Hit below the belt: GU trauma

Genitourinary trauma has a few high-stakes pattern recognitions that change imaging and disposition fast. Testicular rupture needs ultrasound, penile fracture is usually a clinical diagnosis, blood at the meatus means evaluate the urethra before a Foley, and most renal trauma is managed nonoperatively.

Scrotal and Penile Trauma

• Testicular rupture clues: Blunt scrotal trauma with immediate pain and swelling should raise concern for disrupted tunica albuginea, but physical exam alone cannot rule rupture in or out.
• Ultrasound-confirmed rupture: Scrotal ultrasound is the key test for testicular rupture, with loss of tunica albuginea integrity and possible extrusion of seminiferous tubules as the named findings.
• Urgent salvage window: Testicular rupture needs urgent rather than torsion-level emergent urologic repair, aimed at preserving blood supply, preventing infection, and maximizing testicular salvage.
• Classic penile fracture story: Penile fracture classically presents with a felt pop and immediate detumescence during intercourse or vigorous masturbation, followed by rapid swelling and deformity.
• Eggplant deformity pattern: The combination of eggplant deformity and the classic history is often enough to diagnose penile fracture at the bedside. We get into when imaging still helps in the episode.
• Overnight operative priority: Penile fracture also needs urgent surgery to preserve erectile function, even though it does not usually demand the same all-out immediacy as a crashing OR emergency.

Urethral, Renal, and Bladder Injury

• Blood at meatus warning: Blood at the meatus after trauma is the classic red flag for urethral injury, and a Foley should wait until the urethra is evaluated.
• Sex-specific urethral imaging: Suspected urethral injury is worked up with retrograde urethrogram in males and cystoscopy in females, a distinction that matters before instrumentation. We walk through that sequence in the episode.
• Pelvic fracture association: Posterior urethral injury tracks with severe pelvic fractures, especially pubic symphysis diastasis, where shearing at the bulbomembranous junction is the classic mechanism.
• Renal trauma imaging: Renal injury should be suspected with gross hematuria or hypotension plus microscopic hematuria, and CT abdomen pelvis with delayed images is the imaging study of choice.
• Mostly nonoperative kidneys: Most traumatic renal injuries are observed rather than taken to surgery, with intervention reserved for decompensation, significant urinoma, or infectious complications.
• Bladder rupture split: Pelvic fracture plus gross hematuria makes bladder injury a major concern; intraperitoneal ruptures need operative repair, while extraperitoneal injuries are usually managed with catheter drainage.

References

1. Wang Z, et al. Diagnosis and management of testicular rupture after blunt scrotal trauma: a literature review. Int Urol Nephrol. 2016 Dec;48(12):1967-1976. Epub 2016 Aug 27. PMID: 27567912
2. Kominsky H, et al. Surgical reconstruction for penile fracture: a systematic review. Int J Impot Res. 2020 Jan;32(1):75-80. Epub 2019 Nov 4. PMID: 31685943.
3. Chouhan JD, et al. Contemporary evaluation and management of renal trauma. Can J Urol. 2016 Apr;23(2):8191-7. PMID: 27085822.