Genitourinary Trauma Assessment
Systematic evaluation of the GU system begins with the primary and secondary trauma surveys. Because GU injuries are frequently occult and hematuria is an unreliable marker of injury severity, a protocol-driven approach (guided by mechanism, hemodynamic status, and associated injuries) determines appropriate imaging and intervention.
Initial Evaluation
History and Mechanism
Details that raise suspicion for GU injury:[1][2]
- Rapid deceleration (MVA, fall from height): renal pedicle injury, UPJ avulsion
- Direct flank blow: renal laceration or contusion
- Pelvic ring fracture: bladder rupture, posterior urethral injury
- Straddle impact (fall onto crossbar, saddle): anterior (bulbar) urethral injury
- Penetrating trajectory toward flank, pelvis, or perineum: any GU organ depending on path
- Seatbelt sign across lower abdomen: bladder or mesenteric injury
Physical Examination
| Finding | Implication |
|---|---|
| Flank ecchymosis / flank mass | Perirenal hematoma; renal injury |
| Blood at the urethral meatus | Suspect urethral injury; in male anatomy obtain RUG before catheterization when feasible, while suspected female injury calls for cystourethroscopy and vaginoscopy.[1][5] |
| Perineal / scrotal ecchymosis (butterfly hematoma) | Bulbar urethral injury with Buck's fascia disruption |
| Inability to void with pelvic fracture | Suspect posterior urethral injury in male anatomy or urethral injury in female anatomy.[5] |
| Abdominal distension, ileus | Intraperitoneal bladder rupture (urinary ascites) |
| Vaginal bleeding after pelvic trauma | Suspect vaginal, bladder or urethral injury. Perform a vaginal examination and obtain urologic/urogynecologic assessment; EAU 2026 strongly recommends cystourethroscopy and vaginoscopy for suspected female urethral injury.[5] For confirmed female pelvic-fracture urethral injury, it strongly recommends repair within seven days once the patient is hemodynamically stable.[5] |
Blood at the Meatus.
After stabilization, obtain RUG before catheterization when feasible for suspected male urethral injury; evaluate suspected female urethral injury with cystourethroscopy and vaginoscopy.[1][5] Avoid forced or repeated blind attempts. For suspected male urethral injury, if urgent drainage is necessary and RUG is unavailable, ACS permits a single gentle attempt by an experienced clinician; stop if resistance or blood is encountered or urine does not return, and arrange guided or suprapubic drainage if the attempt fails. Inflate the balloon only after urine drains with the catheter fully inserted.[1] The ACS text describes a 16 Fr straight-tip catheter for that single attempt. It no longer recommends a rectal examination to look for a high-riding prostate, which has low sensitivity and specificity for urethral injury; a rectal exam, with a vaginal exam in female anatomy, is still done to look for a concomitant injury.[1]
Urinalysis and Hematuria
For suspected renal injury, obtain urinalysis (dipstick or microscopy), hematocrit, and baseline creatinine; use mechanism, examination, hemodynamics, and hematuria to select imaging:[1][5]
| Finding | Action |
|---|---|
| Gross hematuria | In a stable patient, obtain IV-contrast CT for suspected upper-tract injury. Add retrograde cystography when pelvic fracture is present , or when the mechanism or findings suggest bladder rupture . In instability, resuscitation and hemorrhage control take priority.[2] |
| Microscopic hematuria after blunt trauma + an episode of hypotension (SBP <90 mmHg) | After stabilization, obtain IV-contrast CT when immediate surgery or angiography is not required . Use immediate and delayed images for suspected renal injury; add an arterial phase when vascular injury is suspected.[1][2] |
| Microscopic hematuria, hemodynamically stable | Assess mechanism; image for a concerning mechanism, examination or associated injury. Obtain retrograde cystography with a high-risk pelvic fracture (obturator-ring disruption with >1 cm displacement or pubic-symphysis diastasis >1 cm), posterior urethral injury, or a pelvic ring fracture with clinical signs of bladder rupture such as inability to void, suprapubic pain or abdominal distension .[1][2][5] |
| No hematuria, penetrating trajectory toward GU | Assess the trajectory; in stable patients, use IV-contrast CT with delayed images for suspected collecting-system or ureteral injury, retrograde cystography for suspected bladder injury, RUG for suspected male urethral injury, or cystourethroscopy and vaginoscopy for suspected female urethral injury.[1][5] |
| No hematuria, low-energy blunt mechanism | Imaging is generally unnecessary when examination and risk factors are reassuring. After lower-force trauma in an older patient with chronic retention or a distended bladder, investigate disproportionate abdominal findings and consider cystography for otherwise unexplained signs of bladder injury.[1] |
Children. Use mechanism, examination, hematuria and associated injuries to select imaging. Isolated microscopic hematuria does not automatically require CT. Hypotension is a late sign in children, so normal blood pressure must not override suspicion of significant injury.[1][2]
Indications for Emergent Intervention
The following findings call for immediate intervention. Imaging should not delay operative or angiographic management in hemodynamically unstable patients:[1][3]
- Hemodynamic instability despite resuscitation with suspected GU source (renal vascular injury, high-grade renal laceration)
- Expanding or pulsatile retroperitoneal hematoma found at laparotomy
- Intraperitoneal bladder rupture: surgical repair as soon as physiologically feasible; diffuse peritonitis after abdominal trauma warrants laparotomy.[1][2]
- Penile amputation or complex degloving requiring emergent surgical control
- Fournier's gangrene with systemic sepsis
Retroperitoneal Hematoma at Laparotomy.
