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Ovid: Oxford Handbook of Urology

Authors: Reynard, John; Brewster, Simon; Biers, Suzanne Title: Oxford Handbook of Urology, 1st Edition Copyright ©2006 Oxford University Press > Table of Contents > Chapter 11 – Trauma to the urinary tract and other urological emergencies Chapter 11 Trauma to the urinary tract and other urological emergencies P.416
Renal trauma: classification, mechanism, grading Classification Two categories: blunt and penetrating. Proportion of all renal injuries which are blunt—Europe 97%, USA 90%, South Africa 25–85%. Proportion depends on whether urban or non-urban community. This classification is useful because it predicts the likely need for surgical exploration to control bleeding. Experience from large series shows that 95% of blunt injuries can be managed conservatively, whereas 50% of stab injuries and 75% of gunshot wounds require exploration. Blunt injures

  • direct blow to the kidney
  • rapid acceleration or rapid deceleration
  • a combination of (1) and (2)

Rapid deceleration frequently causes renal pedicle injuries (renal artery and vein tears or thrombosis, PUJ disruption) because renal pedicle is the site of attachment of kidney to other fixed retroperitoneal structures. Most common cause—motor vehicle accidents (e.g. pedestrian hit by a car; direct blow combined with rapid acceleration and then deceleration). Seemingly trivial injuries (e.g. fall from a ladder), direct falls onto the flank, or sporting injuries can lead to significant renal injuries. Penetrating injuries Stab or gunshot injuries to the flank, lower chest, and anterior abdominal area may inflict renal damage. 50% of patients with penetrating trauma and haematuria have grade III, IV, or V renal injuries. Penetrating injuries anterior to the anterior axillary line are more likely to injure the renal vessels and renal pelvis, compared with injuries posterior to this line where less serious parenchymal injuries are more likely. Thus, renal injuries from stab wounds to the flank (i.e. posterior to anterior axillary line) can often be managed non-operatively. Wound profile of a low-velocity gunshot wound is similar to that of a stab wound. High-velocity gunshot wounds (>350m/s) cause greater tissue damage due to stretching of surrounding tissues (‘temporary cavity’). Mechanism The kidneys are retroperitoneal structures surrounded by peri-renal fat, the vertebral column and spinal muscles, the lower ribs, and abdominal contents. They are therefore relatively protected from injury and a considerable degree of force is usually required to injure them (only 1.5–3% of trauma patients have renal injuries). Associated injuries are therefore common (e.g. spleen, liver, mesentery of bowel). Renal injuries may not initially be obvious, hidden as they are by other structures. To confirm or exclude a renal injury, imaging studies are required. In children, there is proportionately less peri-renal fat to cushion the kidneys against injury, and thus renal injuries occur with lesser degrees of trauma. P.417
Staging of the renal injury Using CT, renal injuries can be staged according to the American Association for the Surgery of Trauma (AAST) Organ Injury Severity Scale. Higher injury severity scales are associated with poorer outcomes.

Grade I Contusion (normal CT) or subcapsular haematoma with no parenchymal laceration
Grade II <1cm deep parenchymal laceration of cortex, no extravasation of urine (i.e. collecting system intact)
Grade III >1cm deep parenchymal laceration of cortex, no extravasation of urine (i.e. collecting system intact)
Grade IV Parenchymal laceration involving cortex, medulla, and collecting system OR renal artery or renal vein injury with contained haemorrhage
Grade V Completely shattered kidney OR avulsion of renal hilum

Paediatric renal injuries The kidneys are said to be more prone to injury in children because of the relatively greater size of the kidneys in children, the smaller protective muscle mass and cushion of peri-renal fat, and the more pliable rib cage.

Table 11.1 Summary of mechanisms, causes, grading, and treatment of renal disease
Mechanisms and cause Blunt or penetrating
  Blunt—direct blow or acceleration/deceleration (RTAs, falls from a height, fall onto flank)
  Penetrating—knives, gunshots, iatrogenic (e.g. PCNL)
Imaging and grading CT—accurate, rapid, images other intra-abdominal structures
Staging—American Association for the Surgery of Trauma Organ Injury Severity Scale:

  1. contusion
  2. <1cm laceration
  3. >1cm laceration
  4. laceration into collecting system
  5. shattered kidney
Treatment Conservative—95% of blunt injuries, 50% of stab injuries, 25% of gunshot wounds can be managed non-operatively (cross-match, bed rest, observation)
   Exploration if:

  • Persistent bleeding (persistent tachycardia and/or hypotension not responding to appropriate fluid and blood replacement)
  • Expanding peri-renal haematoma
  • Pulsatile peri-renal haematoma

Renal trauma: clinical and radiological assessment The haemodynamically stable patient History: nature of trauma (blunt, penetrating) Examination: pulse rate, systolic blood pressure, respiratory rate, location of entry and exit wounds, flank bruising, rib fractures. The lowest recorded systolic blood pressure is used to determine need for renal imaging. Indications for renal imaging

  • Macroscopic haematuria
  • Penetrating chest and abdominal wounds (knives, bullets)
  • Microscopic (>5 RBCs per high-powered field) or dipstick haematuria in a hypotensive patient (systolic blood pressure of <90mmHg recorded at any time since the injury1)
  • A history of a rapid acceleration or deceleration (e.g. fall from a height, high speed motor vehicle accident). Falls from even a low height can cause serious renal injury in the absence of shock (SBP < 90mmHg) and of haematuria (PUJ disruption prevents blood reaching the bladder)
  • Any child with microscopic or dipstick haematuria who has sustained trauma

Adult patients with a history of blunt trauma and microscopic or dipstick haematuria need not have their kidneys imaged as long as there is no history of acceleration/deceleration and no shock, since the chances of a significant injury being found are <0.2%. Degree of haematuria v. severity of injury While significant renal injury is more likely with macroscopic haematuria, in some cases of severe renal injury haematuria may be absent. Thus the relationship between the presence, absence, and degree of haematuria and the severity of trauma is not absolute. Broadly speaking, in blunt trauma, macroscopic haematuria predicts the likelihood of significant renal injury. Conversely, in penetrating trauma, haematuria may be absent in severe renal injury (renal vascular injury, PUJ, or ureter avulsion): Blunt renal trauma in adults: chance of significant renal injury v. degree of haematuria and SBP

Degree of haematuria; systolic BPmmHg Significant renal injury
Microhaematuria;* SBP >90 0.2%
Macroscopic haematuria; SBP >90 10%
Macroscopic haematuria; SBP <90 10%
* Dipstick or microscopic haematuria

The haemodynamically unstable patient Haemodynamic instability may preclude standard imaging such as CT, the patient having to be taken to the operating theatre immediately to P.421
control the bleeding. In this situation, an on-table IVU (see box) is indicated if:

  • a retroperitoneal haematoma is found and/or
  • a renal injury is found which is likely to require nephrectomy.

