Lower Genitourinary Injuries
51
Donald Hannoun and Charles D. Best
51.1 Acute Scrotal and Testis Injuries
Trauma to the external genitalia can be separated into blunt
versus penetrating injury. Differentiating between these two
mechanisms will have the immediate benefit of facilitating
patient care in the trauma suite. Noting the mechanism of
injury will also help you determine the likelihood of need for
eventual surgery, the potential length of convalescence, and
the possibility of injury to the contralateral testis. Particularly
with penetrating injuries, you should have a high index of
suspicion of injury to the contralateral testicle. It may also
assist in the prediction of future fertility.
Several features of the scrotum and testis make these
structures relatively resilient to trauma. The mobility of the
scrotum allows displacement from an inciting injury, and the
cremasteric reflex helps move the testis superiorly upon
scrotal contact. Additionally, the testis has a relatively tough
tunica albuginea, which can help contain a developing hema-
toma and prevent seminiferous tubule extrusion.
The vast majority (between 75 and 85 %) of scrotal/tes-
ticular injuries result from blunt trauma and are typically
unilateral. Penetrating injuries to the scrotum are typically
gunshot or stab wounds and are more likely to result in bilat-
eral testicular injury (30 %), while only 1.5 % of blunt scrotal
injuries are bilateral. A detailed history and physical exam
will usually indicate the likely mechanism and underlying
injury, often dictating further workup and management. We
will often acquire a testicular ultrasound to determine
whether the testicle itself is injured and assess the contralat-
eral testicle as well. Basic palpation is also a simple but very
helpful aspect of the initial physical exam. Inability to pal-
pate the testis may suggest the presence of testicular rupture
or testicular displacement (often back towards the superficial
D. Hannoun (*) C.D. Best
Department of Urology and Surgery, USC Institute of Urology,
USC Keck School of Medicine, LAC + USC County Medical
Center, Los Angeles, CA, USA
e-mail: dhannoun@usc.edu; cbest@usc.edu
Springer-Verlag Berlin Heidelberg 2017
G.C. Velmahos et al. (eds.), Penetrating Trauma, DOI 10.1007/978-3-662-49859-0_51
or external inguinal ring) by an expanding scrotal hematoma.
As always, you should always maintain a high index of sus-
picion for urethral injury, especially with penetrating trauma.
Inability to void and an expanding scrotum with or without
scrotal ecchymosis may suggest urinary extravasation and
should proceed to work-up with a retrograde urethrogram
(RUG) or gentle passage of a urethral catheter.
During the initial evaluation and work-up of scrotal or
testicular injury, you should also take into account the
patients clinical status and hemodynamic stability. Lower
genitourinary injuries are not often life-threatening. If the
patient is clinically stable for transfer, a scrotal ultrasound
can help identify the injury (i.e., hypoechoic testicular
lesions suggest hematoceles, disruption of the tunica albu-
ginea suggests rupture, lack of blood flow suggests torsion,
etc.). Facilitating these diagnostic studies early in a clinically
stable patient allows for early diagnosis.
If the patient is physiologically unstable, then a portable
study can be performed at the bedside in the intensive care
setting. Unfortunately, scrotal ultrasounds can have a high
false-negative rate even in the presence of an experienced
examiner. For this reason, if the index of suspicion for tes-
ticular injury is high, which is often the case with penetrating
injuries of the scrotum, explore the patient if noninvasive
diagnostic testing is unavailable or unsafe. Realistically, if
the patient is unstable, the scrotal or testicular injury is low
on the list of priorities.
The management of scrotal/testicular injury will also
often depend on the overall clinical status of the patient. In
the face of multiple medical or surgical comorbidities, the
patient may not be stable enough for transfer to the operative
suite for intervention. Communication between the primary
team and consulting services should dictate the appropriate
plan of action best suited for the patients overall
improvement.
In the case of multiple injuries requiring exploration, sur-
gical intervention for scrotal or testicular injury should be as
rapid as clinically possible. Even when the involved testicle
is an isolated injury, we recommend minimizing any delay in
397
398
repair. Several studies have shown that prompt surgical
intervention with testicular rupture, especially if performed
within 72 h of the injury, will often prevent superinfection of
the scrotal hematoma, lessen the length of convalescence,
decrease the potential for chronic pain, and may even
improve fertility. Gross et al. reported an improvement in
testicular salvage rate from 32 to 80 % if surgical exploration
was performed within 3 days of the inciting injury, and
Jeffrey et al. and Lupetin et al. went on to show testicular
salvage rates of 90 % when surgical intervention was per-
formed within 72 h.