Zone 1 (central): Explore for aorta/IVC injury. Zone 2 (perinephric/lateral): Explore a ruptured, pulsatile or expanding hematoma, or one with ongoing instability attributable to renal bleeding. Leave a nonexpanding blunt-trauma hematoma found at laparotomy for other injuries undisturbed if renal bleeding is not the source of instability. After penetrating trauma, explore most Zone 2 hematomas to assess the renal pelvis, proximal ureter and renal vessels; a small, nonexpanding hematoma lateral to the colon may be left undisturbed in a stable patient with low suspicion for these injuries. When ureteral injury is suspected during laparotomy without adequate preoperative imaging, directly inspect the ureter .[2] If the hematoma remains unexplored and no preoperative imaging was obtained, obtain IV-contrast CT with delayed images once stable.[1] Zone 3 (pelvic): Leave a stable, nonexpanding blunt hematoma undisturbed; persistent pelvic hemorrhage may require packing or angiography according to physiology and the bleeding source.[3][1]
Imaging Overview
Imaging selection follows hemodynamic stability and suspected injury. Full protocols are covered in the organ-specific pages; a summary is provided here.
Cross-Reference. Detailed imaging modalities, contrast protocols, and interpretation are covered in the Imaging page of the Evaluation & Workup section.
CT Abdomen and Pelvis with IV Contrast
For stable patients with suspected renal or ureteral injury, IV-contrast CT is the primary cross-sectional study. Protocol considerations:[1][2][4]
| Phase | Timing After Contrast | Purpose |
|---|---|---|
| Arterial (~20–40 sec) | Early | Renal vascular injury, active hemorrhage detection |
| Portal venous (~70 sec) | Standard trauma CT | Parenchymal injuries, solid organ lacerations |
| Delayed / excretory (3–10 min typical; about 10 min optimal for collecting-system injury) | Added when urinary injury suspected | Collecting-system or ureteral extravasation |
AUA calls for immediate and delayed contrast-enhanced images when renal injury is suspected , and delayed CT for stable patients with suspected ureteral injury (Statement 9a; Recommendation, Grade C).[2] Additional delay may be needed with poor ureteral opacification. Suspected bladder rupture requires retrograde cystography, because routine excretory-phase filling can miss a leak.[1][2] FAST is neither sensitive nor specific for GU injury and cannot assess the retroperitoneum, although fluid may point to an intraperitoneal bladder rupture.[1]
Retrograde Urethrogram (RUG)
The RUG is the preferred study for male urethral injury and is obtained before Foley catheter placement when injury is suspected:[1]
- Blood at urethral meatus after pelvic trauma [2]
- Perineal / scrotal ecchymosis
- Pelvic fracture with inability to void
- Mechanism consistent with straddle injury
Technique: Position the patient supine at 30–45° oblique when feasible, with the penis on stretch. When oblique positioning cannot be achieved because of pelvic injury, angle the X-ray source/collimator obliquely relative to the stretched penis instead of repositioning the patient. Seat a Foley catheter with its balloon in the fossa navicularis (inflated with 1–3 mL) and slowly inject 10–15 mL of contrast under fluoroscopy until the injury is delineated or contrast reaches the bladder. The ACS guideline describes a 16 Fr catheter; smaller catheters are also used. Obtain a scout film first, because vascular contrast extravasation from an earlier IV-contrast CT in a pelvic fracture can mimic a urethral leak. When CT is being used to look for arterial extravasation in a pelvic fracture, do the CT before the RUG, because urethral contrast can obscure active bleeding. Any extravasation, or occlusion with no advance of contrast, needs urologic consultation. If a Foley catheter is already in place, leave it and perform a pericatheter RUG.[1]
CT Cystography
For stable patients with suspected bladder injury, use retrograde CT or conventional cystography; CT cystography can delineate complicated injury even when a separate pelvic CT has not been performed.[1] Passive filling by clamping the Foley during CT is insufficient. Use active retrograde filling; in adults, aim for 300 mL or stop when the patient cannot tolerate further filling or contrast stops flowing. Use an age-appropriate expected bladder capacity in children.[1] See Bladder Trauma for full protocol.