What imaging study? The IVU has been replaced by contrast enhanced CT scan as the imaging study of choice in patients with suspected renal trauma. Compared with IVU, it provides clearer definition of the injury, allowing injuries to the parenchyma and collecting system to be more accurately graded, and therefore determines subsequent management. An arterial-venous phase scan is done within minutes of contrast injection, followed by a repeat scan 10–20 min after contrast administration to allow time for contrast to reach collecting system. While ultrasound can establish the presence of two kidneys and identify blood flow in the renal vessels (power Doppler) it cannot accurately identify parenchymal tears, collecting system injuries, or extravasation of urine until a later stage when a urine collection has had time to accumulate. Imaging is designed to:

  • grade injury
  • document presence and function of contralateral kidney
  • detect associated injuries
  • detect pre-existing renal pathology in affected kidney.

On contrast enhanced CT look for:

  • depth of parenchymal laceration
  • parenchymal enhancement (absence of enhancement suggests renal artery injury)
  • presence of urine extravasation (medial extravasation of contrast suggests disruption of PUJ or renal pelvis)
  • presence, size, and position of retroperitoneal haematoma (haematoma medial to the kidney suggests a vascular injury)
  • presence of injuries to adjacent organs (bowel, spleen, liver, pancreas, etc)
  • presence of a normal contralateral kidney.

On table IVU When, because of shock and need for immediate laparotomy, a patient is transferred immediately to the operating theatre without having had a CT scan, and a retroperitoneal haematoma is found, a single shot abdominal X-ray, taken 10 min after contrast administration (2ml/kg of contrast), can establish the presence/absence of a renal injury and the presence of a normally functioning contralateral kidney where the ipsilateral kidney injury is likely to necessitate a nephrectomy. Footnote 1 Remember, in young adults and children hypotension is a late manifestation of hypovolaemia; blood pressure is maintained until there has been substantial blood loss. P.422
Renal trauma: treatment Conservative (non-operative) management Most blunt (95%) and many penetrating renal injuries (50% of stab injuries and 25% of gunshot wounds) can be managed non-operatively. Dipstick or microscopic haematuria: if systolic BP since injury has always been >90mmHg and no history of acceleration or deceleration, imaging and admission is not required. Macroscopic haematuria: in a cardiovascularly stable patient, having staged the injury with CT, admit for bed rest and observation, until the macroscopic haematuria, if present, resolves (cross-match in case blood pressure drops). High-grade (IV and V) injuries can be managed non-operatively if they are cardiovascularly stable. However, grade IV and, especially, grade V injuries often require nephrectomy to control bleeding (grade V injuries function poorly if repaired). Surgical exploration Is indicated (whether blunt or penetrating injury) if:

  • the patient develops shock which does not respond to resuscitation with fluids and/or blood transfusion
  • the haemoglobin decreases (there are no strict definitions of what represents a ‘significant’ fall in haemoglobin)
  • there is urinary extravasation and associated bowel or pancreatic injury
  • expanding peri-renal haematoma (again the patient will show signs of continued bleeding)
  • pulsatile peri-renal haematoma

An expanding and/or pulsatile peri-renal haematoma suggests a renal pedicle avulsion. Haematuria is absent in 20%. Urinary extravasation Not in itself necessarily an indication for exploration. Almost 80–90% of these injuries will heal spontaneously. The threshold for operative repair is lower with associated bowel or pancreatic injury—bowel contents mixing with urine is a recipe for overwhelming sepsis. In these situations the renal repair should be well drained and omentum interposed between the kidney and bowel or pancreas. If there is substantial contrast extravasation, consider placing a JJ stent. Repeat renal imaging if the patient develops a prolonged ileus or a fever, since these signs may indicate the development of a urinoma which can be drained percutaneously. Renal exploration is required for a persistent leak. Devitalized segments Exploration is usually not required for patients with devitalized segments of kidney and with urinary extravasation.1 Hypertension and renal injury Excess renin excretion occurs following renal ischaemia from renal artery injury or thrombosis or renal compression by haematoma or fibrosis. This can lead to hypertension months or years after renal injury. The P.423
exact incidence of post-traumatic hypertension is uncertain. It may occur in <1% of individuals. Technique of renal exploration Midline incision allows:

  • exposure of renal pedicle, so allowing early control of the renal artery and vein, and
  • inspection for injury to other organs.

Lift the small bowel upwards to allow access to the retroperitoneum. Incise the peritoneum over the aorta, above the inferior mesenteric artery. A large peri-renal haematoma may obscure the correct site for this incision. If this is the case, look for the inferior mesenteric vein and make your incision medial to this. Once on the aorta, the inferior vena cava may be exposed, then the renal veins and the renal arteries. Pass slings around all of these vessels. Expose the kidney by lifting the colon off of the retroperitoneum. Bleeding may be reduced by applying pressure to the vessels via the slings. Control bleeding vessels within the kidney with 4/0 vicryl or monocryl sutures. Close any defects in the collecting system with 4/0 vicryl. If your sutures cut out, place a strip of Surgicel over the site of bleeding, place your sutures through the capsule on either side of this, and tie them over the Surgicel. This will stop them from cutting through the friable renal parenchyma. Finding a non-expanding, non-pulsatile retroperitoneal haematoma at laparotomy The finding of an expanding and/or pulsatile retroperitoneal haematoma at laparotomy will often indicate a renal pedicle injury (avulsion or laceration), and nephrectomy may be required to stop further haemorrhage. Controversy surrounds the correct management of the finding at laparotomy of a non-expanding, non-pulsatile retroperitoneal haematoma. Most can be left alone. Remember, exploration increases the chances of loss of the kidney (because of bleeding which can be controlled only by nephrectomy). The decision to explore is based on whether pre-operative or on-table imaging has been done and is normal or abnormal:

Pre-operative or intra-operative imaging Action
Normal Leave the haematoma alone
Abnormal; contralateral kidney normal Explore and repair renal injury
Abnormal; abnormal or absent contralateral kidney Leave the haematoma alone*
None Explore and repair renal injury
* Exploration increases the chances of loss of the kidney (because of bleeding which can be controlled only by nephrectomy), which is a disaster if the contralateral kidney is absent or damaged.

