Urogenital Injuries Research Articles

Sports and Genitourinary Traumas

Introduction Statistical data referring to sports-related traumas of the urinary tract are quite scarce; nevertheless, it is possible to draw general data on the relationship between sports and urological traumas. Methods Literature review of peer-reviewed articles published by May 2009. Results Urological traumas account for about 10% of all traumas, and about 13% of them is sports-related. Genitourinary traumas are among the most common cause of abdominal injuries in sports. Blunt injuries are more common than penetrating ones and renal injuries are by far the most common, followed by testicular injuries; ureters, bladder and penis injuries are much more infrequent. Considering chronic microtraumas, injuries of bulbar urethra are also common in sports that involve riding. Overall, the incidence of genitourinary trauma due to sports is low. Renal traumas in sports injuries usually consist of grade 1–11 lesions and usually do not require surgical treatment. Cycling is the sporting activity most commonly associated with genitourinary injuries, followed by winter sports, horse riding and contact/collision sports. Literature data suggest that significant injuries are rare also in athletes with only one testicle or kidney. General preventive measures against sport-related injuries, along with the use of protective cups for male external genitalia, are generally sufficient to reduce the incidence of urogenital trauma. Conclusions Overall, studies show that urogenital injuries are uncommon in team and individual sports, and that most of them are low-grade injuries. Participation in sports that involve the potential for contact or collision needs to be carefully assessed in the athletes with only one testicle or kidney, even though urogenital injuries should not preclude sports participation to an appropriately informed and counseled patient. Further research is needed to acquire more knowledge on genitourinary injuries according to age, sports type and technical skill.

Threatened fertility and gonadal function after a polytraumatic, life-threatening injury

Trauma literature regarding management of genitalia trauma affecting future fertility and gonadal function in the face of coexisting life-threatening injuries is underdeveloped. We present a unique case that necessitated integrative management of a 24-year-old male who became entangled within the blades of a manure spreader and presented with life-threatening trauma in addition to severe genital trauma, including penile degloving, bilateral testicular avulsion and bilateral spermatic cord laceration. During the initial stabilization and surgical management, urology and plastic surgery were consulted to assess the urogenital injuries. Together, the surgical team orchestrated potentially life-saving interventions while successfully performing both a testicular sperm extraction and a testicular revascularization. Viable sperm was collected on the day of surgery and initial follow-up showed preserved sexual function and adequate perfusion to the testicle. This report presents a case and provides a review discussing the management of traumatic genital injuries and the importance of early involvement of surgical specialties in genitalia trauma to optimize future fertility and gonadal function. The literature search was performed in August 2008 using Medline for articles only in English, including any of the following terms: polytrauma, trauma, penis, testicle, degloving, avulsion, spermatic cord, laceration, fertility, reproduction or revascularization.

Genitourinary Injuries in Pelvic Fracture Morbidity and Mortality Using the National Trauma Data Bank

Pelvic fractures from blunt force trauma place the bladder and urethra at risk for injury, often resulting in significant complications. We sought to compare morbidity, mortality, and health care resource utilization in patients with and without genitourinary injuries (GUI) associated with pelvic fractures. In this retrospective study of patients with blunt force pelvic fractures, the incidence of GUI, initial emergency department data, mechanism of injury, morbidity, health care resource utilization, associated injuries, discharge disposition, and mortality were investigated using chi tests for categorical variables and Student's t test for continuous variables comparing pelvic fractures with and without GUI. Multiple logistic regression analysis was used to detect significant predictors of mortality. Of the 31,380 patients with pelvic fractures, 1,444 had GUI. Men more commonly sustained pelvic fractures with GUI than women (66.14% vs. 33.86%). The incidence of urogenital, bladder, and urethral injuries for men and women was 5.34%, 3.41%, 1.54%, and 3.62%, 3.37%, 0.15%, respectively. Patients with GUI remained hospitalized longer (median 10 vs. 6 d, p < 0.001), had more intensive care unit stay days (median 3 vs. 1 d, p < 0.001), were less often discharged home (31.02% vs. 42.82%), and had an increased mortality rate (13.99% vs. 8.08%, p < 0.001) when compared with patients without GUI. Motor vehicle collisions were the most common mechanism of injury for all pelvic fractures. Spleen and liver were the most commonly injured abdominal organs associated with pelvic fractures as a whole. Pelvic fractures with GUI were more likely to result in associated injuries of the bowel, and reproductive organs. Although GUI was not found to be an independent predictor of mortality, age >or=65 years, initial systolic blood pressure in the emergency department 0 mm Hg to 90 mm Hg, Injury Severity Score >or=25, Glasgow coma score of <or=8, and female gender were independent predictors of mortality. Patients sustaining a pelvic fracture with GUI have an increase in morbidity. Although GUI was not an independent predictor of mortality, patients who sustained a pelvic fracture with GUI had a greater number of concomitant injuries resulting in an increase in overall mortality compared with those without an associated GUI.

