • Fractures of the pelvis can result in injuries to the urethra, bladder, and ureters.
  • Ureteral injuries rarely occur as isolated injuries following blunt abdominal trauma.
  • Ureteral injuries account for 1% of all genitourinary injuries (1,2,3)[A].
  • Bladder contusion or rupture may occur as a result of lower abdominal blunt trauma and pelvic fractures.
  • Although males are susceptible to blunt injury of the urethra, this type of injury is uncommon in females (2)[A].
  • Urethral injuries in children may result from a straddle mechanism (ie, direct trauma to the perineum commonly due to contact with the cross-bar of a bicycle) (4,5)[B].
  • Impingement of the bulbous urethra against the pubic symphysis results in urethral injuries from the straddle mechanism (3)[C].
  • Straddle injuries in females may result in labial hematoma and urinary retention. These injuries have been reported in in-line skating (3)[B].
  • Most posterior urethral injuries occur by a shearing mechanism (6)[C].
  • Patients admitted with multiple trauma injuries will have associated genitourinary injuries as well 10% of the time (1)[C].
Risk Factors
  • Especially in children with multiple injuries, genitourinary (GU) injuries are common (7)[C].
  • Although rare, avulsion of the ureter secondary to blunt trauma is known to occur in children (8)[C].
  • Rupture of the bladder may occur following blunt or penetrating trauma. The bladder is especially at risk for injury when full (9)[C].
  • The abdominal position of the bladder in childhood places it at great risk for traumatic injury (8)[C].
  • Bladder injuries often occur in association with pelvic fractures (6)[B].
Genetics
  • There is no specific genetic predisposition for GU injuries.
  • However, genetic malformations and solitary kidney are often diagnosed in young children after workup for GU trauma (7)[C].
Diagnosis
Pre Hospital
  • Since these injuries are often associate with multiple trauma, stabilization of the patient is important.
  • Signs of shock may be present and should be addressed immediately.
  • Other more life-threatening organ trauma, renal injuries, for example, likely will need to be addressed 1st.
History
  • Ureter: Trauma to the back or flank, hematuria, expanding flank mass (2)[C]
  • Bladder: Hematuria, urethrorrhagia, or inability to void following a traumatic injury to the abdomen (2)[C]
  • Urethra: Trauma to the pelvis possibly resulting in fracture, urethrorrhagia, hematuria, inability to void, lower abdominal or perineum pain (2)[C]
Physical Exam
  • Ureter: Flank pain, flank mass (urine or hematoma), hematuria, fever, chills, rarely shock (1)[C]
  • Bladder: Hematuria, urethrorrhagia, or inability to void (1)[C]
  • Urethra: Urethrorrhagia and inability to void, especially if pelvic fracture is present or suspected (1)[C]
  • Localized tenderness: Ureter, flank pain; bladder, abdominal pain; urethra, perineum pain
  • Extravasation, especially of the bladder, may result in peritoneal signs (10)[C].
  • Ecchymosis in the pubic area or perineum (10)[C]
  • Findings consistent with pelvic fracture
  • Ureter: Flank mass; lower abdominal pain, chills, fever, urgency, frequency, and pyuria (6)[C]
  • Urethra: Blood at the meatus; rectal exam reveals a floating or absent prostrate; ecchymosis and swelling of the external genitalia (10)[C].
Diagnostic Tests & Interpretation
Lab
  • Hematuria on urinalysis, though nonspecific, can be an indication of lower collecting system injury (urethra, bladder, ureter) (2)[C].
  • The degree of hematuria is not necessarily correlated with the degree of injury. Small urethral injuries may present with significant gross blood. Large ureteral injuries may present with microscopic hematuria (3)[C].
Imaging
  • Plain x-rays can identify associated injuries (eg, pelvic fractures, lower rib fractures, and spinal vertebrae fractures), which may raise suspicion of a GU injury (6)[C].
  • Ureter: IV pyelography (IVP) or retrograde pyelography is diagnostic (10)[B].
  • Bladder: Retrograde cystography can establish presence of bladder rupture (9)[B].
  • Urethra: Retrograde urethrography is diagnostic (3)[C].
  • Children: Some recommend all children with or not stable should be imaged if they have gross hematuria or >50 RBCs per high-power field (7)[C].
  • US is not reliable at differentiating urine and blood. Thus US is not the imaging technique to use in patients with high risk of bladder injury (3)[B].

