You are in: eMedicine Specialties >
Emergency Medicine > TRAUMA AND ORTHOPEDICS
Trauma, Lower Genitourinary
Article Last Updated: Nov 8, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Imad S Dandan, MD, Consulting Surgeon, Department of Surgery, Trauma Section, Scripps Memorial Hospital
Imad S Dandan is a member of the following medical societies: American College of Surgeons, American Medical Association, American Trauma Society, California Medical Association, and Society of Critical Care Medicine
Coauthor(s):
Walid Farhat, MD, Fellow, Department of Surgery, Division of Urology, The Hospital for Sick Children at Toronto
Editors: David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
lower genitourinary trauma, lower GU trauma, renal trauma, renal injury, multiple trauma, GU trauma, upper GU tract injuries, ureteral trauma, ureteral injury, kidney trauma, kidney injury, urethral injuries, straddle-type injuries, bladder injury, extraperitoneal bladder injuries, intraperitoneal bladder injuries, bladder trauma, penile trauma, scrotal trauma, urethral trauma
Background
Injuries to the lower genitourinary (GU) tract alone are not life threatening, but their association with other potentially more significant injuries necessitates an organized approach to diagnosis and management. Because trauma is a multisystem disease, multiple injuries may be present in the trauma patient. Other injuries often take priority over injuries to the GU system and may initially interfere or postpone a complete urologic assessment. Coordinated efforts between various services caring for the patient are crucial to ensure comprehensive care.
Initial evaluation of the injured patient suspected to have GU trauma should not differ from that of other trauma patients. Follow the protocols of the Advanced Trauma Life Support program of the American College of Surgeons.
Pathophysiology
The lower GU tract comprises the urinary bladder, urethra, and external genitalia.
Most bladder injuries occur in association with blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures, with the remaining 15% occurring with penetrating trauma and blunt mechanism not associated with a pelvic fracture (ie, full bladder blowout).
Urethral injury is predominantly a male problem. In males, the urethra is divided into the proximal (posterior) segment and the distal (anterior) segment by the urogenital diaphragm. The anterior urethra is further divided into membranous (sphincteric) and prostatic segments. About 3 cm long, the posterior urethra extends from the bladder to the urogenital diaphragm.
Injuries to the posterior urethra are mostly secondary to pelvic fractures, while injuries to the anterior urethra are caused by straddle-type (eg, bicycles, skateboards) or penetrating (often self-inflicted) injuries. Urethral injuries from trauma constitute only 10% of all GU injuries, with iatrogenic etiology constituting a significant fraction of all urethral injuries.
Injuries to the external genitalia (ie, the penis and the scrotum) are usually secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation (self-inflicted or otherwise).
Frequency
United States
Three to ten percent of all trauma patients have injuries involving the GU tract, while 10-15% of trauma patients with abdominal injuries have associated GU tract involvement. Urethral injuries constitute 10% of all injuries to the GU tract, with bladder injuries comprising another 40%.
Mortality/Morbidity
Mortality from lower GU trauma is attributed to associated injuries, especially pelvic fractures.
Sex
Urethral trauma is primarily a male problem.
Age
Urethral trauma affects all age groups but seems to have a higher incidence in persons aged 15-25 years.
History
In blunt trauma, history is obtained regarding the time and mechanism of injury, eg, the position of the patient in a motor vehicle accident (MVA) and whether restraints were used. The speed of the vehicle and the manner in which the accident occurred provide information about forces applied to the victim.
In penetrating trauma, knowing the size of the stabbing weapon or the caliber of the gun and the distance from which it was discharged helps in assessment. Question paramedics as to the condition of the patient immediately after injury occurred and during transport to the care facility.
In patients with GU trauma, symptoms are nonspecific and may be masked by or attributed to other injuries.
- Bladder trauma
- In the ED, question the patient about suprapubic abdominal pain and the ability to void after the injury.
- If the patient cannot provide such information and gross hematuria is present, suspect bladder injury.
- Urethral trauma
- Knowledge of associated injuries that can cause urethral injury is required for diagnosis.
- A history of inability to void indicates the possibility of urethral trauma.
- In external genitalia trauma, a history of psychiatric problems, use of penile rings, and excessive sexual activity is pertinent in specific conditions. A history of sudden pain, loss of erection, and swelling is important.
Physical
Signs of lower GU injury are a small part of a massive conglomeration of signs related to associated injuries; therefore, always keep a high index of suspicion.