Iatrogenic renal injury: renal haemorrhage after percutaneous nephrolithotomy (PCNL) Significant renal injuries can occur during percutaneous nephrolithotomy (PCNL) for kidney stones. This is the surgical equivalent of a stab wound and serious haemorrhage results in ~1% of cases.2 Bleeding during or after a PCNL can occur from vessels in the nephrostomy track itself, from an arteriovenous fistula, or from a pseudoaneurysm which has ruptured. Track bleeding will usually tamponade around a large-bore nephrostomy tube. Traditionally persistent bleeding through the nephrostomy tube is managed by clamping the nephrostomy tube and waiting for the clot to tamponade the bleeding. While this may control bleeding in some cases, in others a rising or persistently elevated pulse rate (with later hypotension) indicates the possibility of persistent bleeding and is an indication for renal arteriography and embolization of the arteriovenous fistula or pseudoaneurysm (Figs. 11.1 and 11.2). Failure to stop the bleeding by this technique is an indication for renal exploration. Arteriovenous fistulae can sometimes occur following open renal surgery for stones or tumours, and arteriography with embolization again can be used to stop the bleeding in these cases. However, the bleeding usually occurs over a longer time course (days or even weeks), rather than as acute haemorrhage causing shock.

Fig. 11.1 Renal arteriography after PCNL where severe bleeding was encountered. An arteriovenous fistula was found and embolized
Fig. 11.2 Post-embolization of AV fistula. Note the embolization coils in the lower pole

Ureteric injuries: mechanisms and diagnosis Types, causes, and mechanisms

  • External (rare—blunt (e.g. high speed road traffic accidents, fall from a height); penetrating (knife or gunshot wounds)).
  • Internal trauma (= iatrogenic) (during pelvic or abdominal surgery e.g. hysterectomy, colectomy, AAA repair; ureteroscopy). The ureter may be divided, ligated, or angulated by a suture; a segment excised or damaged by diathermy.

External injury: diagnosis Based on a high index of suspicion for the possibility of ureteric injury in the above types of scenarios. Imaging studies: IVU or CT can be used to determine the presence of a ureteric injury. If doubt remains regarding the integrity of the ureters, retrograde ureterography should be done. Internal (iatrogenic) injury: diagnosis The injury may be suspected at the time of surgery, but injury may not become apparent until some days or weeks post-operatively. Intra-operative diagnosis For ureteric contusions and perforations seen at the time of ureteroscopy, insert a JJ stent. During abdominal or pelvic surgery firstly optimize exposure of the suspected injury site by packing bowel out of the way, controlling bleeding, and ensuring the theatre lights are appropriately positioned. Examine both ureters (bilateral injuries can occur). Direct inspection of the ureter A good way of inspecting the ureter for injury, but requires exposure of a considerable length of ureter to establish that it has not been injured. Lower ureteric exposure is more difficult than upper ureteric. Extravasation after injection of methylene blue into the ureter Look for leakage of dye from a more distant section of ureter. On-table IVU Technically difficult; does not always demonstrate the presence or site of injury. On-table retrograde ureterography Via an incision made in the bladder or via a cystoscope. A very accurate method of establishing the presence or absence of a ureteric injury (Fig. 11.3). Both ureters can easily be examined. Post-operative diagnosis The diagnosis is usually apparent in the first few days following surgery (see box), but it may be delayed by weeks, months, or years (presentation: flank pain; post-hysterectomy incontinence—a continuous leak of urine suggests a ureterovaginal fistula).

Fig. 11.3 A normal retrograde ureterogram

Symptoms and signs of ureteric injury May include:

  • an ileus (due to urine within the peritoneal cavity)
  • prolonged post-operative fever or overt urinary sepsis
  • persistent drainage of fluid from drains, the abdominal wound, or the vagina. Send this for creatinine estimation. Creatinine level higher than that of serum = urine (creatinine level will be at least 300µmol/l)
  • flank pain if the ureter has been ligated
  • abdominal mass, representing a urinoma (a collection of urine)
  • vague abdominal pain
  • the pathology report on the organ that has been removed may note the presence of a segment of ureter!

Investigation: IVU or retrograde ureterogram. Ultrasonography may demonstrate hydronephrosis, but hydronephrosis may be absent when urine is leaking from a transected ureter into the retroperitoneum or peritoneal cavity. The IVU usually shows an obstructed ureter or occasionally a contrast leak from the site of injury. P.428
Ureteric injuries: management When to repair the ureteric injury Generally, the best time to repair the ureter is as soon as the injury has been diagnosed. Delay definitive ureteric repair when:

  • the patient is unable to tolerate a prolonged procedure under general anaesthetic
  • there is evidence of active infection at the site of proposed ureteric repair (infected urinoma).

A percutaneous nephrostomy should be placed, the infection drained radiologically (percutaneous drain), intravenous antibiotics given, and ureteric repair delayed until the patient is apyrexial. Traditional teaching held that surgical repair should be delayed when the injury was diagnosed between roughly day 7 and day 14 after ureteric injury, the time when maximal oedema and inflammation at the site of repair was believed to occur. However, favourable outcomes have been demonstrated after early repair and the time of the original injury is nowadays seen as a less important determinant of time of definitive repair.3 Definitive treatment of ureteric injuries The options depend on:

  • whether the injury is recognized immediately
  • level of injury
  • other associated problems.

The options are:

  • JJ stenting for 3–6 weeks (e.g. ligature injury recognized immediately)
  • primary closure of partial transection of the ureter
  • direct ureter to ureter anastomosis (primary ureteroureterostomy)—if the defect between the ends of the ureter is of a length where a tension-free anastomosis is possible
  • reimplantation of the ureter into the bladder (ureteroneocystostomy) either using a psoas hitch or a Boari flap (Figs. 11.4 and 11.5)
  • transureteroureterostomy (Fig. 11.6)
  • autotransplantation of the kidney into the pelvis—where the segment of damaged ureter is very long
  • replacement of the ureter with ileum—where the segment of damaged ureter is very long
  • permanent cutaneous ureterostomy—where the patient’s life expectancy is very limited
  • nephrectomy—traditionally advocated for ureteric injury during vascular graft procedures (e.g. aortobifemoral graft for AAA), but the trend is towards ureteric repair and renal preservation, reserving nephrectomy only where a urine leak develops post-operatively (continuing drainage of urine from the drain placed at the site of ureteric anastomosis).4
Fig. 11.4 A psoas hitch. (Reproduced with permission from McAninch 1996.)1