Surgical intervention is usually performed transscrotally,
with the incision made down the midline raphe of the scro-
tum to allow bilateral testicular assessment and manage-
ment. Carry down the dissection through the dartos layer to
the tunica vaginalis, which may or may not be intact. Bring
the testis, epididymis, and distal spermatic cord onto the field
and examine closely for any evidence of injury. If the testicu-
lar injury is severe and salvage is unlikely, then proceed to an
orchiectomy. Tunica albuginea violation should be apparent
once the testis is delivered from the tunica vaginalis. With
tunica albuginea disruption, you should attempt to debride
any unviable seminiferous tubule tissue. The presence of
active bleeding is a sign that remaining tissue is viable. If
there is any question about testicular viability, an intraopera-
tive Doppler study should be performed to guide further
intervention. Repair the defect with a running 4-0 suture,
prolene being the suture of choice at our institution
(Fig. 51.1b). Damage to the vas deferens should be addressed
with ligation and delayed reconstruction. Vasovasostomy is
not a trivial procedure and should not be done in an acute
setting.
You should always anticipate potential postsurgical com-
plications and should pay strict attention to hemostasis prior
to scrotal closure. In the presence of persistent bleeding or an
underlying coagulopathy, place a quarter inch Penrose drain
in the inferior/dependent portion of the scrotum to prevent
accumulation of a postoperative hematoma. The dartos clo-
sure is carried out with a running 4-0 Vicryl stitch and the
scrotal skin closure with a running or interrupted 3-0 chro-
mic suture with locking of each suture. Leave the Penrose
drain to gravity drainage into a Kerlix roll, which is held
closely to the scrotum with a scrotal support for comfort and
elevation. Remove the drain 2448 h postoperatively.
Antibiotics are routinely recommended for 710 days post-
operatively to prevent abscess formation or infections along
the incision line. Apply antibiotic ointment to the suture line
three times a day for 710 days.
Genital avulsion injuries can be considered another form
of penetrating trauma to the scrotum. These injuries are sus-
tained during rapid deceleration of the body and concomitant
shearing mechanism against the scrotum and perineum, lead-
ing to loss of the scrotal skin. In the majority of situations,
D. Hannoun and C.D. Best
you can close the scrotal skin primarily at the time of surgery
with a running chromic suture as previously described after
copious irrigation. Even with up to 60 % of the scrotal skin
lost, the skin can still often be closed primarily. Larger
amounts of genital skin loss will necessitate wet-to-dry
dressings postoperatively with delayed grafting. As always,
scrotal avulsion injuries should always be assessed for under-
lying testicular injury, and you should manage them
appropriately.
51.2 Penile Injury
Penetrating penile injuries are relatively rare and usually
take the form of gunshot and stab wounds. However, one can
also encounter penile avulsion injuries from motor-vehicle
or bicycle accidents as well as the occasional self-mutilating
injuries and animal or human bites. Despite the abovemen-
tioned multiple possible mechanisms of penile trauma, sig-
nificant penile injuries remain rare secondary to the tough
tunica albuginea covering of the penis. Penetrating penile
injuries may result in a tear of the tunica albuginea encasing
the corpora cavernosa, which allows extravasation of blood
from the corpora into the penile shaft. Because of the pene-
trating nature of the injury, blood will exit out of the wound
site, typically not extending along fascial lines as with penile
fracture. The penis may swell and have some ecchymosis,
but you usually do not see the so-called eggplant penis
appearance in penetrating injuries.
With penetrating injuries to the penis, you should always
suspect compromise of the tunica albuginea. The mechanism
alone will almost always mandate surgical exploration.