Operative Management of Wartime Genitourinary Injuries at Balad Air Force Theater Hospital, 2005 to 2008

We detail the 3-year experience of operative combat urology of genitourinary surgeons stationed at Balad Air Force Theater Hospital, Balad, Iraq. We performed an institutional review board approved, retrospective review of operative logs of the 9 urologists deployed to Balad Air Force Theater Hospital from June, 1 2005 to June 1, 2008. All operative cases performed by the urologists deployed to this facility were reviewed. Patients were grouped by injury location and operative approach. Analysis included the calculation of relative injury rates by location and the incidence of organ preservation. During the 36 months reviewed 273 patients underwent a total of 361 operative and 25 endoscopic procedures for 1 or more genitourinary injuries. Of the patients 227 (83.1%) had wounds to the lower genitourinary tract, 39 (14.3%) had wounds to the upper genitourinary tract and 7 (2.6%) had upper and lower genitourinary injuries. Exploration, débridement and repair of soft tissue injury to the external genitalia were the most commonly performed procedures. Of the 88 testicular injuries explored testicular salvage was achieved in 45 (51.1%). Nephrectomy was required in 17 of the 27 operative renal injury cases (63.0%). Most genitourinary injuries treated at Balad Air Force Theater Hospital involve the lower genitourinary tract. The high frequency of genital trauma often requires staged reconstructive procedures. Acceptable renal and testicular salvage rates are attainable. This study highlights the diverse array of surgical treatment modalities needed to manage genitourinary trauma during Operation Iraqi Freedom.

Urogenitale Begleitverletzungen bei Beckenringfrakturen

Follow-up of patients with pelvic ring fractures and associated injuries of the lower urogenital tract was performed from January 2000 to October 2004. Analysis focused on incidence, fracture type, type of urogenital injury, associated intrapelvic lesions, mortality, and urologic outcome. The retrospective study included 18 of 111 patients (16.2%). Nine patients had a rupture of the urethra, six a rupture of the bladder, three a rupture of the penile root, and two a gonadal defect. The type of the pelvic ring fracture according to the AO classification was type A in 1, type B in 6, and type C in 11 cases. Fifteen patients (83.3%) were followed up clinically for a mean duration of 26 months (range: 12-66 months) after trauma. Seven patients were asymptomatic concerning the urogenital injury, five had erectile dysfunction, two had urethral stenosis, in one case associated with incontinence, and one patient with bilateral defect of the testicles was under hormone substitution therapy. Urogenital injuries, often associated with intrapelvic lesions in so-called complex pelvic trauma, are typical for high-grade pelvic ring fractures and have an essential prognostic value for the patient's morbidity and quality of life.