General principles of ureteric repair

  • The ends of the ureter should be debrided, so that the edges to be anastomosed are bleeding freely.
  • The anastomosis should be tension free.
  • For complete transection, the ends of the ureter should be spatulated, to allow a wide anastomosis to be done.
  • A stent should be placed across the repair.
  • Mucosa to mucosal anastomosis should be done, to achieve a watertight closure.
  • Use 4/0 absorbable suture material.
  • A drain should be placed around the site of anastomosis.
Fig. 11.5 A Boari flap. (Reproduced with permission from McAninch 1996.)1
Fig. 11.6 Transureteroureterostomy. (Reproduced with permission from McAninch 1996.)1

Pelvic fractures: bladder and ureteric injuries associated with pelvic fractures Pelvic fractures are usually due to run-over or crush injuries, where massive force is applied to the pelvis. Associated head, chest, intra-abdominal (spleen, liver, mesentery of bowel), pelvic (bladder, urethra, vagina, rectum), and genital injuries are common and these injuries + the massive blood loss from torn pelvic veins and arteries account for the substantial (20%) mortality after pelvic fracture. Initial assessment Pelvic fractures are often occult. Screen run-over or crush victims with a pelvic X-ray. Assess:

  • vital signs (PR, SBP)
  • neurovascular integrity of lower limb (lumbosacral plexus, peripheral nerves, and major vessels may be damaged)
  • examine for head, chest, abdominal, and perineal injuries
  • determine stability/instability of the fracture from pelvic X-rays

Is the fracture stable or unstable? See box. Abdominal and pelvic imaging in pelvic fracture

  • Abdominal/pelvic CT. Establishes presence/absence of associated pelvic (rectum, bladder) and abdominal organ injury (liver, bowel, spleen).
  • Retrograde urethrogram. To detect urethral injury. Some hospitals perform retrograde urethrography only when blood is present at the meatus; others do this in all pelvic fracture patients where the pubic rami have been disrupted.
  • If the urethra is intact a retrograde cystogram is done to assess integrity of the bladder.

Is urethral catheterization of a pelvic fracture patient safe? If there is no blood present at the meatus, a gentle attempt at urethral catheterization may be made. It has been suggested that this could convert a partial urethral rupture into a complete rupture. However, leading US trauma centres state ‘We and others have not seen any evidence that this can convert an incomplete into a complete transection … and we usually make one gentle attempt to place a urethral catheter in suspected urethral disruption’.5 If any resistance is encountered, stop, and obtain a retrograde urethrogram. If the retrograde urethrogram demonstrates a normal urethra, proceed with another attempt at catheterization, using plenty of lubricant. If there is a urethral rupture, insert a suprapubic catheter via a formal open approach, to allow inspection of the bladder (and repair of injuries if present). Is the fracture stable or unstable? Stable = the fracture can withstand normal physiologic forces. Unstable = the fracture cannot withstand normal physiologic forces. Instability suggests a greater degree of trauma to the pelvis and increases the likelihood of serious associated injuries. In addition, fixation of an unstable fracture reduces blood loss, mortality, hospital stay, leg length discrepancy, and long-term disability; makes nursing care easier; and reduces analgesic consumption. Stability can be defined according to the Tile classification system of pelvic ring fractures (see Table 11.2) Of unstable pelvic fractures, 70% are B2 and B3, 10–20% are open book type (B1), and 10–20% are type C.

  • Open book pelvic fracture (B1): caused by anteroposterior compression. A dramatic rise in pelvic volume stretches vessels, nerves, and organs (e.g. bladder) (see Figs. 11.7 and 11.8)
  • Closed book pelvic fracture (B2 or B3): caused by a lateral compression force to the pelvis. The pubic rami fracture and overlap, and the ilium and sacral wings may be fractured. Nerves and vessels are not stretched, but the urethra is more likely to be damaged by scissors like action of overlapping pubic rami.
  • Vertically unstable pelvic fracture (C): vessels and nerves can be damaged by stretching.

Radiological determination of stability Based on inlet (for anteroposterior displacement) and outlet views (for vertical displacement) of the pelvis, the X-ray beam being angled accordingly. CT provides better definition of sacral, sacroiliac, and acetabular fractures and dislocations.

Table 11.2 The Tile classification system of pelvic ring fractures
Type A—stable A1 Fracture of pelvis not involving the pelvic ring
A2 Minimal displacement of pelvic ring with no instability
Type B—rotationally (horizontally) unstable B1 Open book
B2 Closed book. Lateral compression: ipsilateral fracture
B3 Closed book. Lateral compression: contralateral fracture (bucket handle fracture)
Type C—rotationally (horizontally) and vertically unstable C1 Unilateral
C2 Bilateral
C3 With acetabular fracture

Bladder injuries associated with pelvic fractures ~10% of male and 5% of female pelvic fractures are associated with a bladder injury (fracture type leading to bladder injury is usually an antero-posterior pelvic compression fracture—i.e. open book pelvic fracture; Tile classification B1). 60% of pelvic fracture bladder ruptures are extra-peritoneal, 30% intraperitoneal, and 10% combined extraperitoneal and intraperitoneal. Urethral injuries associated with pelvic fractures The posterior urethra (essentially the membranous urethra) is injured with roughly the same frequency as the bladder in subjects who sustain a pelvic fracture, occuring in 5–15% of such cases. Most posterior urethral injuries occur in association with pelvic fractures.6 Cass found bladder ruptures in 6% of pelvic fractures, urethral rupture in 2%, and combined bladder and urethral rupture in 0.5%.7 Combined bladder and posterior urethral injuries following pelvic fracture One third of patients with a traumatic bladder rupture have injuries to other urinary structures, most commonly the urethra. 10–20% of patients with a pelvic fracture and bladder rupture also have a posterior urethral rupture. Symptoms and signs of bladder or urethral injury in pelvic fracture

  • blood at meatus—in 40–50% of patients; (no blood at meatus in 50–60%)
  • gross haematuria
  • inability to pass urine
  • perineal or scrotal bruising
  • ‘high riding’ prostate
  • inability to pass a urethral catheter

‘High riding prostate’ The prostate and bladder become detached from the membranous urethra and are pushed upwards by the expanding pelvic haematoma. The high riding prostate is said to be a classic sign of posterior urethral rupture. Traditional teaching states that a DRE should be done in cases of pelvic trauma to determine prostatic position. However, the presence of a high riding prostate is an unreliable sign.8 The pelvic haematoma may make it impossible to feel the prostate, so the patient may be thought to have a high riding prostate when, in fact, it is in a normal position. Conversely, what may be thought to be a normal prostate in a normal position may actually be the palpable pelvic haematoma. In pelvic fracture, a DRE is done not to identify a high riding prostate, but rather to establish the presence of an associated rectal injury (blood seen on the examining finger). However, rectal injury can still occur in the absence of rectal blood.