However, if the diagnosis is in question, further imaging
studies are available, although with highly variable results
and inter-interpreter variations. Cavernosograms can be per-
formed with injection of contrast material into the corpus
cavernosum, with serial radiographs taken to identify the site
of extravasation. The false-negative rate is unfortunately
very high with this modality, as the tear can be too small to
see, and often the presence of a clot at the tear site will mask
the extravasation. False-positive studies result when the
physiologic egress of contrast through emissary veins is mis-
interpreted as extravasation. Similarly, penile ultrasound
cannot consistently identify the site of tear unless in the
hands of a very skilled examiner. MRI in the T1 phase,
although more sensitive than cavernosography and ultra-
sound, has a limited role secondary to the time required, the
difficulty with transportation, and the frequent clinical insta-
bility of the patient. These studies have no role in significant
penetrating injuries. They have value in cases of penile frac-
ture, when there is an atypical presentation. You should
always suspect underlying urethral injury with any penetrat-
ing penile trauma. If the patient has not spontaneously voided
51 Lower Genitourinary Injuries
Fig. 51.1 (a) Often with
penetrating injuries, the testicular a
injury is obvious, as is seen here
where the tunica albuginea has
been disrupted (arrow). (b)
Repair the defect with a running
4-0 suture, prolene being the
suture of choice at our institution
clear urine or has hematuria, either gross or microscopic, an
RUG should be performed prior to surgical exploration to
assess for urethral injury.
Tunical violation injuries of the penis should ideally be
surgically corrected within 36 h of sustaining the injury.
Exploration is mandatory to prevent the sequelae of infected
hematomas, impotence, and penile curvature that may result
without prompt operative intervention. Again, other more
life-threatening injuries should be identified and addressed
first.
Once the patient has reached the operative suite, the
appropriate area is prepped and draped in standard sterile
fashion. Insert a urethral catheter at the beginning to ensure
399
ease of passage into the bladder. You can then use this cath-
eter for the retrograde instillation of saline/dye during the
procedure to evaluate for any urethral discontinuity. First
make a circumferential (degloving) incision, which allows
access to the length of the corpora cavernosa and spongio-
sum. Place a tourniquet at the base of the penis as it can aid
with hemostasis and dissection (Fig. 51.2a). Carry out evacu-
ation of the hematoma, and localize the site of tunical viola-
tion after you dissect free Bucks fascia. Once you have
identified the defect, debride the wound edges and do copi-
ous irrigation, particularly important with gunshot injuries or
bites. Carry on primary closure of the defect with 4-0 prolene
suture in a figure-of-eight fashion. We prefer to do this with
400 D. Hannoun and C.D. Best

Fig. 51.2 (a) Place a tourniquet

at the base of the penis as it can a
aid with hemostasis and
dissection. (b) Debride the
wound edges and do copious
irrigation, particularly important
with gunshot injuries or bites.
Carry on primary closure of the
defect with 4-0 prolene suture in
a figure-of-eight fashion, and
avoid any significant length of
running suture, as any cinching
of the tissue may result in penile
curvature. In this figure, a
corporal injury is present with the
bullet visible (arrow)

Dorsal
neuro-
vascular
bundle

the knots buried to decrease the chance of the patient
potentially feeling the suture under the thin penile skin
(Fig 51.2b). Avoid any significant length of running suture,
as any cinching of the tissue may result in penile curvature.
If there has been any rupture of the tunica albuginea close to
1 cm or larger, perform an artificial erection after the repair.
This is necessary to determine if any curvature has resulted
from the repair. Do this by applying a tourniquet at the base
of the penis and injecting one of the cavernosal bodies, via a
butterfly needle, with normal saline until appropriate turgor
is achieved. If there is any notable curvature, a plication of
the tunica on the opposite side of the defect may be neces-
sary. Repair any urethral injuries over a urethral catheter as
mentioned in the chapter section to follow. After you have
reapproximated the skin, place a compressive dressing and
remove it the evening of surgery or the following morning.
Leave the catheter in place until the following morning
unless a urethroplasty is performed. Administer antibiotics
for 710 days following the repair to prevent penile abscess
development.
Surgical exploration may be unnecessary if the penetrat-
ing penile injury fails to result in tunical violation. Relatively
small penile tears can be locally irrigated, debrided, and
repaired with simple, interrupted closure and an absorbable
2-0 or 3-0 suture. With larger defects, initially perform local
irrigation and debridement. Evaluate the wounds later for
51 Lower Genitourinary Injuries
either primary closure with reapproximation or reconstruction
with delayed grafting. These wounds are frequently contami-
nated, and all patients should be placed on a 10-day antibi-
otic course with an antibiotic that provides adequate coverage
of typical skin flora, such as cephalexin. For penicillin-
allergic patients, you can use chloramphenicol.