Maternal morbidity and mortality associated with delivery after intrauterine fetal death

To determine the maternal morbidity and mortality associated with delivery after intrauterine fetal death (IUFD) and to find out the place of fetal destructive procedures and cesarean section. Cross-sectional study. Labour Room, Nishtar Hospital, Multan from January to December 2003. All women were included in the present study who presented before the onset of labour pains, after intrauterine fetal death at 26 weeks or onward with singleton pregnancy. Assessment of maternal demographic characteristics, gestational age at fetal demise, delivery-IUFD interval, mode of delivery; vaginal with or without fetal destructive procedures/cesarean section and maternal complications were the main outcome measures. There were 1834 live birth and 63 deliveries with intrauterine fetal death. Mode of delivery was vaginal in 87.4% and cesarean section in 12.6% of the cases. Twelve (21%) of the vaginal deliveries were complicated by lower urogenital tract injuries in certain cases, whereas 75% (6/8) of patients delivered by cesarean section developed major postoperative complications like postpartum haemorrhage, shock, endometritis, peritonitis and wound dehiscence. No maternal death was identified. Rate of delivery with intrauterine fetal death was 34.3/1000 live-birth deliveries. Maternal morbidity like perineal tear, urinary tract infection, menstrual disorder and even secondary infertility may follow after vaginal mode of delivery by forceps and destructive procedures. The frequency and severity of complications after cesarean delivery are quite higher and may rarely lead to even maternal death.

Traumatische Hemipelvektomie

With an incidence of only 0.6% of all pelvic injuries, traumatic hemipelvectomy is a rare event. It is defined as open or closed avulsion of one hemipelvis with occlusion or disruption of the main vessels and lengthening or disruption of the nerves, often complicated by urogenital or anorectal injuries. The mechanism of injury in this case is a typical one with extreme abduction and external rotation of the leg, causing sacroiliac joint disruption and symphysis separation. Two other mechanisms described are avulsion when the leg becomes entangled in a piece of machinery or a massive crushing at the groin. After a fast treatment in the field, the patient described was treated with immediate open revision, tamponade and stabilization of the pelvis. Upper leg preservation by reconstruction of the femoral vessels with vascular prostheses was attempted. Because of a broad necrosis of soft tissues, early completion of the hemipelvectomy was performed. The patient recovered well. Miction and bowel evacuation as well as sexual function could be preserved. The resulting quality of life is high and the patient is socially reintegrated without problems.

The epidemiology of trauma of the genitourinary system after traffic accidents: analysis of a register of over 43 000 victims

To analyse the frequency and type of injury to the genitourinary system, by user category, after traffic accidents. The register which forms the basis of this study is unique in Europe and includes 43,056 victims of road traffic accidents, and was compiled between 1996 and 2001. The categories of road users included: motorists, motorcyclists, cyclists, pedestrians, van and bus users, and roller skaters. The urological complication rate was analysed for each category. In all, 199 cases of trauma of the genitourinary system (0.46%) were recorded. The most frequent urological complications were renal (43%) and testicular trauma (24%), the former most frequent in motorists (65%) and pedestrians (29%), and the latter in motorcyclists (41%). An analysis of this register provides better knowledge of the urogenital injuries after traffic accidents. Renal and testicular injuries are the most frequent.

Akzidentelles Seitspagat als Ursache eines komplexen Beckentraumas

Complex pelvic ring fractures are defined as injuries of the pelvic ring in association with lesions of the pelvic organs or the pelvic soft tissues. These injuries are typically caused by high-energy accidents. In contrast to the typical mechanism of injury a case is described in which a low energy trauma led to a complex pelvic ring trauma. An obese woman suffered an open-book injury of the pelvis with severe open urogenital soft-tissue damage by accidentally doing forced splits. Primary stabilization of the pelvic ring with external fixation and secondary internal fixation with a double-plate osteosynthesis of the symphysis led to a good clinical outcome concerning the osseous lesion. The urogenital injuries with rupture of the bladder, the urethra and the vagina led despite immediate urological management to an incontinence, which finally required definitive urine drainage via an ileum conduit.

Epidemiologic study of 284 patients with urogenital trauma in three trauma center in Tehran.