Fig. 11.7 An open book pelvic fracture before fixation
Fig. 11.8 An open book pelvic fracture after fixation

Management of bladder injuries associated with pelvic fractures Extraperitoneal—urethral catheter until the bladder has healed (usually 2–3 weeks) Intraperitoneal—open surgical repair Management of urethral injuries associated with pelvic fractures Suprapubic catheter. Placement via an open approach is generally better than a percutaneous approach, partly because it allows inspection of the bladder for associated injuries which may require repair (see below), but also because the catheter may inadvertently be placed into the large pelvic haematoma which always accompanies such fractures. Not only does this mean that the bladder is not being drained (so urine will leak into the pelvic haematoma and fracture site), but the suprapubic can also act as a potential source of infection of the pelvic haematoma, which can lead to life-threatening sepsis. Management of combined urethral and bladder injuries associated with pelvic fractures If a urethral catheter can be passed, and a cystogram shows an extra-peritoneal bladder rupture, leave a urethral catheter in place until the bladder has healed (usually 2–3 weeks). If a urethral catheter cannot be passed (because of a complete urethral rupture), a suprapubic catheter should be placed via an open approach (rather than percutaneously), to allow inspection of the bladder (and repair if the bladder has been torn) at the same time that the suprapubic catheter is placed. The urethral rupture will prevent a cystogram from being done so direct inspection of the bladder is required to establish the presence/absence of a bladder injury. P.437
Bladder injuries Situations in which the bladder may be injured TURBT (Figs. 11.9 and 11.10), cystoscopic bladder biopsy, TURP, cystolitholapaxy, penetrating trauma to the lower abdomen or back, caesarian section (especially as an emergency), blunt pelvic trauma—in association with pelvic fracture or ‘minor’ trauma in the inebriated patient, rapid deceleration injury (e.g. seat belt injury with full bladder in the absence of a pelvic fracture), spontaneous rupture after bladder augmentation, total hip replacement (very rare). Types of perforation

  • Intraperitoneal perforation—the peritoneum overlying the bladder is breached allowing urine to escape into the peritoneal cavity.
  • Extraperitoneal perforation—the peritoneum is intact and urine escapes into the space around the bladder, but not into the peritoneal cavity.

Making the diagnosis During endoscopic urological operations (e.g. TURBT, cystolitholapaxy), the diagnosis is usually obvious on visual inspection alone—a dark hole is seen in the bladder and loops of bowel may be seen on the other side. No further diagnostic tests are required. In cases of trauma, the classic triad of symptoms and signs suggesting a bladder rupture is:

  • suprapubic pain and tenderness
  • difficulty or inability in passing urine
  • haematuria

Additional signs:

  • abdominal distension
  • absent bowel sounds (indicating an ileus from urine in the peritoneal cavity)

These symptoms and signs are an indication for a retrograde cystogram. The diagnosis may be made only at operation for fixation of a pelvic fracture. Imaging studies Retrograde cystography or CT cystography.

  • Ensure the bladder is adequately distended with contrast. With inadequate distension a clot, omentum, or small bowel may ‘plug’ the perforation, which may not therefore be diagnosed. Use at least 400ml of contrast in an adult and 60ml plus 30ml per year of age in children up to a maximum of 400ml in children.
  • Obtain images after the contrast agent has been completely drained from the bladder (a post-drainage film). A whisper of contrast from a posterior perforation may be obscured by a bladder distended with contrast.

In extraperitoneal perforations, extravasation of contrast is limited to the immediate area surrounding the bladder. In intraperitoneal perforations, loops of bowel may be outlined by the contrast.

Fig. 11.9 A bladder perforation following a TURBT, as demonstrated on a cystogram (AP view)
Fig. 11.10 A bladder perforation following a TURBT, as demonstrated on a cystogram (lateral view)

Treatment of bladder rupture Extraperitoneal Bladder drainage with a urethral catheter for ~2 weeks followed by a cystogram to confirm the perforation has healed. Indications for surgical repair of extraperitoneal bladder perforation:

  • If you have opened the bladder to place a suprapubic catheter for a urethral injury
  • A bone spike protruding into the bladder on CT
  • Associated rectal or vaginal perforation
  • Where the patient is undergoing open fixation of a pelvic fracture, the bladder can be simultaneously repaired

Intraperitoneal Usually repaired surgically to prevent complications from leakage of urine into the peritoneal cavity. Spontaneous rupture after bladder augmentation Spontaneous bladder rupture occasionally occurs months or years after bladder augmentation and usually with no history of trauma. If the patient has spina bifida or a spinal cord injury, they usually have limited awareness of bladder fullness and pelvic pain. Their abdominal pain may therefore be mild and vague in onset and nature. Fever or other signs of sepsis may be present. Have a high index of suspicion in patients with augmentation who present with non-specific signs of illness. A cystogram usually, though not always, confirms the diagnosis. If doubt exists, consider exploratory laparotomy. P.441
Posterior urethral injuries in males and urethral injuries in females Mechanisms

• External blunt Pelvic fracture—road traffic accidents, falls from a height, crush injuries—most common cause
• External penetrating Gunshot—rare; stab—rare
• Internal, iatrogenic Endoscopic surgery; radical prostatectomy;TURP (more likely with vascular prostate, prostate cancer, inexperienced surgeon)
• Internal, self-inflicted Foreign bodies inserted into urethra—rare

Male posterior urethral injuries The great majority of posterior urethral injuries are an associated injury following pelvic fracture and their diagnosis and inital management are discussed on p.432. Immediate (within 48 hours) open repair of posterior urethral injuries is associated with a high incidence of urethral strictures (70%) and subsequent re-stenosis after stricture repair, incontinence (20%), and impotence (40%). The surrounding haematoma and tissue swelling makes it difficult to identify structures and to mobilize the two ends of the urethra to allow tension-free anastomosis. In the majority of male posterior urethral injuries, treatment should be deferred for 3 months to allow the oedema and haematoma to completely resolve. As this occurs, the two distracted ends of the urethra come closer together, thereby reducing the amount of mobilization that the surgeon has to do. Most such injuries can be repaired by an anastomotic urethroplasty. Optical urethrotomy (division of the stricture using an endoscopic knife or laser, via a cystoscope inserted into the urethra) is generally not recommended. Immediate repair is indicated where there is an open wound as long as the urethral ends are close (i.e. not distracted by a large haematoma). Urethral injuries in females Rare, because the female urethra is short and its attachments to the pubic bone are weak, such that it is less prone to tearing during pubic bone fracture. When they do occur, such injuries are usually associated with rectal or vaginal injuries. In developing countries, prolonged labour can cause ischaemic injury to the urethra and bladder neck, leading to urethrovaginal or vesicovaginal fistula formation. P.443
Anterior urethral injuries These injuries are uncommon. Mechanisms

