High Yield Topics

External Genital Trauma

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Ovid: 5-Minute Sports Medicine Consult, The


External Genital Trauma
David V. Smith
David T. Bernhardt
Basics
  • Injuries in males:
    • Lacerations, hematomas, avulsions of penis/scrotum
    • Urethral injury
    • Testicular rupture
    • Hematocele
    • Penetrating injury to penis/scrotum
  • Injuries in females:
    • Lacerations, hematomas, avulsions of vagina/soft tissue
    • Vaginal impalement injuries
    • Vaginal insufflation injuries
    • Pelvic fracture
    • Genital trauma from sexual abuse
Pediatric Considerations
  • Consider nonaccidental trauma or sexual abuse.
  • Sexual abuse is a common etiology in females.
  • Urethral damage is frequently caused by traumatic mechanisms similar to those in adults.
Description
  • Females:
    • Injuries to the urethra are rare owing to the short, unexposed, and mobile urethra. Most occur at the bladder neck.
    • Most traumatic injuries are secondary to accidental falls onto objects resulting in impalement or blunt trauma.
      • Blunt trauma:
        • Vulvar lacerations, ecchymosis, hematoma
        • Can result in crush injury or pelvic fractures
      • Impalement:
        • Physical findings can mimic penetration by blunt forceful trauma, so must evaluate for possible sexual abuse.
        • Vagina, urethra, bladder, anus, rectum, and peritoneal cavity can be pierced by a sharp object.
    • Insufflation with high-pressure water (eg, falls off jet skis or water skis) can result in vaginal tears.
  • Males:
    • Blunt trauma:
      • Penile/soft tissue:
        • Urethral injuries are more common in prostatic urethra vs bulbar or penile urethra.
        • ∼95% of posterior urethral injuries are caused by pelvic fractures.
        • As many as 25% of pelvic fractures have concomitant urethral injuries.
        • Laceration, ecchymosis, hematoma, avulsion injuries
      • Scrotal trauma:
        • Most testicular injuries are from blunt trauma in athletics.
        • Scrotal ecchymosis, hemorrhage
        • Hematoceles: Blood accumulation in space between tunica albuginea and tunica vaginalis.
        • Testicular rupture: Disruption of the tunica albuginea
        • Traumatically induced hydroceles
        • Traumatically induced testicular torsion
        • Pelvic fracture with significant blunt trauma
    • Penetrating injury: Can cause significant injury to soft tissues and scrotum
Diagnosis
Pediatric Considerations
  • If an examination of the introitus and perineum cannot be performed easily, examination under anesthesia should occur.
  • An examination in the OR, in addition to being better tolerated by the patient, can help the physician to evaluate for sexual abuse and to confirm that the injury is consistent with the history.
  • The workup of male pediatric patients also should include an examination in the OR if an adequate ED examination does not occur or if suspicion of abuse exists.
History
  • Mechanism of injury
  • Prior history of trauma
  • Pelvic pain, bleeding, inability to void
  • Blood at the urethral meatus or hematuria
  • History of possible sexual abuse
Physical Exam
  • Females:
    • Genitourinary (GU) examination to determine extent of injury
    • Collection of laboratory and forensic specimens if history of sexual abuse
    • If injury is minor superficial laceration or hematoma and no history of penetrating injury, normal exam is sufficient.
    • Vaginal lacerations with active bleeding should be repaired by provider with experience to avoid urethra, bladder, and rectal injury.
    • Indications for exam under anesthesia:
      • Young or uncooperative patient
      • Transection of the hymen with inability to see the full extent of injury
      • Vaginal hemorrhage
      • Expanding vulvar or vaginal hematoma
      • History of significant blunt, forceful, or penetrating trauma
      • Significant vaginal laceration or soft tissue injury
      • Complex vaginal and perineal lacerations associated with pelvic fracture or rectal injury
      • Perforation into peritoneal cavity requires exploratory laparotomy/laparoscopy.
  • Males:
    • GU examination to determine extent of injury
    • Examine for high-riding prostate, perineal or genital swelling, blood at meatus.
    • Examine testicles for pain or swelling concerning for rupture, hematocele, torsion.
    • Evaluate for rectal injuries.

