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Falls, assaults, motor vehicle crashes, and sports injuries are the most common mechanisms for blunt GU injuries, whereas gunshot wounds and stab wounds are the most common causes for penetrating injuries.1 The majority of ureteral injuries are caused by penetrating trauma.1–3 Bladder injuries are typically caused by pelvic fracture, with urethral injuries seen in 5% to 10% of pelvic fractures.4 Children are more susceptible to GU injury than the general population. Children lack periadipose tissue, and kidney size is large relative to overall body size.5 Appropriate management will minimize or prevent complications such as renal function impairment, urinary incontinence, and sexual dysfunction.6

Perform an ordered and systematic clinical evaluation to allow for the timely identification and management of GU injuries. To avoid missing GU injury, perform a thorough GU evaluation in all patients with multiple trauma. Consider the mechanism of injury, perform a focused physical examination, and obtain appropriate diagnostic imaging and laboratory testing.


A detailed history is important to determine the time and mechanism of injury and the magnitude of forces involved. Seat location in motor vehicle crashes, use of restraints, speed of the vehicle, and manner in which the crash occurred provide vital information about forces applied to the victim. Any injury caused by rapid deceleration can cause major vascular and parenchymal damage to the kidneys and bladder, even in the absence of symptoms and physical findings. In penetrating trauma, information regarding the caliber of weapon or type of knife involved can help identify the extent of damage. The length of the weapon, any contamination of it, and whether or not it was found or removed intact are key historical components.

An inability to urinate may be due to an empty bladder, or inability to void because of pain, but can also result from bladder perforation, urethral injury, or spinal cord injury.

Physical Examination

Inspect the perineum during the secondary survey. Blood on the underwear or pants is an important finding and may be an indication of genital trauma. Inspect the folds of the buttocks for signs of perineal injury, which may be related to an open pelvic fracture. Do not deeply probe perineal injuries because such examination could result in disruption of a clot. One study reported that 25% of patients sustaining injury to the external genitalia required red blood cell transfusion due to blood loss from genital injury alone.7 Rectal examination identifies sphincter tone, position of the prostate gland, and presence of blood. If the prostate is “missing” or riding high or feels boggy, assume disruption of the membranous urethra until proven otherwise.

In males, examine the scrotum for ecchymoses, laceration, and testicular disruption. Palpate and inspect the penis for ecchymoses, deformity, and blood at the meatus. In females, examine the vaginal introitus for lacerations and hematomas. Lacerations and hematoma can accompany pelvic ...

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