- Bladder trauma
- Bruising or edema of the lower abdomen, perineum, or genitalia indicates bladder injury.
- Always suspect urethral and bladder injuries in patients with pelvic fractures and inability to void.
- Inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury.
- Urethral trauma
- The classic sign is blood at the meatus.
- Penile or perineal edema and/or hematoma are present in anterior injuries.
- A distended bladder may be present in posterior injuries, as 65% of posterior injuries are complete transections.
- Penile trauma
- Loss of skin
- Edema
- Angulation
- Level of mutilation
- Viability of mutilated segment
- Scrotal trauma
- Edema
- Loss of skin
- Discoloration
- Condition of testes
Causes
Bladder injuries are best classified as intraperitoneal and extraperitoneal. Extraperitoneal bladder injuries account for 65-85% of bladder injuries and are usually associated with pelvic fractures, especially pubic ramus fractures (95%). Intraperitoneal bladder injuries account for 15-35% of bladder injuries and are infrequently associated with pelvic fractures. These injuries may be due to blunt rupture of a distended bladder or penetrating injury.
Blunt trauma is responsible for 60% of urethral injuries, and penetrating and iatrogenic etiologies cause 40%. Blunt injury in the anterior urethra usually is caused by a straddle-type mechanism compressing the urethra between a hard object and the symphysis pubis. In 70% of patients, penetrating trauma to the anterior urethra involves the perineum and bulbar urethra, and in 30%, the pendulous urethra is involved.
Posterior urethral injury in blunt trauma is secondary to pelvic fractures because of proximity to the bony pelvis. Missiles and knives can also cause penetrating injury to the posterior urethra.
In gunshot wounds, look for associated injuries to the pelvis, bladder, rectum, and sphincter mechanism.
- Main causes of bladder injuries
- MVAs
- Bicycle accidents
- Stabbings
- Impalements
- Gunfire
- Iatrogenic
- Main causes of urethral injuries
- Straddle-type mechanism (eg, bicycles, skateboards, falls onto the perineum)
- MVAs
- Mutilation (self-inflicted or otherwise)
- Gunfire
- Stabbings
- Iatrogenic
Trauma, Upper Genitourinary
Lab Studies
- Complete blood count (CBC) to obtain a hematocrit and a platelet count
- Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to check for coagulopathy
- Blood type and crossmatch
- Urinalysis to assess for gross hematuria
Imaging Studies
- Plain radiograph of the pelvis to assess presence and extent of bony injury
- Retrograde urethrogram
- This is indicated prior to the insertion of a Foley catheter when urethral injury is suspected.
- Urethrography is performed with water-soluble contrast material and preferably under fluoroscopy. If fluoroscopy is unavailable, multiple plain films are obtained with 10-mL injections of contrast material into the distal urethra.
- Extravasated contrast material indicates urethral trauma.
- Retrograde cystogram
- Cystography is the most reliable and easily available modality. A water-soluble contrast material is used, and, initially, 250 mL are introduced through the Foley catheter.
- If the patient reports no discomfort, another 150 mL are introduced, and the catheter is clamped.
- Obtain and view anteroposterior and lateral radiographs of the lower abdominal area; obtain identical views after the patient empties his or her bladder. Latter views provide information about posterior extraperitoneal injuries that may not be detected when the bladder is full.
- Flame-like extravasations (sunburst) superior or lateral to the bladder indicate extraperitoneal rupture.
- Extravasated contrast material throughout the peritoneal cavity, which could outline the bowel and fill the cul-de-sac and the paracolic gutters, indicates intraperitoneal rupture. Pericystic hematomas may be seen on cystograms as compression or displacement of the bladder.
- Gross hematuria without extravasation indicates bladder contusion. Extravasation of contrast material into the bowel lumen or into the vagina is possible in penetrating trauma.
- CT scan of abdomen and pelvis
- CT scanning is specific in aiding in the diagnosis of bladder injuries but carries low sensitivity.
- CT scanning is useful for diagnosis of associated abdominal and pelvic injuries.
- Ultrasonography
- Ultrasonography is used as a screening tool to indicate bladder wall abnormalities or presence of fluid in the abdomen but suffers from low sensitivity in excluding bladder injury.
- It is also used in assessing the condition of the testes.
- Ultrasonography may be useful in the acute setting of abdominal trauma as part of the focused abdominal sonography in trauma (FAST) examination of the injured patient.