• External blunt Straddle injury (e.g. forceful contact of perineum with bicycle cross-bar2)—most common cause of injury; kick to perineum; penile fracture
• External penetrating Gunshot; stab
• Internal, iatrogenic Catheter balloon inflated in urethra; endoscopic surgery; penile surgery
• Internal, self-inflicted Foreign bodies inserted into urethra

History and examination The patient usually presents with difficulty in passing urine and frank haematuria in the context of a straddle injury. Blood may be present at the end of the penis and a haematoma around the site of the rupture. If Buck’s fascia has been ruptured (the deep layer of the superficial fascia of penis), urine and blood track into the scrotum causing swelling and a ‘butterfly wing’ pattern of bruising, reflecting the anatomical attachments of Colles’ fascia—the membranous layer of the superficial fascia of the groin and perineum (see Fig. 11.11). Confirming the diagnosis and subsequent management Retrograde urethrography delineates the extent of urethral injury. Extravasation of urine can create a collection of urine around the urethra (a urinoma) and generates an inflammatory reaction, with subsequent stricture formation. Superadded infection can lead to abscess formation, which may burst onto the surface of the skin leading to a urethrocutaneous fistula. More rarely, Fournier’s gangrene supervenes. Urinary diversion (urethral or suprapubic catheter) prevents further extravasation of urine, and antibiotics may reduce the likelihood of superadded infection. Anterior urethral contusion Typical history: blood at meatus, no extravasation of contrast on retrograde urethrogram. Pass a small gauge urethral catheter (12 Ch in an adult) and remove a week or so later. Partial rupture of anterior urethra Leak of contrast from urethra with retrograde flow into bladder. Most can be managed by a period of suprapubic urinary diversion. 70% heal without stricture formation (primary closure can be difficult because of oedema and of haematoma at site of injury and can convert a short area of urethral injury into a longer one). Give a broad spectrum antibiotic to prevent infection of extravasated urine and blood. If a voiding cystogram 2 weeks later confirms urethral healing, remove suprapubic catheter. If contrast still extravasates, leave it in place a little longer.

Fig. 11.11 Butterfly bruising following rupture of Buck’s fascia

Suprapubic catheterization (percutaneously) is preferred over urethral catheterization because a partial rupture can be converted to a complete rupture. If the bladder cannot be palpated, such that a suprapubic catheter cannot safely be inserted, then perform open suprapubic cystostomy (under general anaesthetic). Complete rupture of anterior urethra Leak of contrast from urethra on retrograde urethrogram, no filling of the posterior urethra or bladder. The urethra may either be immediately repaired (if a surgeon with sufficient experience is available) or a suprapubic catheter can be placed with delayed repair. Penetrating partial and complete anterior urethral injuries Knife or gunshot wound: primary (i.e. immediate) repair may be carried out, if a surgeon experienced in these techniques is available; if not, suprapubic diversion and subsequent repair by an appropriate surgeon. Immediate surgical repair of anterior urethral injuries is only done in the context of penile fracture or where there is an open wound. The anatomical explantation for ‘butterfly wing’ pattern of bruising in anterior urethral rupture Fascial layers of penis from superficial to deep:

  • penile skin
  • superficial fascia of the penis (= dartos fascia)—continuous with the membranous layer of the superficial fascia of the groin and perineum (= Colles’ fascia)
  • Buck’s fascia (= the deep layer of the superficial fascia)
  • deep fascia of the penis (the tunica albuginea) which covers the two dorsal rods of erectile tissue, the corpora cavernosa, and the ventrally located corpus spongiosum which surrounds the urethra (see Fig. 11.12)

If Buck’s fascia is intact, bruising from a urethral rupture is confined in a sleeve-like configuration, along the length of the penis. If Buck’s fascia has ruptured, the extravasation of blood and thus the subsequent bruising, is limited by the attachments of Colles’ fascia which forms a ‘butterfly’ like pattern in the perineum and is continuous in the upper abdomen and chest with Scarpa’s fascia. P.446
How to perform a retrograde urethrogram

  • Aseptic technique.
  • Urografin 150 (sodium amidotrizoate and meglumine amidotrizoate), but other contrast agents can be used.
  • Position the patient at an oblique angle (bottom leg flexed at the hip and knee).
  • A 12 Ch catheter is placed in the fossa navicularis of the penis 1–2cm from the external meatus, with the catheter balloon with 2ml of water or with a penile clamp applied to prevent contrast spilling out of the urethra and to hold the catheter in place.
  • Continuous screening (fluoroscopy) is done as contrast is instilled until the entire length of the urethra is demonstrated. Remember, as the urethra passes through the pelvic floor (the membranous urethra) there is a normal narrowing, and similarly the prostatic urethra is narrower than the bulbar urethra.
Fig. 11.12 The fascial layers of the penis

Footnote 2 Bulbar urethra being crushed against pubic bone. P.447
Testicular injuries Testicular injuries are uncommon. Mechanisms Blunt or penetrating. Most in civilian practice are blunt, a blow forcing the testicle against the pubis or the thigh. Bleeding occurs into the parenchyma of the testis, and if sufficient force is applied, the tunica albuginea of the testis (the tough fibrous coat surrounding the parenchyma) ruptures, allowing extrusion of seminiferous tubules. Penetrating injuries occur as a consequence of gunshot and knife wounds and from bomb blasts; associated limb (e.g. femoral vessel), perineal (penis, urethra, rectum), pelvic, abdominal, and chest wounds may occur. Where bleeding is confined by the tunica vaginalis, a haematocele is said to exist. Intraparenchymal (intratesticular) haemorrhage and bleeding beneath the parietal layer of tunica vaginalis will cause the testis to enlarge slightly. The testis may be under great pressure as a consequence of the intra-testicular haemorrhage confined by the tunica vaginalis. This can lead to ischaemia, necrosis, and atrophy of the testis. The force is usually sufficient to rupture the tunica albuginea and the tunica vaginalis, and seminiferous tubules and blood extrude into the layers of the scrotum. This is a haematoma. History and examination Severe pain is common, as are nausea and vomiting. If the testis is surrounded by haematoma it will not be palpable. If it is possible to palpate the testis, it is usually very tender. The resulting scrotal haematoma can be very large and the bruising and swelling so caused may spread into the inguinal region and lower abdomen. Testicular ultrasound in cases of blunt trauma A normal parenchymal echo pattern suggests there is no significant testicular injury (i.e. no testicular rupture). Hypoechoic areas within the testis (indicating intraparenchymal haemorrhage) suggests testicular rupture. Indications for exploration in scrotal trauma

  • Testicular rupture. Exploration allows evacuation of the haematoma, excision of extruded seminiferous tubules, and repair of the tear in the tunica albuginea.
  • Penetrating trauma. Exploration allows repair to damaged structures (e.g. the vas deferens may have been severed and can be repaired).