To perform an epidemiologic study of urogenital injuries in traumatic patients who were referred to three traumatic centers in Tehran during one year. This study included a part of data of National Trauma Registries, which was performed within one year. Questionnaires were completed by trained staff in three different geographical regions of Tehran: Shohada-e-Tajrish hospital (north of Tehran), Sina hospital (south of Tehran), and Shaheed Faiazbakhsh (west of Tehran). Two hundred and eighty four (5%) out of 57367 patients who were referred to the above mentioned centers had genitourinary trauma, of whom, 145 (42%) were hospitalized. Males with a frequency of 92% (258 patients) were the most injured group. Patients mean age was 25+/-14 years, mostly between 20 and 29 years (33.6%) followed by 10-19 years age group with a frequency of 25.6%. Non-penetrating trauma with a frequency of 96% was the most common type and accident was the most mechanism of trauma. One hundred and one patients out of the studied population had associated injuries. The most frequent injuries were occurred in extremities (40%) and the less in head and neck (7%). There were 22 (21.7%) intra-abdominal organ injuries. Sixty nine percent of patients developed mild injury (ISS<7), 20% developed severe injury and (ISS>12), and 4.2% of patients died. The most common injured organ was kidney (3.3%) and the least one was ureter, as no ureteral injury was reported. Although a low percentage of traumatic patients develop urogenital injuries, disregarding these injuries may lead to serious complications and it is recommended to consider these injuries while dealing with such patients. Considering the fact that these complications which could be preventable, are mostly developed in the youth, making solution for such problem is recommended.

Urological emergencies

Urological emergencies that require specialist treatment include testicular torsion, gross hematuria, urogenital injuries and acute flank pain. After initial symptoms-adapted therapy, patients should be transferred immediately to an urological department for imaging (e.g. ultrasound, IVP, CT) and further specific examinations (e.g.blood tests, urine analysis, microbiology). Acute lower abdominal and scrotal pain in young men may be symptomatic of testicular torsion, which requires immediate urological surgery. Gross hematuria is usually not a life-threatening emergency. Nevertheless, urogenital tumor has to be ruled out by an urologist. Patients with urogenital injuries are triaged into surgical and non-surgical treatments. Differential diagnosis of acute flank pain falls into several medical fields. After initial symptom-related therapy, further diagnostic procedures have to be performed. Septic presentation may be symptomatic of infectious hydronephrosis which requires immediate urological intervention.

Surgical Management of Urogenital Injuries at A War Hospital in Bosnia-herzegovina, 1992 to 1995

Our experience with urogenital surgery during the Bosnia-Herzegovina conflict of 1992 to 1995 is compared with data from previous wars and peacetime practice. A total of 5,370 wounded patients, including 136 (2.5%) with 1 or more urogenital injuries, were treated at a war hospital in northern Bosnia-Herzegovina during 37 months. The hospital was based at a village school and was poorly equipped but it was only 10 to 16 km. from the front line and average transportation time was 30 minutes. Of the 136 patients 72 (52.9%) were injured by explosive weapons, while the other 64 (47.1%) had bullet wounds. The 169 urogenital injuries were to the kidney in 65 cases (38.5%), scrotum in 44 (26%), bladder in 23 (13.6%), penis in 16 (9.5%), urethra in 9 (5.3%), ureter in 6 (3.6%) and other in 6. There was associated damage to organs other than the urogenital system in 116 patients (85.3%). Preference was given to organ sparing operations when possible, but 33.8% of renal injuries required nephrectomy and orchidectomy was performed for 58.3% of testicular injuries. In war settings when injuries are often severe and multiple, and the hospital may lack staff, instruments and other medical supplies, the surgeon frequently must improvise. Even so, the results achieved need not fall far below those of peacetime surgery provided that, as in this hospital in Bosnia-Herzegovina, wounded patients present to the surgeon rapidly, they are young and the surgeons are experienced with the management of war injury.