- Simultaneous suprapubic cystography and retrograde urethrography
- If the urethrogram is inconclusive and the patient still cannot void with a distended bladder, a suprapubic cystostomy catheter is inserted pending further investigation.
- This is the procedure of choice about a week after the injury.
- Radionuclide scan to assess the viability of the testes, especially after blunt trauma
Procedures
- Bladder irrigation: Bladder rupture is indicated by inability to retrieve the total amount of the irrigant.
Prehospital Care
Advancement of prehospital care for the trauma patient is one of the biggest leaps forward in trauma care. Principles do not change with varying organ injuries.
- Paramedics quickly assess the patient and mechanism of injury, especially for patency of ABCs.
- Establish an airway if needed and/or administer oxygen.
- Establish 2 large-bore IVs.
- Take cervical spine precautions (eg, hard collar, back-board).
- Leave the scene as soon as possible and quickly transport the patient to the trauma center.
Emergency Department Care
- Administer oxygen and ventilatory support if needed.
- Resuscitate with crystalloids (lactated Ringer solution or isotonic sodium chloride solution) and blood (O-negative packed red blood cells) if indicated.
- Treat life-threatening injuries (eg, tension pneumothorax, open pneumothorax, cardiac tamponade) should be addressed emergently in the ED.
- Use diagnostic procedures as indicated (cystogram and retrograde urethrogram).
Consultations
- Trauma surgeon for associated intra-abdominal injuries
- Urologist for lower GU tract injury
- Orthopedic surgeon for management of frequently associated pelvic fractures
- Other specialists as injuries require
Medications for patients with lower GU tract injuries relate to the management of patients as critically injured rather than management specific to the GU injury.
Drug Category: Antibiotics
Used for prophylaxis against infections of the GU tract. Empiric antimicrobial therapy must be comprehensive, covering all likely pathogens in the clinical setting.
| Drug Name | Ampicillin and sulbactam (Unasyn) |
|---|
| Description | Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens. |
|---|
| Adult Dose | 1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 (2 g ampicillin + 1 g sulbactam) g IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin |
|---|
| Pediatric Dose | <3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Probenecid and disulfiram decrease renal excretion and increase antibiotic levels; allopurinol increases excretion; also may potentiate ampicillin rash and decrease effect of PO contraceptives |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
|---|
| Precautions | Dose adjustment may be required in patients diagnosed with renal failure; mononucleosis increases incidence of rash with ampicillin-sulbactam therapy; carefully evaluate rash appearance to differentiate a nonallergic ampicillin rash from a hypersensitivity reaction |
|---|
| Drug Name | Cefotetan (Cefotan) |
|---|
| Description | Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.
Dosage and route of administration depends on condition of patient, severity of infection, and susceptibility of causative organism. |
|---|
| Adult Dose | Loading dose: 2 g IV
Maintenance dose: 1-2 g q12h IV/IM for 5-10 d |
|---|
| Pediatric Dose | 20-40 mg/kg/dose IV/IM q12h for 5-10 d |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Alcoholic beverages consumed concurrently <72 h after taking cefotetan may produce acute alcohol intolerance (disulfiramlike reaction); hypoprothrombinemic effects of anticoagulants may be increased; monitor renal function in patients receiving potent diuretics (eg, loop diuretics); risk of nephrotoxicity may be increased; aminoglycoside nephrotoxicity may potentiate effects in the kidney when used concurrently; monitor renal function closely |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
|---|
| Precautions | Reduce dosage by a half for patients with CrCl of 10-30 mL/min and by a quarter for patients with a CrCl of <10 mL/min; antibiotics (especially prolonged or repeated therapy) may result in bacterial or fungal overgrowth of nonsusceptible organisms, leading to a secondary infection; take appropriate measures if superinfection occurs |
|---|
Drug Category: Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma.
| Drug Name | Fentanyl (Sublimaze) |
|---|
| Description | A synthetic opioid that is 75-200 times more potent and much shorter half-life than morphine sulfate. Has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal-to-no associated histamine release. By itself, it causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process.
Consider continuous infusion because of the short half-life of fentanyl.
Parenteral form is DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period.
Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.
After initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than q3h or q6h thereafter.
Transdermal form is used only for chronic pain conditions in opioid tolerant patients. When using transdermal dosage form, majority of patients are controlled with 72 h dosing intervals; however, some patients require dosing intervals of 48 h.