Penile injuries Amputation Blood loss can be severe; resuscitate the shocked patient and cross-match blood. Place the penis, if found, in a wet swab inside a plastic bag, which is then placed inside another bag containing ice (‘bag in a bag’). It can survive for 24 hours. Knife and gunshot wounds Associated injuries are common (e.g. scrotum, major vessels of the lower limb). Most injuries, other than minor ones, should undergo primary repair. Remove debris from wound (e.g. particles of clothing) and debride necrotic tissue and repair as for penile fractures (see box). Penile fracture Rupture of the tunica albuginea of the erect penis (i.e. rupture of one or both corpora cavernosa ±rupture of corpus spongiosum with rupture of the urethra). The tunica albuginea is 2mm thick in the flaccid penis. It thins to 0.25mm during erection, and is therefore vulnerable to rupture if the penis is forcibly bent (e.g. during vigorous sexual intercourse). The patient usually reports a sudden ‘snapping’ or ‘popping’ sound and/or sensation, with sudden penile pain and detumescence of the erection. The penis is swollen and brusied, sometimes resembling an aubergine. If Buck’s fascia has ruptured, bruising extends onto the lower abdominal wall and into the perineum and scrotum. A tender, palpable defect may be felt over the site of the tear in the tunica albuginea. If the urethra is damaged, there may be blood at the meatus or haematuria (dipstick/ microscopic or macroscopic) and pain on voiding or urinary retention. Arrange a retrograde urethrogram in such cases. Treatment There has been a trend away from conservative management towards surgical repair (lower complication rate e.g. reduced penile deformity, less chance of penile scar tissue and prolonged penile pain). Conservative: application of cold compresses to the penis; analgesics and anti-inflammatory drugs; abstinence from sexual activity for 6–8 weeks to allow healing. Surgery: expose the fracture site in the tunica albuginea, evacuate the haematoma, and close the defect in the tunica. P.451
Surgical reimplantation of amputated penis Repair the urethra first, over a catheter, to provide a stable base for subsequent neurovascular repair. Close the tunica albuginea of the corpora (4/0 absorbable suture). Cavernosal artery repair is technically very difficult and does not improve penile viability. Anastomose the dorsal artery of the penis (11/0 nylon), then the dorsal vein (9/0 nylon) to provide venous drainage, and, finally, the dorsal penile nerve (10/0 nylon). Surgical repair of penile fracture Expose the fracture site by degloving the penis via a circumcising incision around the subcoronal sulcus or by an incision directly over the defect if palpable. A degloving incision allows better exposure of the urethra for associated urethral injuries. Alternatively, use a midline incision extending distally from the midline raphe of the scrotum, along the shaft of the penis. This latter incision, along with a degloving incision, allows excellent exposure of both corpora cavernosa so that an unexpected bilateral injury can be repaired easily, as can a urethral injury should this have occurred. Close the defect in the tunica with absorbable sutures or by non-absorbable sutures (bury the knots so that the patient is unable to palpate them). Non-absorbable sutures may possibly be associated with prolonged post-operative pain. Leave a urethral catheter (voiding can be difficult immediately post-operatively). Repair a urethral rupture, if present, with a spatulated single or two-layer urethral anastomosis, and splint repair with a urethral catheter for 3 weeks. Penile bites Clean the wound. Give broad spectrum antibiotics (e.g. cephalosporin and amoxycillin). Zipper injuries If the penis is still caught in the zipper, use lubricant jelly and gently attempt to open it. The zipper may have to be cut with orthopaedic cutters or prised apart with a pair of surgical clips on either side of the zipper. P.452
Torsion of the testis and testicular appendages Definition A testicular torsion is a twist of the spermatic cord resulting in strangulation of the blood supply to the testis and epididymis. Testicular torsion occurs most frequently between the ages of 10–30 (peak incidence 13–15 years of age), but any age group may be affected. History and examination Sudden onset of severe pain in the hemiscrotum, sometimes waking the patient from sleep. It may radiate to the groin, loin, or epigastrium (reflecting its origin from the dorsal abdominal wall of the embryo and its nerve supply from T10/11). There is sometimes a history of minor trauma to the testis. Some patients report previous episodes with spontaneous resolution of the pain (suggesting previous torsion with spontaneous detorsion). The patient may have a slight fever. The testis is usually slightly swollen and very tender to touch. It may be high-riding (lying at a higher than normal position in the testis) and may be in a horizontal position due to twisting of the cord. Differential diagnosis and investigations Epididymo-orchitis, torsion of a testicular appendage, and causes of flank pain with radiation into the groin and testis (e.g. a ureteric stone). Colour doppler ultrasound (reduced arterial blood flow in the testicular artery) and radionuclide scanning (decreased radioisotope uptake) can be used to diagnose testicular torsion, but in many hospitals these tests are not readily available and the diagnosis is based on symptoms and signs. Surgical management Scrotal exploration should be undertaken as a matter of urgency. Delay in relieving the twisted testis results in permanent ischaemic damage to the testis causing atrophy, loss of hormone and sperm production, and, as the testis undergoes necrosis and the blood–testis barrier breaks down, an autoimmune reaction against the contralateral testis (sympathetic orchidopathia). Fix BOTH testes since the bell-clapper abnormality which predisposes to torsion can occur bilaterally. Torsion of testicular appendages The appendix testis (hydatid of Morgagni—a remnant of the Müllerian duct) and the appendix epididymis (a remnant of a cranial mesonephric tubule of the Wolffian duct) can undergo torsion causing pain that mimicks a testicular torsion. At scrotal exploration they are easily removed with scissors or a diathermy probe. P.453
Paraphimosis Definition and presentation This is where the foreskin is retracted from over the glans of the penis, becomes oedematous, and cannot then be pulled back over the glans into its normal anatomical position. It occurs most commonly in teenagers or young men and also in elderly men (who have had the foreskin retracted during catheterization, but where it has not been returned to its normal position). Paraphimosis is usually painful. The foreskin is oedematous and a small area of ulceration of the foreskin may have developed. Treatment The ‘iced-glove’ method: apply topical lignocaine gel to the glans and foreskin for 5 min. Place ice and water in a rubber glove and tie a knot in the cuff of the glove to prevent the contents from pouring out. Invaginate the penis into the thumb of the glove. This may reduce the swelling and allow reduction of the foreskin. Granulated sugar placed in a condom or glove and applied over the end of the penis has been used to reduce the oedema by osmosis. The Dundee technique9: give the patient a broad spectrum antibiotic such as 500mg of ciprofloxacin by mouth. Apply a ring block to the base of the penis using a 26G needle and 10–20ml of 0.5% plain bupivicaine (children usually require general anaesthesia). Clean the skin of the foreskin and the glans with cleaning solution. Using a 25G needle make approximately 20 punctures into the oedematous foreskin. Squeeze the oedema fluid out of the foreskin (Fig. 11.13) and return to its normal position. Approximately one third of patients subsequently require elective circumcision for an underlying phimosis. If this fails, the traditional surgical treatment is a dorsal slit under general anaesthetic or ring block. A longitudinal incision is made in the tight band of constricting tissue and the foreskin pulled back over the glans. Close the incision transversely to lengthen the circumference of the foreskin and prevent recurrences.

