Topic breakdown

1. Renal injuries: mechanism, AAST grading, imaging, management
2. Ureteric injuries: mostly iatrogenic (gynaecological and endoscopic surgery)
3. Bladder injuries: extraperitoneal vs intraperitoneal rupture, cystography
4. Urethral injuries: posterior (pelvic fracture) vs anterior (straddle), retrograde urethrogram
5. Penile injuries: penile fracture, amputation, strangulation
6. Scrotal and testicular injuries: blunt trauma, rupture, degloving
7. Urological emergencies:
   • Acute urinary retention
   • Renal colic with obstructed infected system (pyonephrosis)
   • Acute pyelonephritis and urosepsis
   • Testicular torsion
   • Priapism
   • Paraphimosis
   • Fournier's gangrene
   • Clot retention and gross haematuria
   • Anuria and post-renal AKI

Overview

Topic breakdown

1. Renal injuries: mechanism, AAST grading, imaging, management
2. Ureteric injuries: mostly iatrogenic (gynaecological and endoscopic surgery)
3. Bladder injuries: extraperitoneal vs intraperitoneal rupture, cystography
4. Urethral injuries: posterior (pelvic fracture) vs anterior (straddle), retrograde urethrogram
5. Penile injuries: penile fracture, amputation, strangulation
6. Scrotal and testicular injuries: blunt trauma, rupture, degloving
7. Urological emergencies:
   • Acute urinary retention
   • Renal colic with obstructed infected system (pyonephrosis)
   • Acute pyelonephritis and urosepsis
   • Testicular torsion
   • Priapism
   • Paraphimosis
   • Fournier's gangrene
   • Clot retention and gross haematuria
   • Anuria and post-renal AKI

Overview

Injuries of the Kidneys, Urinary Tract and Male Genital Organs, and Urological Emergencies: Short Notes

A. Renal trauma

• Epidemiology: the kidney is the most commonly injured urological organ. It is present in about 5% of all trauma, and blunt injury is far more common than penetrating injury. Usual causes are road traffic accidents, falls and contact sports. It is usually part of polytrauma. - Bailey and Love's Short Practice of Surgery, p. 1499
• Deceleration injury: can avulse the pelviureteric junction (PUJ) or renal pedicle. It can also cause renal artery intimal tear and thrombosis.
• Clinical: suspect it with flank pain or bruising, lower rib or transverse process fractures, and haematuria. Haematuria is gross or microscopic. The degree of haematuria does not correlate with severity, and its absence does not exclude serious injury (for example pedicle injury or PUJ avulsion).
• Imaging:
  • Contrast-enhanced CT (CECT) with a delayed (excretory) phase is the investigation of choice in a stable patient.
  • Indications for CECT:
    • Blunt trauma with gross haematuria.
    • Microscopic haematuria with hypotension (systolic <90 mmHg).
    • Rapid deceleration injury.
    • Any penetrating injury.
    • Children with more than 5 RBC per high-power field.
  • In an unstable patient going to theatre, do a one-shot intra-operative IVU.
• AAST grading (summary):

• Management:
  • Conservative treatment suits most isolated renal trauma, and sometimes grade IV. It means bed rest, serial vital signs and haematocrit, antibiotics, and repeat imaging if there is fever or deterioration.
  • Angioembolisation is for active bleeding in a stable patient.
  • Urine leaks: a stent or percutaneous drainage.
  • Surgical exploration is for haemodynamic instability, an expanding or pulsatile retroperitoneal haematoma, and grade V injury with pedicle avulsion. Get early vascular control of the pedicle, and try renorrhaphy or partial nephrectomy before total nephrectomy.
• Complications: early ones are secondary haemorrhage, urinoma, abscess and infection. Late ones are hypertension (Page kidney, renin-mediated), hydronephrosis, AV fistula, and chronic pain.
• Evidence: a 2024 meta-analysis (PMID 38566265) supports conservative management in selected high-grade renal trauma. A 2025 guideline update (PMID 40295331) covers initial surgical management of urogenital injuries in polytrauma. Neither contradicts the above.

