Renal injuries caused by blunt trauma or penetrating missiles may involve the parenchyma, capsule, or pedicle. Trauma to the urinary tract is rarely a solitary event: more serious or life-threatening problems may take precedence. However, morbidity associated with significant renal trauma is often high.

Penetrating wounds of the kidney usually result from gunshots or stabbing. These are often complicated by perforation of other structures such as abdominal organs, chest, spine, or remote bony structures, depending on the character and direction of the missile. Approximately 90 per cent of gunshot wounds and 60 per centof stab wounds to the kidney are associated with intra-abdominal injuries.

The liver and colon may be injured in up to 60 per cent of patients with injuries to the right kidney. Injuries to the left kidney are associated with injury to the spleen, stomach, or pancreas in 60 per cent of patients. Chest injuries occur in 20 per cent of all patients with injury to the kidneys.

The wounds in the renal and surrounding tissues may be perforating, lacerating, or explosive (Fig. 1) 1544. The degree of injury depends on the velocity of the missile as well as on the internal structure of the organ: the higher the velocity the greater the injury. Damage created by a bullet is related to the muzzle velocity. As the missile enters the body gaseous vaporization produces more tissue damage. The bullet also tumbles in its trajectory and occasionally fragments causing still more damage, and creating an exit wound which is larger than the entry wound. Missiles travelling at a velocity of 585 m/s (1900 ft/s) are considered to be ‘high velocity’. Such missiles come from ‘assault’ rifles.

The presentation of penetrating trauma is shock in about 30 per cent of patients. Primary symptoms arising from associated abdominal or chest injuries are present in 70 per cent. Gross haematuria is present in at least 60 per cent of patients and microscopic haematuria occurs in another 20 per cent. Renal colic, or clot colic, occurs in patients with gross haematuria: the passage of blood clots down the ureter causes intermittent urinary obstruction and pain similar to that associated with the passage of kidney stones. The absence of blood in the urine does not exclude renal injury.

Local signs of tenderness, muscle spasms, ecchymosis, and the palpation of a flank mass are some of the common physical findings.

Blunt trauma causes 65 per cent of all renal injuries. This usually results from a direct blow to the abdomen that compresses the kidneys between the lower ribs and the spine.

Indirect injury is much less common. This acceleration–deceleration type of injury is caused by falling and landing on the buttocks or feet, or when the patient is abruptly stopped as in a motor vehicle accident (Fig. 3(a)) 1546. The kidney remains in motion with respect to the rest of the body and aorta. The media and adventia of the renal artery stretch readily, whereas the relatively inelastic intima tears (Fig. 3(b)) 1546. The intimal tear initiates clotting, resulting in distal thrombus propagation and eventual total renal artery thrombosis (Fig. 3(c)) 1546. Blunt trauma causes injury to the renal pedicle in 85 per cent of cases: 90 per cent of these occur in patients under 25 years of age. The artery is injured in 70 per cent of patients, the vein in 20 per cent and both vessels in the remaining 10 per cent. The mortality rate approaches 50 per cent, due mainly to the severity of associated injuries.

Fortunately, renal injury caused by blunt trauma is minor in the majority of patients. Contusion of the kidney or small subcapsular renal haematomata are the rule (Fig. 4) 1547. Lacerations, tears in the renal pelvis, and rupture of the renal vascular pedicle are classified as major renal injuries.

Only 5 per cent of patients with blunt trauma to the kidney present with shock. Associated abdominal injuries cause the primary symptoms in 15 per cent of cases. The local and generalized symptoms and signs of major blunt trauma to the kidney may be identical to those of penetrating injuries. Haematuria, gross and microscopic, is also a constant sign.

The patient with acute renal artery thrombosis resulting from an indirect injury may present with non-colicky flank pain or may be totally asymptomatic. There may be no haematuria. Laceration or avulsion of the renal pedicle often produces a rapidly expanding flank mass with exsanquination.

Radiographic evaluation is essential in determining the site and extent of renal injury. Despite recent advances in radiographic modalities and techniques, flat plate studies of the abdomen (kidney, ureter, bladder) and the intravenous pyelogram are still the mainstays for evaluating renal trauma in the emergency setting.

When the critically injured patient arrives in the emergency ward there may be very little time for evaluation prior to surgical exploration. While he or she is being prepared, a plain radiograph of kidneys, ureter, and bladder can be obtained easily. Obliteration of the psoas shadow, poor renal outline, and scoliosis towards the side of injury may all indicate blood or urine in the pararenal space. Once the patient is hydrated, an intravenous pyelogram determines the presence and function of the contralateral kidney as well as the degree of injury. Major extravasation of contrast material or non-visualization of the kidney, is an indication for selective renal angiography. Permanent, progressive loss of renal function begins after 2 h of warm ischaemia time: attempts to repair the injured kidney must be undertaken promptly if salvage of the kidney is a priority.