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Pathological Findings
  • Pelvic fractures patterns associated with high risk of GU injury are pubic rami fractures of all 4 rami, ipsilateral rami fracture with massive posterior disruption of the sacrum, sacroiliac joint, or ilium (2)[B].
  • Pelvic fracture patterns associated with low risk are single rami fractures, ipsilateral rami fractures without ring disruption (2)[B].
  • Very little risk of ureteral injury with isolated fractures of acetabulum, ilium, and sacrum (3)[C].
Differential Diagnosis
  • Hematuria: Kidney contusion, kidney laceration, sports-induced hematuria, kidney failure, renal calculi, cystitis
  • Inability to void: Kidney failure, renal calculi, kidney laceration
Treatment
  • Acute treatment
  • Analgesia: Oral analgesia may be adequate; however, pain from associated trauma may require IM or IV administration of strong narcotics (3)[C].
  • Long-term treatment:
    • Prognosis is good for full recovery if the injury is diagnosed early and treated appropriately.
    • Most patients will require urologic consultation and possible surgical intervention.
Additional Treatment
Additional Therapies
  • Special considerations:
    • Ureteral fistulas and strictures can occur as a result of missed injuries or from entrapment associated with fibrosis from healed dislocation of sacroiliac joints (3)[C].
    • IV pylorogram should be performed prior to the cystogram (10)[C].
    • Retrograde urethrography should be performed prior to catheterization in the male athlete who has sustained a pelvic fracture and is unable to void following the trauma (1)[C].
  • Rehabilitation:
    • No specific rehabilitation, but general reconditioning is usually required following the period of convalescence.
    • Following surgical procedures, rehabilitation exercises directed at the back or pelvic musculature may be necessary.
Surgery/Other Procedures
  • Transection of the ureter requires prompt repair, ureteropyelostomy (1)[C].
  • Any bladder rupture associated with pelvic fracture where penetration of the bladder by a bony spicule is possible is best managed with surgical débridement (1)[C].
  • Intraperitoneal rupture of the bladder is appropriately treated with transperitoneal exploration, débridement, and repair (3)[C].
  • Initial management of urethral injuries remains controversial. Although early exploration and realignment have been successful, lower complication rates have been found with conservative treatment and delayed realignment (3)[C].
Ongoing Care
Follow-Up Recommendations
  • Delayed diagnosis of ureteral injury can result in nephrectomy (3)[C].
  • Small, uncomplicated extraperitoneal rupture of the bladder may be managed nonoperatively with a urethral catheter for 7–14 days (2)[C].
References
1. Lynch TH, Martínez-Piñeiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol. 2005;47:1–15.
2. Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: external genitalia. BJU Int. 2004;94:507–515.
3. Runyon MS. Blunt genitourinary trauma. UpToDate. On-line: www.uptodat.com accessed 8/28/2009.
4. Asplund C, Barkdull T, Weiss BD. Genitourinary problems in bicyclists. Curr Sports Med Rep. 2007;6:333–339.
5. Yelon JA, Harrigan N, Evans JT. Bicycle trauma: a five-year experience. Am Surg. 1995;61:202–205.
6. Gillenwater JY, Grayshack JT, Howards SS, et al. Adult and pediatnc urology. St. Louis: CV Mosby, 1998.
7. Livne PM, Gonzales ET. Genitourinary trauma in children. Urol Clin North Am. 1985;12:53–65.
8. Mandell J, Cromie WJ, Caldamone AA, et al. Sports-related genitourinary injuries in children. Clin Sports Med. 1982;1:483–493.
9. Bryan ST, Coleman NJ, Blueitt D, et al. Bladder problems in athletes. Curr Sports Med Rep. 2008;7:108–112.
10. Rosen P, Barkin R, Danzl DF. Emergency medicine: concepts and clinical practice. St. Louis: CV Mosby, 1998.
Codes
ICD9
  • 867.0 Injury to bladder and urethra without mention of open wound into cavity
  • 867.1 Injury to bladder and urethra with open wound into cavity
  • 867.2 Injury to ureter without mention of open wound into cavity
Clinical Pearls
  • Using sport-specific protective equipment, along with appropriate coaching and officiating, will decrease the likelihood of these rare sports injuries.
  • Usually these injuries occur after significant trauma. Avoiding high-risk behaviors may decrease the occurrence. However, there is no specific limitation to participation.


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