B. Ureteric injuries

• Cause: mostly iatrogenic, from gynaecological surgery (hysterectomy), colorectal surgery, and ureteroscopy. External trauma causes few cases, mostly gunshot wounds.
• Common site: the pelvic ureter, near the uterine artery or the iliac vessels.
• Presentation: often missed. Look for flank pain, fever, ileus, urinary leak from the wound or vagina, urinoma, a rising creatinine, or haematuria (absent in a large share of cases).
• Diagnosis: CT urogram with delayed phase. A retrograde ureterogram gives the best definition.
• Management:
  • Recognised intra-operatively: primary repair over a stent.
  • Delayed recognition: a stent if it can be passed, otherwise a percutaneous nephrostomy, with later definitive repair.
  • Repair options by level:
    • Lower ureter: ureteroneocystostomy (Boari flap or psoas hitch).
    • Middle ureter: ureteroureterostomy (end-to-end).
    • Upper ureter, or long defects: transureteroureterostomy, ileal interposition, or autotransplantation.

C. Bladder injuries

• Cause: about 80-90% are with pelvic fractures, and most of the rest are iatrogenic. A full bladder is at risk from blunt lower abdominal trauma.
• Types:
  • Extraperitoneal (about 60%): bone fragment or shearing force. Contrast shows a flame-shaped extravasation in the pelvis.
  • Intraperitoneal (about 30%): burst of the dome in a full bladder. Contrast outlines bowel loops.
  • Combined: both patterns together.
• Clinical: the classic triad is gross haematuria, suprapubic pain and difficulty voiding. Intraperitoneal rupture may give a rising creatinine from urine reabsorption (pseudo-renal failure with hyperkalaemia).
• Diagnosis: a retrograde cystogram. Fill with at least 300 mL of contrast and take post-drainage films. CT cystography is equally accurate.
• Treatment:
  • Intraperitoneal: surgical repair and catheter drainage for 7-10 days.
  • Uncomplicated extraperitoneal: catheter drainage for 10-14 days, with a cystogram before removal.
  • Repair if the bladder neck is involved, if bone fragments are in the bladder, or if the patient is being explored anyway (for example for orthopaedic fixation).

D. Urethral injuries

• Diagnosis: a retrograde urethrogram (RUG) before any catheter in a suspected injury. Do not pass a catheter blindly.
• Treatment:
  • Posterior: suprapubic catheter first, then delayed urethroplasty at 3 months. Some centres try early realignment over a catheter.
  • Anterior: a partial tear can be managed with a catheter. A complete tear needs a suprapubic catheter and later urethroplasty.
  • Female urethral injury is rare and associated with pelvic fracture.

E. Injuries to the penis, scrotum and testis

• Penile fracture: the tunica albuginea of the erect penis ruptures during intercourse.
  • Features: a snap, pain, rapid detumescence, and an "aubergine" (eggplant) deformity.
  • Treatment: urgent exploration and repair, and check the urethra.
  • Blood at the meatus suggests associated urethral injury.
• Penile amputation and strangulation:
  • Amputation: wrap the part in moist saline gauze in a sealed bag on ice, not in direct contact with ice. Microsurgical reimplantation.
  • Strangulation by a ring or band: remove the constricting object, preferably with a cutting tool.
• Testicular rupture:
  • Blunt injury ruptures the tunica albuginea.
  • Scrotal ultrasound shows a loss of tunical continuity or heterogeneous parenchyma, and haematocoele.
  • Treatment: explore early (ideally within 72 h), debride necrotic tissue, and close the tunica.
• Scrotal degloving: primary closure when skin is available. Otherwise bury the testes in thigh pouches, or use skin grafts.
• Penetrating genital injury: explore. Debride minimally, because genital tissue is very vascular.