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Diagnostic Tests & Interpretation
Lab
  • Urinalysis
  • Hematocrit
  • Blood urea nitrogen (BUN) and creatine (Cr)
  • Consider screen for sexually transmitted infections if history or exam is consistent with sexual abuse.
Imaging
  • Scrotal imaging: Scrotal ultrasound (SUS):
    • Scrotum exam can be difficulty with significant swelling.
    • SUS is the most sensitive and specific imaging for detecting intrascrotal injury (1)[B].
    • SUS assesses the integrity and vascularity of the testes.
    • SUS can distinguish testis rupture from hematocele, hydrocele, torsion, and epididymitis (1).
  • Urethral injury: Retrograde urethrography (RUG):
    • Inability to void, blood at meatus, and any degree of hematuria are absolute indications for RUG (1)[B].
    • Recommended with any penetrating genital injuries (1)[C]
    • Water-soluble contrast material is injected at the urethral meatus.
    • Extravasation of contrast material and location of extravasation can diagnose presence of tear as well as degree of tear.
  • Cystography: 40% of urethral injuries have concomitant bladder injuries.
  • Proctoscopy: In the female when there is a possibility of impalement injury or pelvic fracture, proctoscopy can aid in evaluating the extent of injury (2).
Differential Diagnosis
  • Perineal and vaginal trauma
  • Bladder trauma
  • Ureter or kidney trauma
  • Pelvic fracture
Treatment
Pre-Hospital
Similar considerations as for major trauma victims
ED Treatment
  • Initial stabilization, control of bleeding, pain control
  • After appropriate evaluation and workup, urologic or gynecologic consult if warranted
  • Urethral contusions, lacerations, and avulsions are best managed by an experienced urologist.
  • Scrotal hematomas, hydroceles, and contusions can be managed with rest, ice, and elevation.
  • Tetanus immunization if warranted for laceration or avulsion.
Medication
Anytime there is injury to the female mucosal genital surfaces, application of topical estrogen cream can benefit the healing process and decrease scarring.
Surgery/Other Procedures
  • Males:
    • When physical exam findings and mechanism of injury suggest significant testicular injury, operative exploration should be undertaken even with equivocal SUS (1)[B].
    • When testicular rupture is suspected, prompt surgical intervention is advised (1)[B].
    • Prompt drainage of large hematoceles is recommended to prevent infectious complications and prevent prolonged pain (1)[B].
    • Following blunt scrotal trauma, probability of testicular salvage decreases significantly if not explored in 72 hr (1).
    • Posttraumatic testicular torsion and testicular dislocation require immediate surgical intervention.
    • Penetrating trauma to the scrotum or penis warrants prompt surgical exploration (1)[C].
    • Complex avulsions are best managed with initial débridement and delayed reconstruction (1)[B].
    • Minor avulsions are managed as simple lacerations with irrigation and primary closure (1)[B].
  • Females:
    • Simple perineal and vulvar lacerations usually can be repaired in the ED (2).
    • Large hematomas should be incised and drained (2).
    • See “Physical Exam” for indications for exam under anesthesia.
    • In exam under anesthesia, if peritoneal or rectal cavities are entered, exploratory laparotomy is indicated (3).
In-Patient Considerations
Initial Stabilization
ABCs of trauma care take precedence.
Admission Criteria
  • Concurrent closed head injury, blunt abdominal trauma, or pelvic fracture
  • Need for operative management of urethral, penile, vaginal, pelvic, or bladder injuries
Discharge Criteria
Isolated urethral injuries frequently may be managed in the outpatient setting after appropriate urinary catheterization or suprapubic cystostomy with urologic follow-up.
Ongoing Care
Complications
  • Impotence
  • Incontinence
  • Strictures
  • Infection
  • Disfigurement
  • Pain
  • Scarring
  • Infertility
References
1. Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: external genitalia. BJU Int. 2004;94:507–515.
2. Wessells H, Long L. Penile and genital injuries. Urol Clin North Am. 2006;33:117–126, vii.
3. Merritt DF. Genital trauma in children and adolescents. Clin Obstet Gynecol. 2008;51:237–248.
Additional Reading
Carter CT, Schafer N. Incidence of urethral disruption in females with traumatic pelvic fractures. Am J Emerg Med. 1993;11:218–220.
Lee SH, Bak CW, Choi MH, et al. Trauma to male genital organs: a 10-year review of 156 patients, including 118 treated by surgery. BJU Int. 2007.
Codes
ICD9
  • 867.0 Injury to bladder and urethra without mention of open wound into cavity
  • 878.2 Open wound of scrotum and testes, without mention of complication
  • 959.14 Other injury of external genitals


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