Penile amputation injuries can be accidental or self-
inflicted. The timing of the incident and the presence and
handling of the severed penis are crucial to the initial man-
agement. The severed penis should be wrapped with saline-
soaked gauze, placed into a sterile bag (if possible), and
immediately placed in ice water. The ice should never be in
direct contact with the penis to prevent necrosis. If possi-
ble, the amputated penis should be reimplanted within 24 h
of the injury. Transfer to a tertiary medical center is usually
required for the expertise of microvascular anastomoses
that is often necessary. After appropriate medical and psy-
chosocial issues have been addressed and other more life-
threatening injuries have been ruled out, the patient is taken
to the operating room immediately for reimplantation. It is
extremely important to have an experienced team of urolo-
gists, plastic surgeons, and OR staff in order to have a good
result. Of primary importance is the cavernosal and spon-
giosum/urethral reanastomoses. A urethral catheter is
inserted prior to the urethral anastomosis. Microsurgical
techniques can be used to reapproximate the dorsal arteries
and nerve of the penis to improve the recovery of postop-
erative perfusion and sensation, respectively. Next, the
tunica should be reconstructed. Finally, the debrided skin
should be sewn together, much like any other superficial
anastomosis. It is not unusual to have delayed sloughing of
the penile skin. This does not necessarily imply that the
reimplant as a whole has not survived. Delayed skin graft-
ing may be all that is necessary. If the severed penis is not
available, then overclosure of the corpus cavernosum with
advancement of the urethral stump can be performed to
allow voiding while standing. An inadequate distal urethral
remnant may obviate the need for perineal urethrostomy
with delayed genital reconstruction pending complete psy-
chosocial evaluation.
51.3 Urethral Injury
As with other traumatic genitourinary injuries, the mecha-
nism of urethral injury can be divided into blunt versus pen-
etrating. Urethral injuries can be further subdivided into
posterior (prostatic/membranous urethra) and anterior (bul-
bar/pendulous urethra) in location. These subdivisions not
only classify the location of the injury but also dictate further
management. Penetrating anterior and posterior urethral
injuries are usually secondary to gunshot and stab wounds.
These injuries are much more prevalent in males than females
401
owing to the shorter urethral length, greater urethral mobil-
ity, and lesser pubourethral attachments in females.
The diagnosis of urethral injury would ideally be elicited
from a detailed history and physical examination. For obvi-
ous reasons, this is not always the case. Often, the urologic
team becomes involved after prior failed attempts have
already been made in the emergency department (ED) to
place a urethral catheter. This often culminates in improper
catheter placement with possible conversion of a partial ure-
thral tear to a full and circumferential urethral tear. We try to
emphasize not attempting blind urethral catheterization if
there is any suspicion of urethral injury. The mechanism of
injury should prompt the initial suspicion for urethral injury.
Failure to void since the incident or suprapubic fullness/dis-
tention should be assumed to represent urethral injury until
proven otherwise. Gunshot wounds with either an entrance
or exit from the perineum or penis should alert any diagnosti-
cian to a possible urethral injury.
The classical finding of a urethral injury on examination
is the presence of blood at the meatus, though its presence is
not definitive evidence and its absence is not exclusionary.
Severe or expanding scrotal swelling, with or without ecchy-
mosis, may also suggest urinary extravasation. Perineal
hematomas, which can take on the classic butterfly hema-
toma pattern, should also alert the clinician for further ure-
thral workup. Hematoma along the entire penile shaft
(so-called sleeve hematoma) can be secondary to penile, ure-
thral, or testicular injury.
