What is the initial treatment approach for a patient presenting with genitourinary trauma, potentially complicated by significant blood loss, shock, and impaired renal function?

Initial Treatment of Genitourinary Trauma

In patients with genitourinary trauma complicated by hemodynamic instability, immediate resuscitation takes priority, followed by rapid hemorrhage control through angioembolization or surgical intervention depending on stability, while hemodynamically stable patients should undergo contrast-enhanced CT imaging with delayed phases to guide non-operative management. 1

Immediate Resuscitation and Stabilization

Hemodynamic Assessment and Initial Management

• Apply external pelvic compression immediately in all patients with suspected pelvic trauma using pelvic binders placed around the greater trochanters, as this is the first-line intervention for controlling pelvic hemorrhage. 1

• Classify patients into hemodynamic categories to guide treatment:

  • Hemodynamically stable: systolic BP ≥90 mmHg, responsive to initial resuscitation 1
  • Transient responders: temporary response to fluids but recurrent instability 1
  • Non-responders (WSES IV): persistent shock despite aggressive resuscitation, requiring immediate operative intervention 1

• Consider Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a bridge to definitive hemorrhage control in hemodynamically unstable patients. 1

Diagnostic Imaging Based on Hemodynamic Status

For hemodynamically stable patients:

• Perform IV contrast-enhanced CT scan with immediate and delayed urographic phases as the gold standard for all suspected genitourinary injuries. 1

• Obtain CT imaging for patients with:

  • Gross hematuria (any hemodynamic status) 1
  • Microscopic hematuria with systolic BP <90 mmHg 1
  • High-energy deceleration mechanism, significant flank trauma, rib fractures, or penetrating injuries regardless of hematuria 1

For hemodynamically unstable patients:

• Obtain pelvic X-ray and E-FAST at bedside during ongoing resuscitation, as these are the only imaging modalities compatible with simultaneous resuscitation efforts. 1

• E-FAST helps identify intraperitoneal bleeding that may require laparotomy versus isolated pelvic/retroperitoneal hemorrhage amenable to angioembolization. 1

• Do not transport unstable patients to CT scanner; proceed directly to angiography suite or operating room based on E-FAST findings. 1

Hemorrhage Control Strategies

Renal Injuries

For hemodynamically stable/stabilized patients:

• Non-operative management (NOM) is the treatment of choice for all grades of renal injury (AAST I-V) in stable patients. 1

• Perform selective angioembolization for:

  • Arterial contrast extravasation on CT 1
  • Pseudoaneurysms or arteriovenous fistulas 1
  • Non-self-limiting gross hematuria 1

• Angioembolization should be performed as selectively as possible to preserve renal parenchyma. 1

• In solitary kidneys with moderate (AAST III) or severe (AAST IV-V) injuries showing arterial extravasation, angioembolization should be considered first-line. 1

For hemodynamically unstable/non-responder patients:

• Immediate operative management is mandatory for WSES IV patients who remain unstable despite resuscitation. 1

• Severe renal vascular injuries (main renal artery or vein) without self-limiting bleeding require surgical intervention, not angioembolization. 1

• During damage control laparotomy, do not explore stable zone II (retroperitoneal) hematomas unless they are expanding. 2

Pelvic Hemorrhage

Angioembolization approach:

• Transfer hemodynamically stable patients with pelvic fractures and arterial bleeding to angiography suite for embolization. 1

• Do not perform routine secondary angiographic verification after initial embolization unless clinical deterioration or CT suggests rebleeding. 1

Surgical pelvic packing:

• Perform pre-peritoneal pelvic packing with external fixation when:

  • Patient too unstable to transfer to CT or angiography suite 1
  • Angioembolization cannot be performed within 60 minutes of diagnosis 1

• This is a temporizing measure until definitive angioembolization, not a substitute. 1

External fixation:

• Apply early external fixation (Ganz clamp or anterior external fixator) in hemodynamically unstable patients with pelvic ring disruption to limit hematoma expansion. 1

• Use Ganz clamp primarily for Tile C fractures after heavy traction (15% body weight) on displaced limb. 1

• Place anterior external fixators inferiorly to allow concurrent laparotomy if needed. 1

Specific Organ Injury Management

Bladder Injuries

• Intraperitoneal bladder rupture requires surgical exploration and primary repair. 1

• Extraperitoneal bladder injuries can be managed non-operatively with urethral or suprapubic catheter drainage for 10-14 days, unless:

  • Bladder neck involvement 1
  • Associated pelvic ring fracture requiring fixation 1
  • Concomitant vaginal or rectal injuries 1
  • Patient requires laparotomy for other injuries 1

• Perform retrograde cystography (not CT cystography) as the diagnostic gold standard, but postpone until after angioembolization if pelvic bleeding requires embolization first. 1

Ureteral Injuries

• Partial ureteral injuries should be managed with ureteral stenting ± percutaneous nephrostomy in the absence of other indications for laparotomy. 1

• Complete transections require operative repair with primary anastomosis or ureteral reimplantation for distal injuries, always with stent placement. 1

• During emergency laparotomy, directly inspect the entire ureter in all high-energy blunt trauma (especially deceleration) and penetrating abdominal trauma. 1

Urethral Injuries

• Suspect urethral injury with post-traumatic urethral hemorrhage, blood at meatus, or inability to void. 1, 3

• Perform retrograde urethrography (95.9% diagnostic accuracy) before attempting catheterization if urethral injury suspected. 4, 3

• Initial management: establish urinary drainage via gentle urethral catheter attempt (if partial injury) or suprapubic catheter (if complete disruption), followed by delayed definitive repair. 4

• Exception: Uncomplicated penetrating anterior urethral injuries in hemodynamically stable patients should undergo immediate primary surgical repair. 4

External Genital Injuries

Penile fracture:

• Diagnose clinically by history of forceful bending during intercourse, audible "pop," rapid detumescence, and ecchymosis. 1

• Immediate surgical exploration and repair reduces erectile dysfunction and curvature compared to conservative management. 1

• Evaluate for concomitant urethral injury (occurs in 10-22% of cases) with retrograde urethrography. 1

Testicular rupture:

• Perform urgent scrotal ultrasound looking for loss of testicular contour and heterogeneous parenchyma. 3

• Immediate scrotal exploration is indicated when rupture confirmed or highly suspected, with debridement of non-viable tissue and tunica albuginea repair. 3

• Early exploration (within 72 hours) significantly increases testicular salvage rates. 1

Critical Pitfalls to Avoid

• Never transport hemodynamically unstable patients to CT scanner; imaging must not delay hemorrhage control. 1

• Do not explore stable retroperitoneal hematomas during laparotomy in unstable patients unless expanding, as exploration increases mortality. 2

• Isolated urinary extravasation is not an absolute contraindication to non-operative management in renal injuries without other surgical indications. 1

• Do not perform nephrectomy reflexively in unstable patients with severe renal injuries; kidney-preserving techniques should be attempted when feasible. 1, 2

• Never delay scrotal exploration when testicular rupture is suspected, as salvage rates decline rapidly after 72 hours. 1

• In children, angioembolization should be first-line even with labile hemodynamics if angiography suite, surgery, and blood products are immediately available. 1