F. Urological emergencies

1. Testicular torsion
   • Typical in adolescents. The cause is a bell-clapper deformity.
   • Features: sudden severe scrotal pain, nausea and vomiting, a high-riding transverse testis, and absent cremasteric reflex. Elevation does not relieve the pain (Prehn's sign is negative).
   • Treatment: it is a clinical diagnosis. Do not delay surgery for an ultrasound.
   • Window: salvage is near 100% within 6 h, and falls steeply after 12 h.
   • Manual detorsion ("open the book") can be tried while arranging surgery.
   • Surgery: explore the scrotum, detort, and warm the testis to assess viability. Fix both testes (orchidopexy) with non-absorbable sutures. Do an orchidectomy if the testis is nonviable.
   • Differential: torsion of the testicular appendage (blue dot sign) and epididymo-orchitis.
2. Priapism
   • Ischaemic (low flow): the commonest and a true emergency. The penis is rigid and painful.
     • Causes: sickle cell disease, intracavernosal injection, PDE5 inhibitors, psychotropics (clozapine, trazodone), leukaemia.
     • Cavernosal blood is dark, with pH <7.25, pO2 <30 mmHg and pCO2 >60 mmHg.
     • Treatment: aspiration and saline irrigation, then intracavernosal phenylephrine, then a shunt (distal, such as Winter or T-shunt, or proximal) if this fails. Irreversible damage (fibrosis and impotence) develops after about 4-6 h of ischaemia.
     • In sickle cell disease also give fluids, oxygen and analgesia.
   • Non-ischaemic (high flow): usually after perineal trauma. It is painless and the penis is semi-rigid. Observe, and use selective arterial embolisation if needed.
3. Paraphimosis
   • A retracted foreskin cannot be returned and the glans swells. - Bailey and Love's Short Practice of Surgery, p. 1569
   • Treatment: gentle manual compression, hyaluronidase injection or osmotic reduction (granulated sugar), then a dorsal slit under local anaesthesia, and circumcision if manipulation fails.
4. Acute urinary retention
   • Painful inability to void. Causes: BPH, urethral stricture, clots, constipation, drugs (anticholinergics, opioids), neurological problems.
   • Treatment: urethral catheter. If that fails, use a suprapubic catheter or trocar puncture.
   • After relief, watch for post-obstructive diuresis (more than 200 mL/h for 2 consecutive hours) and haematuria ex vacuo. Replace fluids as needed.
5. Obstructed infected kidney (pyonephrosis, obstructive pyelonephritis)
   • Stone with fever, loin pain and sepsis. Treatment: urgent decompression with a percutaneous nephrostomy or retrograde ureteric stent, plus IV antibiotics and fluids. Treat the stone later.
6. Acute pyelonephritis and urosepsis: culture, IV antibiotics, fluids, imaging for obstruction or abscess.
7. Fournier's gangrene
   • Necrotising fasciitis of the perineum and genitalia. Risk factors: diabetes, immunosuppression, alcoholism.
   • Treatment: resuscitation, broad-spectrum IV antibiotics (including anaerobic cover), wide surgical debridement with repeat looks, and often faecal or urinary diversion.
8. Clot retention and gross haematuria: a 3-way catheter with manual washout and continuous bladder irrigation. Resuscitate and find the source (tumour, stone, trauma, BPH).
9. Anuria or post-renal acute kidney injury
   • Diagnosis: ultrasound for hydronephrosis. Treatment: catheter, then nephrostomy or stent. Treat hyperkalaemia and consider dialysis.
10. Other emergencies: acute epididymo-orchitis, renal colic with a solitary kidney or AKI, and urethral bleeding after instrumentation.

Quick exam points

• Always get a RUG before catheterising in suspected urethral injury.
• A pelvic fracture with blood at the meatus means a posterior urethral injury until proven otherwise.
• Unstable patient with renal trauma: surgery. Stable: CT, usually with conservative management.
• Torsion is a clinical diagnosis, and surgery should not wait for imaging.
• Obstruction plus infection needs urgent drainage.