Scrotal Ultrasound
AUA recommends scrotal ultrasound for most blunt injuries with findings suggestive of testicular rupture (Statement 30a; Recommendation, Grade C). Suspected rupture warrants exploration and repair when salvageable .[2] Inconclusive ultrasound also warrants exploration , and a hematocele larger than three times the contralateral testis warrants surgery.[5] For most penetrating scrotal injuries, the AUA recommends prompt surgical exploration with repair or orchiectomy when non-salvageable, given frequent testicular injury and limited ultrasound sensitivity (Statement 30b; Recommendation, Grade C). Contour loss and heterogeneous testicular echotexture are concerning findings.[2] See Genital & Scrotal Trauma.
Urinary Diversion Decisions
When urethral injury is confirmed or suspected prior to definitive diagnosis:[1]
| Situation | Preferred Diversion |
|---|---|
| Confirmed or suspected urethral injury | Establish prompt drainage with urologic input; avoid repeated blind attempts. AUA favors percutaneous or open SPT initially for most PFUI cases (Statement 20b; Recommendation, Grade C); ACS specifies SPT for complete male PFUI and permits either SPT or urethral catheterization for partial PFUI.[1][2] Selected stable patients may undergo primary endoscopic realignment without prolonged attempts .[2] In a 26-center prospective cohort of 69 patients with complete PFUI after failed retrograde cystoscopic catheter placement, urethral obstruction developed in 36/37 after realignment and 30/32 after SPT at mean 463-day follow-up.[6] |
| Bladder injury requiring prolonged catheterization | For most uncomplicated extraperitoneal blunt injuries managed without repair, ACS describes continuous drainage with a large-bore urethral catheter (≥18 Fr). After most bladder repairs, urethral drainage alone suffices; reserve SPT for selected indications.[1] |
| Incomplete ureteral injury with delayed diagnosis | Attempt retrograde stenting; percutaneous nephrostomy if stenting fails or is not possible [2] |
| Intraoperative ureteral injury, damage control | Temporary drainage followed by delayed repair when stable : ureteral ligation with nephrostomy, or an externalized catheter secured to the proximal ureteral defect[2]. ACS also describes cutaneous ureterostomy[1] |
Confirm catheter placement. After any catheter is placed in a trauma patient, confirm correct intravesical placement by following urine output, with hand irrigation/aspiration or imaging if needed. Poor or absent drainage is often attributed reflexively to hypovolemic shock or oliguria, but can instead be the first sign of an occult urethral injury with a malpositioned catheter, for example in a false passage.
Documentation and Workup Completeness
Every trauma patient with a suspected GU injury should have documentation of:[2]
- Mechanism and energy level
- Presence and degree of hematuria; injury side or source when established
- Hemodynamic parameters on arrival and trajectory
- Physical exam findings (meatus, perineum, flank, abdomen)
- Imaging obtained and findings
- Urologic consultation (or documentation of transfer plan if unavailable)
- Urinary diversion decision and catheterization strategy
Podcasts
References
1. American College of Surgeons Trauma Quality Programs. ACS TQP Best Practices Guidelines: Management of Genitourinary Injuries. Chicago, IL; August 2025. ACS guideline PDF
2. Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408. Full guideline, published 2014; amended April 2017 and August 2020.
3. Feliciano DV, Mattox KL, Moore EE, eds. Trauma. 9th ed. McGraw-Hill; 2020. Chapter on retroperitoneal hematoma and zone management.
4. Santucci RA, Wessells H, Bartsch G, et al. Evaluation and management of renal injuries: Consensus statement of the renal trauma subcommittee. BJU Int. 2004;93(7):937–954. doi:10.1111/j.1464-4096.2004.04820.x. PMID 15142141
5. European Association of Urology. EAU Guidelines on Urological Trauma. 2026. Guideline.
6. McCormick BJ, Keihani S, Hagedorn J, et al. "A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury." J Trauma Acute Care Surg. 2023;94(2):344–349. doi:10.1097/TA.0000000000003774