Easily and quickly reversed by naloxone. |
|---|
| Adult Dose | Emergency: 0.5-2 mcg/kg/dose IV/IM
Analgesia: 0.5-1 mcg/kg/dose IV/IM q30-60min
Transdermal: Apply a 25 mcg/h system q48-72h |
|---|
| Pediatric Dose | <2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg/dose IV/IM q60min
>12 years: Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; hypotension or potentially compromised airway where it would be difficult to establish rapid airway control |
|---|
| Interactions | Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation |
|---|
| Drug Name | Morphine sulfate (Astramorph, Duramorph) |
|---|
| Description | DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained. |
|---|
| Adult Dose | Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose |
|---|
| Pediatric Dose | Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose |
|---|
| Contraindications | Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult |
|---|
| Interactions | Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate |
|---|
Further Inpatient Care
- Bladder contusion
- Adequate drainage of the bladder should result in resolution within a few days.
- Follow-up cystography is recommended to assess integrity of the bladder wall.
- Intraperitoneal rupture
- Intraperitoneal rupture is surgically repaired with a watertight stitch and absorbable suture.
- Adequate drainage with a urethral catheter and suprapubic cystostomy catheter for 10 days should be provided.
- A cystogram should be performed to assess the integrity of the repair before removing catheters.
- The urethral catheter should be removed and the postvoid residuals should be checked for to ensure adequate bladder evacuation before removing the suprapubic cystostomy catheter the following day.
- Extraperitoneal rupture
- Cystogram should be performed after 7-10 days with adequate bladder drainage and broad-spectrum antibiotics.
- The catheter should be removed if extravasation has resolved, but if the extravasation is persistent, surgical intervention is required.
- Persistent severe hematuria and infection of the pelvic hematoma are contraindications to conservative therapy.
- Surgical repair is performed by opening the dome of the bladder and repairing the laceration from within.
- Penetrating injuries
- The preferred method is surgical intervention; open the dome of the bladder and perform a full inspection.
- Indigo carmine IV injection is used to help identify distal ureters.
- Management of urethral injuries - Related to type of injury sustained, but basic principles apply
- Bladder should be drained with a suprapubic catheter percutaneously or open technique to prevent further extravasation.
- Initial urethral repair is not recommended because of risk of hemorrhage, impotence, and infection of pelvic hematoma.
- Commence definitive management of urethral injuries after stabilizing the patient and attending to associated injuries.
- Repair can be performed as immediate primary closure, delayed primary closure (10-14 d), or late primary closure (>3 mo).
- Management of penile injuries - Depends on severity of trauma and extent of tissue damage
- Treat penile skin injuries by debridement and split-thickness skin grafting.
- Penile fractures are ruptures of the Buck fascia and the corpus cavernosum that occur when the penis is subjected to trauma during erection.
- Symptoms are immediate pain with loss of erection followed by edema.
- Urethral injury is reported in 23% of patients.
- Management is conservative with spontaneous resolution rates of 90%.
- The remaining 10% of patients require surgical intervention with evacuation of the hematoma and repair of Buck fascia with absorbable sutures.
- Give preference to treating penile mutilation (self-inflicted or otherwise) by replantation, if the warm ischemia time does not exceed 4 hours.
- Conduct microvascular repair of dorsal vein and both arteries with repair of urethra, Buck fascia, and skin.
- Place the amputated segment in cold, lactated Ringer solution containing heparin and antibiotics to prolong ischemia time.
- If replantation is not possible, debridement is followed with skin closure constructed with a spatulated urethra-to-skin anastomosis.
- Dirty wounds may have to be left open after debridement.
- Manage penile strangulation by removal of the strangulating object, administration of antibiotics, and debridement of all necrotic skin. Skin grafting is required if primary repair of the skin is not possible.
- Blunt trauma
- Radionuclide scan or ultrasonography can help assess the condition of the testes.
- Surgical exploration and repair of ruptured testis reduces pain and duration of recovery.
- If scrotal skin loss is significant, the testes can be moved to an alternate location (ie, to the perineum or subcutaneously).
- The skin is debrided and closed.
- Over time, the scrotum dilates and the testes can be returned.
Further Outpatient Care
- Further outpatient care in the patient with lower GU tract trauma mainly depends on the extent of associated injuries. The need for rehabilitation secondary to either orthopedic or neurologic injuries must be assessed on a patient-by-patient basis.