Urogenital Tract Trauma in Port Harcourt

.A retrospective study of urogenital tract injuries treated in the Urology Unit of Port Harcourt University Teaching Hospital from January 1985 to December 1994 was done. There were 67 injuries in 62 patients. Fifty-five (82%) of these were blunt injuries. Males were more frequently injured (85%) than females. Patients younger than 60 years sustained 61 of the 67 injuries (91%) with peak incidence in the age groups 0–10 years (22%) and 21–30 years (28%). The urethra was the most frequently injured structure (49%) followed by the bladder (24%). The anatomically secured kidney and ureter as well as the fairly mobile penis and scrotum were much less frequently injured. The commonest aetiological factor was road traffic accident (57%). There were ten injuries (15%) resulting from industrial activities. Eight injuries (12%) were iatrogenic.Treatment was successful in 52 injuries (78%). It was satisfactory in the few urethral injuries that required repeated dilations. Four injuries (6%) resulted in permanent disability. There were two deaths (2%) both from iatrogenic causes involving an ureteric injury at hysterectomy and haemorrhage from cultural circumcision in the village. Prevention is the most effective way to avoid these injuries.

Urogenital injuries in childhood: a strong association of bladder trauma to bowel injuries.

We analysed the inter-relationships of the cause and the type of trauma, the presence of pelvic fracture, the associated intraabdominal organ injuries, and the morbidity and mortality rates in 154 patients presenting and being treated for UGT between 1983 and 1997. The cause of injury was blunt in 77% of cases and penetrating in 13%. The most frequently injured organs were kidney followed by urethra and bladder. Bowels, liver and spleen were the most frequently associated injured organs. Moreover, bladder injuries were strongly associated with bowel injuries (p < 0.0001). Hemodynamically normal 49 children with minor or major kidney injuries were managed conservatively. Hemodynamically non-stable 11 patients were explored. The majority of urogenital injuries can be managed conservatively even when associated with intraabdominal organ injuries. Solid genitourinary organ injuries may accompany more frequently to intraperitoneal solid organ injury. Whereas, non-solid genitourinary organ injuries may more frequently associated with injuries of intraperitoneal hollow viscus.

Aktuelle Therapie der Verletzungen von Colon und Retroperitoneum

Injuries of the colon and retroperitoneum are rarely observed after blunt abdominal trauma and occur in about 5 - 20 % of the patients. The majority of complications are due to initial misdiagnoses and a delay in treatment. Lesions of the pancreas and duodenum are the most frequent diagnoses in the retroperitoneal space, while major vascular traumata or urogenital injuries are rare. Retroperitoneal hematoma are most likely due to pelvic fractures. The survival of patients after colon or retroperitoneal injuries depends on the severity of concomitant organ trauma, the time of diagnosis, and a situation-adapted therapeutic strategy. The treatment of the typical caudal retroperitoneal hematoma following pelvic fractures is conservative in most patients. Early pelvic stabilization, e. g., with external fixation, is recommended in these patients. Central retroperitoneal hematoma in the supra - or inframesocolic space should be treated surgically, as major vascular injuries are most likely in these patients. Duodenal or pancreatic injuries need surgical exploration in the majority of patients; the therapeutic spectrum ranges from simple sutures to pancreatoduodenal resection. The treatment of colon injuries depends on the degree of peritonitis and the severity of concomitant trauma. Early diagnosed injuries are suitable for primary repair, while deviation stomata or a Hartmann procedure with or without resection should be offered to patients with delayed diagnoses, peritonitis, or severe concomitant diseases. Long-lasting procedures should be abandoned in the emergency situation; in these severe cases, laparotomy should be aimed towards primary "damage control" and followed by definite surgery after stabilization of the patient.

Therapeutic Urogenital Modalities during the Last Three Years of the Iran and Iraq War (1985–1987)