With any of the aforementioned history or physical
exam findings (suspected mechanism of injury, penetrating
injury, blood at the meatus, scrotal/perineal hematoma),
one should proceed with a retrograde urethrogram (RUG)
or attempt gentle catheter placement. The RUG can be per-
formed in several ways and can be done either in a formal
radiology suite with the combination of fluoroscopy, in the
ED, operating room, or at the bedside. A 1214 Fr catheter
can be inserted just into the fossa navicularis, with only
12 cm3 instilled into the balloon to tamponade the urethra
and prevent the antegrade leakage of contrast. Next, inject
about 1520 cm3 of contrast, with the radiograph being per-
formed at the end of the injection to ensure adequate ure-
thral distention. Alternatively, the aforementioned
procedure can be performed with a 60 cm3 catheter tip
syringe (filled with contrast) inserted very gently into the
urethra until a snug fit is obtained. At our institution, the
RUG is performed by placing the patient in a slightly lat-
eral (about 3045) decubitus position. The penis is appro-
priately sterilized with a Betadine preparation and sterile
draping placed underneath the penis. Next, about 20 cm of
a small Kerlix roll is cut, soaked with water/saline, and then
tied to the subcoronal position of the penis with a simple
tie. This maneuver will allow penile traction during con-
trast instillation to help delineate the entire urethra, as well
402
as appropriately shield the examiners hands/body from the
radiation field. A separate catheter tip is then lubricated and
placed on a 60 cm3 Luer-Lok syringe prefilled with con-
trast, and the injection is performed. The radiograph is
taken after 20 cm3 of contrast has been instilled. Urethral
injuries on an RUG will appear as a disruption of the nor-
mally concentric urethra from the meatus to the bladder
neck. A partial disruption represents extravasation along
the course of the urethra with some contrast instillation into
the bladder, whereas a complete disruption will fail to fill
the bladder at all, with contrast accumulating in a periure-
thral or perivesical location.
The management of urethral injuries can be divided
simply into immediate open surgical repair versus tempo-
rary urinary diversion with suprapubic or urethral catheter
placement. With temporary urinary diversion, delayed
repair and/or reconstruction would be performed, if nec-
essary, 612 weeks following the injury. In any situation,
the initial management of urethral injury should proceed
first and foremost with prompt bladder decompression
and broad-spectrum antibiotics. The controversial aspect
of managing penetrating urethral injury, however, is
whether immediate open repair versus diversion with
delayed repair and reconstruction should be performed. In
a recent study and review of posterior urethral injuries
with pelvic fractures, immediate open repair was associ-
ated with a 49 % stricture rate, 21 % incontinence rate,
and 56 % impotence rate. When primary realignment was
performed, the stricture rate remained at 53 %, but the
incontinence and impotence rate dropped to 5 % and 36 %,
respectively. When suprapubic urinary diversion was the
initial management option, the urethral stricture rate rose
to 97 %, with a 4 % incontinence and 19 % impotence rate.
In a recent retrospective series by Hadjizacharia et al., 14
patients presenting with an acute urethral injury were
managed with immediate endoscopic realignment (IER),
compared to seven patients treated with delayed (open)
therapy. The outcomes of the study showed the immediate
realignment group to have a lower rate of stricture forma-
tion (14 %) compared to the delayed therapy group
(100 %). In addition, the authors found a shorter time to
spontaneous voiding in the immediate realignment group
(35 23 days) compared to the delayed therapy group
(229 79 days). A long-term review at the same institu-
tion had similar results. Thirty-five patients with poste-
rior, acute urethral injury underwent immediate
endoscopic realignment. Five of these patients had pene-
trating injury as the mechanism. After 18 months, the rate
of stricture formation was stable at 17 %. Only three of the
six patients who developed stricture required urethro-
plasty, and none of the patients with penetrating mecha-
nism went on to develop stricture. In general, no single
treatment protocol will fit each patient perfectly.
D. Hannoun and C.D. Best
Therefore, the overall clinical status of the patient as well
as concomitant injuries should be taken into account
before final management decisions are made. These same
complications do not apply to penetrating injuries, with
the exception of stricture rates. The high impotence and
incontinence rates are more specific to the nature of the
pelvic fracture injury. Penetrating injuries are more com-
mon in the anterior urethra, with less disruption of the
surrounding neurovascular bundles.
Immediate surgical repair of posterior urethral injuries
is indicated in the presence of a concurrent bladder neck or
rectal injury to prevent subsequent urinary incontinence,
fistula formation, or persistent leak. Urinary continence is
a function of both the internal and external sphincter
mechanisms. Posterior urethral injuries are usually associ-
ated with damage to the external sphincter mechanism for
urinary continence. This would leave the internal sphinc-
ter, located at the bladder neck, as the only remaining
source of urinary continence. For this reason, any bladder
neck injuries should be explored and repaired immedi-
ately; without proper repair and reapproximation of the
sphincter, eventual urinary incontinence is almost guaran-
teed. In the absence of a bladder neck or rectal injury, pos-
terior urethral injuries should be managed with temporary
urinary diversion via suprapubic or urethral catheter place-
ment. The placement of a urethral catheter in the presence
of a urethral injury is called immediate endoscopic (or pri-
mary) realignment (IER). Regardless of mechanism, pos-
terior urethral injuries are initially managed with an
attempt at immediate endoscopic realignment. Traverse
the normal urethral mucosa by using flexible cystoscopy
with low-flow irrigation. Once you reach the site of injury,
the cystoscope is often successful in identifying some nor-
mal mucosa or the other side of the defect (Fig. 51.3).