- Arrange for follow-up care for delayed repair of urethral injuries.
- Penile injuries require close follow-up care, especially if skin grafting was performed.
- Perform follow-up hormonal studies and semen analysis on patients with scrotal or testicular injuries.
In/Out Patient Meds
- Use prophylaxis against infections of the GU tract, especially for penile injuries.
Transfer
- Assess capabilities of the ED to handle the patient with multiple injuries that include lower GU trauma; the decision to transfer is based on that assessment.
- Treat all life-threatening injuries prior to transfer; stabilize and resuscitate the patient.
- The responsibility of the transfer, choice of transfer modality, and selection of accepting facility lies with the transferring physician.
- The receiving physician confirms the ability of the receiving institution to handle the patient's condition.
- An institutional transfer protocol facilitates the transfer process.
- Lower GU trauma patients benefit from transfer when the following conditions exist at the transferring center:
- CT scan not available
- No staff urologist
- Multiple injuries that surpass hospital's resources
- Unavailability of specialized care required by patient's injuries
Deterrence/Prevention
- Patients with urethral and penile injuries should refrain from sexual activity until the injury has healed.
Complications
- Bladder injuries
- Urinomas
- Fistulization (rectum, vagina, bowel, cutaneous)
- Pelvic hematoma infection
- Difficulties voiding
- Distal ureteral obstruction
- Urethral injuries
- Strictures
- Incontinence
- Impotence
- Penile injury
- Angulation
- Painful erection
- Impotence
- Scrotal injuries
- Infection
- Loss of testes
- Skin necrosis
- Testicular atrophy
- Decreased fertility
Prognosis
- Prognosis for patients with lower GU tract injuries is related to their associated injuries.
Patient Education
Special Concerns
- Pediatrics
- Preferential use of suprapubic catheters in boys to avoid complications of prolonged indwelling catheters in small urethras
- Cutaneous vesicostomy desirable in infants
- Urethral injury in women is extremely rare because of mobility and length of the female urethra. When it occurs, it is secondary to injury by bone spicules.
| Media file 2:
Retrograde urethrogram showing an irregularity of the urethra indicating injury secondary to a shotgun wound. |
 |  View Full Size Image | |
Media type: Radiograph
|
| Media file 4:
Ruptured dome of urinary bladder detected by retrograde cystogram. |
 | View Full Size Image | |
Media type: Radiograph
|
| Media file 6:
Extravasated contrast in abdominal cavity secondary to ruptured bladder. |
 | View Full Size Image | |
Media type: CT
|
- American College of Surgeons Committee on Trauma. Initial assessment and management. Advanced Trauma Life Support Program for Physicians;1993:9-46.
- Cutinha P, Chapelle CR. Bladder injuries. Surg Int. 1997;37:107-12.
- Guerriero WG. Trauma to the kidneys, ureters, bladder, and urethra. Surg Clin North Am. Dec 1982;62(6):1047-74. [Medline].
- James MJ. Investigation of the lower urinary tract. Surgery. 1995;13(2):37.
- Krieger JN, Algood CB, Mason JT, et al. Urological trauma in the Pacific Northwest: etiology, distribution, management and outcome. J Urol. Jul 1984;132(1):70-3. [Medline].
- Patel A, Harrison SCW. Scrotal trauma. Surg Int. 1997;37:118-20.
- Peterson NE. Traumatic posterior urethral avulsion. Monogr Urol. 1986;7:61.
- Peterson NE. Current management of urethral injuries. Urol Annual. 1988;143-79.
- Png D, Chapelle CR. Urethral injuries. Surg Int. 1997;37:97-101.
- Richardson JR Jr, Leadbetter GW Jr. Non-operative treatment of the ruptured bladder. J Urol. Aug 1975;114(2):213-6. [Medline].
- Styles RA. Hematuria. Surgery. 1996;14:213.
- Trunkey D. Initial treatment of patients with extensive trauma. N Engl J Med. May 2 1991;324(18):1259-63. [Medline].
- Walsh PC. Genitourinary trauma. In: Campbell's Urology. 6th ed. WB Saunders Co; 1992:2574.
- Ziran BH, Chamberlin E, Shuler FD, Shah M. Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J Trauma. Mar 2005;58(3):533-7. [Medline].
Trauma, Lower Genitourinary excerpt Article Last Updated: Nov 8, 2007
|