Fig. 11.13 Paraphimosis reduced by the Dundee technique. (Reproduced from Reynard 1999, permission sought)

Malignant ureteric obstruction Locally advanced prostate cancer, bladder or ureteric cancer may cause unilateral or bilateral ureteric obstruction. Locally advanced non-urological malignancies can also obstruct the ureters (e.g. cervical cancer, rectal cancer, lymphoma). Unilateral obstruction is often asymptomatic; an incidental ultrasound finding that requires no specific treatment in the presence of a normal contralateral kidney. Occasionally, loin pain and systemic symptoms may develop due to infection of the obstructed upper urinary tract. In this circumstance, drainage by nephrostomy or stenting is required. Bilateral ureteric obstruction is a urological emergency. The patient presents either with symptoms and signs of renal failure, or anuric without a palpable bladder. A mass will probably be palpable on rectal examination. Investigations: renal ultrasound will demonstrate bilateral hydronephrosis and an empty bladder; CT urography will confirm the presence of dilated ureters down to a mass at the bladder base. Immediate treatment of bilateral ureteric obstruction After treating any life-threatening hyperkalaemia, options include bilateral percutaneous nephrostomy or ureteric stenting. A clotting screen is required prior to nephrostomy insertion. Insertion of retrograde ureteric stents in this setting is usually unsuccessful because tumour involving the trigone obscures the location of the ureteric orifices. More successful is antegrade ureteric stenting following nephrostomy insertion, both of which are performed under sedoanalgesia. The full-length double-J silicone or polyurethane ureteric stents require periodic (4–6 monthly) changes to prevent calcification or blockage. In the case of prostate cancer, hormone therapy should be commenced if not previously used; even in patients with androgen-independent disease, high-dose parenteral oestrogens may relieve ureteric obstruction. Long-term treatment of bilateral ureteric obstruction Longer-term treatment options include urinary diversion by formation of ileal conduit, ureteric re-implantation, insertion of short ‘permanent’ metallic ureteric stents, or ureteric replacement with isolated ileal segments or prosthetic graft material. Such procedures are often complicated and inappropriate in these poor-prognosis patients. P.457
Spinal cord and cauda equina compression Spinal cord compression due to spinal metastases from urological cancers This is a urological oncological emergency; failure to diagnose and treat promptly can lead to permanent paraplegia and autonomic dysfunction (failure of bladder and bowel emptying; inability to achieve an erection). Due to epidural compression arising from vertebral body metastasis in the majority of cases, 95% of patients will complain of back pain and have a positive bone scan. 10% of cases do not exhibit these features because their disease is paravertebral. Patients with back pain should be examined neurologically and evaluated radiologically. Pain usually precedes cord compression by about 4 months. Other clinical features include sensory changes and muscle weakness in the lower limbs, bladder and bowel dysfunction, and these can progress rapidly to become irreversible. If cord compression is suspected, the investigation of choice is spinal MRI, which will reveal the deposits (multiple in 20% of cases). Treatment Initial treatment is with high-dose intravenous corticosteroids (e.g. dexamethasone 10mg followed by 4mg 6-hourly for 2–3 weeks). Without delay, further treatment with radiotherapy or neurosurgical decompression is carried out. Surgery should be considered preferable if there is pathological fracture, unknown tissue diagnosis, or previous history of radiotherapy. Cauda equina compression The adult spinal cord tapers below L2 vertebral level into the conus medullaris. The cauda equina consists of the nerve roots of all spinal cord segments below L2, as they run in the subarachnoid space to their exit levels in the lower lumbar and sacral spines. Pathophysiology: the cauda equina may be compressed by central intervertebral disc prolapse (1–15% of cases), spinal stenosis, or by a benign or malignant tumour within the lower lumbar or sacral vertebral canal. Symptoms: the diagnosis should be considered in any female or young male presenting with difficulty voiding or in urinary retention. There may be back pain. Signs: palpable bladder, loss of perianal (S2–4) and lateral foot sensation (S1–2), reduced anal tone, priapism. Investigations: MRI lumbosacral spine; urodynamic studies reveal a normally compliant but areflexic bladder. Treatment: emergency neurosurgical decompression (laminectomy within 48 hours of onset of symptoms), intermittent self-catheterization. References 1 Toutouzas KG (2002) Non-operative management of blunt renal trauma: a prospective study. Am Surg 68:1097–103. 2 Martin X (2000) Severe bleeding after nephrolithotomy: results of hyperselective embolization. Eur Urol 37:136–39. 3 Blandy JP et al. (1991) Early repair of iatrogenic injury to the ureter and bladder after gynecological surgery. J Urol 146:761–65. 4 McAninch JW (2002) In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds) Campbell’s Urology, 8th Edition. W.B. Saunders: Philadelphia, pp. 3703–14. 5 McAninch JW (2002) In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds) Campbell’s Urology, 8th Edition. Saunders: Philadelphia, pp. 3703–14. 6 Cass AS (1984) Simultaneous bladder ansd prostato membranous urethral rupture from external trauma. J Urol 132: 907–8. 7 Cass AS (1988) Genitourinary Trauma. Boston: Blackwell Scientific Publications. 8 Elliott DS, Barrett DM. (1997) Long-term follow-up and evaluation of primary realignment of posterior urethral disruptions. J Urol 157:814–16. 9 Reynard JM, Barua JM (1999) Reduction of paraphimosis the simple way—the Dundee technique. Br J Urol Int 83:859–60.

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