Once across the defect and into the bladder with the cysto-
scope, advance a guide wire into the bladder. Then remove
the cystoscope and place a Council tip Foley catheter over
the wire and into the bladder. This allows urethral drainage
without necessitating surgery. The majority will heal with-
out significant stricture. If attempts at IER are unsuccess-
ful, a suprapubic tube can be placed, followed by delayed
definitive repair.
Anterior urethral injuries can also be repaired early on
with open surgery, especially in the setting of low-velocity
penetrating injuries where major tissue destruction has not
occurred. In the presence of major tissue destruction,
excessive and often inadvertent tissue debridement may
take place, which can further the risk of ischemic stricture
development. In cases of anterior urethral repair for pen-
dulous urethral injuries, approach with a circumcision/
degloving penile incision and proceed to local debride-
ment of nonviable tissue, spatulation of the two urethral
ends, and a tension-free anastomosis of the lacerated
51 Lower Genitourinary Injuries
Fig. 51.3 Once you reach the
site of urethral injury, the
cystoscope is often successful in
identifying some normal mucosa
or the other side of the defect Cystoscope
corpus spongiosum and urethra with interrupted absorb-
able sutures over a 1416 Fr urethral catheter. For bulbar
urethral injuries, place the patient in the dorsal lithotomy
position, and make a vertical perineal incision to gain
access to the bulbar urethra. Carry a tension-free urethral
anastomosis; perform it over a 1618 Fr catheter in this
relatively dilated portion of the urethra. Keep the catheter
in place for a minimum of 1014 days, and perform a peri-
catheter RUG prior to removal to ensure no further extrav-
asation. The presence of extravasation warrants continued
catheter drainage.
Urinary diversion with delayed repair is another man-
agement option, especially when the patient is too unsta-
ble for surgery or if the injury is very posterior. If IER
fails, urinary diversion can be performed with suprapubic
cystostomy tube placement (percutaneous versus open).
Open suprapubic cystostomy placement will guarantee
placement into the bladder, allow concomitant bladder
repair if present, and allow bladder neck reconstruction if
an injury is found. Open tube placement will also allow
antegrade urethral endoscopy and urethral catheter place-
ment if initial catheter placement or retrograde urethros-
copy failed to reach the bladder. The other option for
suprapubic cystostomy tube placement is a percutaneous
kit, which is less invasive than the open suprapubic tube
placement and can be performed under mild sedation.
Blind urethral catheter placement, on the other hand, can
be attempted in the setting of small, partial lacerations
and in general should be avoided because of the risk of
transforming a partial laceration to a full circumferential
transection. Again, we emphasize obtaining an RUG if
any index of suspicion for urethral injury is present.
However, the catheter can be safely placed under direct
visualization with retrograde urethroscopy and catheter
403
Injury
placement over a wire. As an alternative, antegrade
urethroscopy can be performed at the time of open pelvic
surgery or during repair of a concomitant bladder rupture
with passage of the scope down the urethra and out of the
meatus. This will allow tying of a catheter to the cysto-
scope with a silk suture or over a wire and retrograde pas-
sage of the catheter into the bladder as the cystoscope is
withdrawn.
In summary, penetrating injuries to the urethra, testi-
cles, and external genitalia usually take the form of gun-
shot and stab wounds. The importance of the mechanism
of injury cannot be overemphasized, and combined with a
very thorough and detailed physical examination, it will
lead the diagnostician to the correct diagnosis. If ever in
doubt, or the mechanism does not seem correct, perform
radiological studies to further delineate any underlying
injuries, which may of course change the course of man-
agement. Other life-threatening injuries should always
maintain a higher priority, but it is the responsibility of the
trauma and urology team to work together and maintain
effective communication to deliver the best possible care.
Important Points
An Inferior Vena Cava (IVP) or CAT Scan (CT)
alone is not always reliable to demonstrate bladder
rupture. This requires a high-pressure cystogram.
Undiagnosed bladder rupture in the presence of pel-
vic fracture can lead to serious complications.
Urethral injury can be associated with rupture of the
bladder.
404 D. Hannoun and C.D. Best

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