Research projects in the field of military medicine have a central role in medical logistical planning. Treatment of traumatic lesions (including urogenital system injuries) is an important aspect of military medicine. Triage for urogenital injuries has specific problems and points of concern. The purpose of this study was to evaluate the role and different types of therapeutic modalities in the treatment of urogenital injuries during the final 3 years of the Iran and Iraq War (1985-1987). In a descriptive-analytical study, records of 1,094 patients with urogenital injuries hospitalized from 1985 to 1987 were studied. A checklist and the Statistical Program for the Social Sciences (version 6) were used for data collection and analysis, respectively. A chi 2 test interpreted part of the data. The highest incidence of urogenital injuries and the highest rate of surgical interventions for urogenital injuries were in 1986 and 1987, respectively. The total incidence of urogenital injuries was 0.51%. Among all surgical interventions, bladder repair was most frequent and ureteral repair was least frequent. Partial nephrectomy was the second most frequent surgical intervention and was performed more often than total nephrectomy. There was a significant difference between the urogenital surgery rate and the total surgery rate (chi 2 = 148, p = 0.000). The results suggest progress in the triage of patients with urogenital injuries. The lower incidence of urogenital injuries, however, should be interpreted cautiously because it may be attributable to different combat field conditions. Follow-up studies in this group of patients are necessary.

War Injuries of the Ureter

During the 18 months of war in Croatia, from 1991 until 1992, 4,425 wounded patients were treated at Clinical Hospital Osijek. Urogenital injuries were present in 115 treated patients (2.6%), and among them ureteral injuries were present in 11 patients (9.5%). The ureteral injuries were discovered by chance during exploratory abdominal surgery performed for other accompanying injuries. Ureteroureteral anastomosis was done in three cases. In three cases ureterocystoneostomy was performed. Exploration only was performed in three cases and nephrectomy was performed in two cases. It is important to emphasize that in three cases with contusions of the ureter wall that were not surgically reconstructed, the final result was ureteral stenosis. Moreover, in one case the final result was complete obliteration of the ureteral lumen.

Urogenital War Injuries

Out of 1,350 war casualties treated at the University Hospital Rebro during the defensive war in Croatia, 60 (4.4%) injuries of the urogenital tract were present. Among these 60 casualties, 51 (85.0%) had multiple injuries, most often abdominal and urogenital. These patients were accordingly treated by combined urological and surgical teams. Regarding injuries, there were 21 kidney injuries, 11 ureter (2 patients had bilateral injuries), 7 urinary bladder, 2 urethral, 15 testicular, and 6 penile injuries subjected to surgical treatment. Nephrectomy was performed in 6/21 patients with kidney injuries. Orchiectomy was performed in 40% of patients with testicular injuries. In the remaining patients with urological tract injuries, surgical reconstruction with organ conservation was performed.

Croatian experience in the treatment of 629 urogenital war injuries.

During the war in Croatia, from April 1991 until November 1993, 33,468 wounded persons were reported, and 24,865 of them were hospitalized. Out of the total number of the hospitalized persons 588 wounded suffered 629 injuries of the urogenital system. This study reports on the experience in the treatment of such injuries at 17 urological and surgical institutions.

The interpretation of urogenital findings in children with straddle injuries

Because urogenital trauma frequently raises the question of sexual abuse, it is important to be able to relate the mechanism of injury to expected examination findings. This study was undertaken to characterize the trauma that results from straddling and correlate such injuries with the history, examination, and patient characteristics. The charts of 100 patients examined in an urban pediatric emergency department were reviewed; their conditions met the criteria of straddle injury—a blow to the perineum as a result of falling or striking a surface or an object with the force of one's own body weight. Ages ranged from 9 to 187 months (mean, 77.9; median, 67.2); 72% were female. Most injuries were minor lacerations and abrasions of the genitalia. Eleven percent had injury to the posterior fourchette. Hymenal and vaginal injuries were primarily caused by penetrating mechanisms. Five patients who presented with a history of straddling subsequently received the diagnosis of sexual assault based on disclosure by the patient or a witness and inconsistency of physical findings. There were no urethral or perianal injuries resulting from nonpenetrating straddle mechanisms. Straddle injuries include a variety of mostly minor urogenital injuries. Perianal, hymenal, or vaginal trauma suggests a penetrating mechanism, either unintentional or from sexual assault. An investigation for sexual assault should be initiated in the following cases: infants younger than 9 months of age; perianal, hymenal, or vaginal injury; extensive or severe injury; concurrent nonurogenital injuries; and whenever there is lack of correlation between history and physical findings.