Genitourinary Trauma, Diagnostic Evaluation of

Level 1

There is insufficient Class I and Class II data to support any standards regarding evaluation of bladder trauma.

Level 2

Routine Ct of the abdomen alone (without cystography) is inadequate to detect bladder rupture, even when the foley is clamped and bladder distended.

CT cystography is as accurate as conventional cystography in the detecting bladder rupture and may be used interchangeably with conventional cystography.

Gross hematuria, pelvic fluid, pelvic fractures (other than acetabular fractures) on CT should prompt conventional cystography or CT cystography.  Drainage films and adequate distension of the bladder with contrast medium increases the sensitivity of cystography in the detection of bladder injuries.

Level 3

There are no Level III recommendations for the evaluation of bladder trauma.

Level 1

There is insufficient Class I and Class II data to support any standards regarding evaluation of renal trauma.

Level 2

1. Patients who require urologic imaging after blunt trauma include those with gross hematuria and those with microscopic hematuria in the face of hemodynamic instability. Microscopic hematuria can be reliably detected using urine dipstick, although different brands of dipstick may have different levels of sensitivity and specificity.
2. CT has a higher sensitivity and specificity in the evaluation of blunt renal trauma as compared to IVP and is the diagnostic modality of choice in imaging patients with suspected blunt renal trauma.
3. MRI equals CT in correctly grading blunt renal injuries and detecting the presence and size of perirenal hematomas.  MRI differentiates intrarenal hematoma from perirenal hematoma more accurately and is able to determine recent bleeding in the hematoma by regional differences in signal intensity.  Although MRI can replace CT in patients with iodine allergy and may be helpful in patients with equivocal findings on CT, it should be reserved for selected patients, due to increased cost and increased imaging time.

Level 3

1. There is a correlation between degree of hematuria in blunt trauma and likelihood
   of significant intra-abdominal injury not related to the genitourinary system.
2. Negative ultrasound does not exclude renal injury.
3. There is no correlation between presence and amount of hematuria and extent of
   renal injury after penetrating trauma.
4. Limited one-shot IVP is of no significant value in assessing penetrating abdominal trauma patients prior to laparotomy, other than to determine the presence of a second kidney prior to nephrectomy.
5. CT should be the primary diagnostic study in penetrating trauma at risk for renal trauma.  Renal hematoma area: total body area may be helpful in determining the grade of renal injury.
6. In penetrating renal trauma, after IVP or CT, renal angiogram is the second study of choice because it reliably stages significant injuries and offers the possibility of embolization. 

Level 1

There is insufficient Class I and Class II data to support any standards regarding evaluation of renovascular trauma.

Level 2

There is insufficient Class II data to support any recommendations regarding of
renovascular trauma.

Level 3

There is insufficient Class I and Class II data to support any standards regarding evaluation of renovascular trauma.

Level 1

There is insufficient Class I and Class II data to support any standards regarding evaluation of ureteral trauma.

Level 2

There is insufficient Class I and Class II data to support any standards regarding evaluation of ureteral trauma.

Level 3

1. Urinalysis, IVP, and operative exploration may miss ureteral injuries, requiring a high index of suspicion during celiotomy.
2. Delaying spiral CT for 5–8 minutes after contrast infusion may increase the sensitivity in detecting ureteral disruption from blunt trauma.

Level 1

There is insufficient Class I and Class II data to support any standards regarding evaluation of urethral trauma.

Level 2

Urethral injury should be suspected when a pubic arch fracture exists and an urethrogram performed.  The risk of urethral injury is increased when there is involvement of both the anterior and posterior pelvic arch.

Level 3

Although blood at the urethral meatus, gross hematuria, and displacement of the prostate are signs of disruption and should prompt urologic work-up, their absence does not exclude urethral injury. Successful passage of a foley does not exclude a small urethral perforation.

Although the female urethra is relatively resistant to injury, it should be suspected in patients with either vaginal bleeding or external genitalia injury or with severe pelvic fractures and incontinence problems.