Computed tomography (CT) is a well established method for evaluating renal trauma. Ninety per cent of renal injuries can be assessed using intravenous pyelography and nephrotomography. If enough information is not available, CT often supplies the desired staging. Since CT takes time, the patient needs to be medically stable. This diagnostic modality demonstrates the degree of parenchymal injury more accurately than an intravenous pyelogram but its ability to detect vascular injury as effectively as angiography is still being debated.

Penetrating injury to the kidney is frequently associated with injury to other organs, and management of the renal injury usually follows treatment of these associated injuries. Conservation of renal tissues is the rule, but all patients should be considered individually. The indications for non-operative treatment are diminution of local signs and symptoms, as well as lack of a significant transfusion requirement. However, if inspection of the renal bed shows a large or expanding haematoma, surgery is necessary to conserve kidney parenchyma.

Surgery is indicated less often in patients with blunt trauma, since the majority of injuries are minor. If the history, physical examination, and the presence of haematuria are suggestive of renal injury, an intravenous pyelogram should be obtained. If this study is normal or shows minor extravasation, bed rest with observation is the best mode of treatment. However, if the vital signs become unstable, with fever and perhaps an accompanying blood requirement, surgery is mandatory. If the intravenous pyelogram reveals major extravasation of contrast material and a subsequent renal angiogram or CT demonstrates polar rupture or renal pedicle injury, prompt exploration must be carried out.

The proper treatment of the injured patient depends on a systematic approach combining clinical, radiographic, and surgical modalities (Table 1) 463. Depending on the stability of the patient, CT gives the most information about the degree of renal trauma as well as associated abdominal injuries. If time does not permit, a one-shot intravenous pyelogram will give the surgeon an indication of the presence and function of both kidneys.

Associated visceral organ injuries are common in patients with major blunt and penetrating renal trauma: the transabdominal approach therefore allows the best assessment of the patient. Once the peritoneal contents have been explored and other injured organs have been taken care of, attention should be drawn to the injured kidney, which is best approached from the midline.

The posterior peritoneum is incised over the aorta at the level of the renal pedicle (Fig.6(a)) 1549. A vascular clamp is applied to the renal artery (Fig. 6(b)) 1549, remembering that the right renal artery is posterior to the left renal vein. This manoeuvre allows the renal bed to be explored without excessive bleeding (Fig. 6(c)) 1549.

If the renal pedicle is not controlled prior to opening Gerota's fascia the tamponade effect is lost and the need for nephrectomy increases as the clot is removed and the kidney explored. There is a 30 per cent nephrectomy rate even under the most favourable operative conditions.

When renal repair is possible the operative guidelines are: accurate assessment of the degree of injury; adequate debridement of injured tissue; meticulous haemostasis; watertight repair of the collecting system; and adequate drainage of the renal bed (Fig. 7) 1550.

Early complications of non-operative treatment may be infection or secondary haemorrhage. All missiles are potentially infected after carrying clothing or other debris with them. Urine mixed with blood is a good culture medium; infections of the kidney or pararenal tissues sometimes require incision, drainage, and debridement if the patient does not respond to standard antibiotic treatment.

Secondary haemorrhage is likely to occur if the patient is ambulated too early; it may also result from infarction of renal tissue or if abscesses erode into major vessels. Erosion usually occurs between 1 and 2 weeks after the injury.

If the blood from perirenal haemorrhage is not completely absorbed, encapsulation occurs. Perirenal ‘cysts’ form, and these require drainage if they cause painful flank mass or fever.

Late complications of non-operative treatment may be atrophy of the kidney following unrecognized injury to the renal pedicle. Hypertension occurs in 50 per cent of patients with conservatively managed renal artery thrombosis. Post-traumatic hypertension affects up to 30 per cent of those with an ischaemic renal segment. Ureteropelvic obstruction may cause hydronephrosis, secondary to fibrosis resulting from extravasation of urine and blood.

Periodic radiographic follow-up of the injured kidney should be performed for the first year following trauma.

Traumatic wounds of the ureter are uncommon because of its size, location, and mobility. They do occur, however, during pelvic operations. Gunshot wounds account for over 90 per cent of ureteral lacerations; they are equally divided between the upper, middle, and lower segments. Laceration of the ureter by penetrating missiles is associated with injuries to the small bowel (80 per cent of patients), the colon (60 per cent), and the inferior vena cava (20 per cent).

Blunt abdominal trauma accounts for less than 10 per cent of all external ureteral injuries. The ureteropelvic junction may be disrupted by an extreme flexion injury or secondary to a congenital hydronephrosis associated with sudden, blunt, trauma to the upper abdomen. A crush injury to the pelvis may also injure the lower ureter; this is often associated with a ruptured bladder and damage to the pelvic nerves and blood vessels. Posterior urethral tears and rectal injuries may also be present.

Abdominal pain, tenderness, and fever occur as urine accumulates in the retroperitoneum. Although gross or microscopic haematuria is usually present, the drainage of urine through the surgical wound may be the first indication of ureteral injury.

An intravenous pyelogram is normal in less than 10 per cent of these patients. Extravasation of contrast material is the obvious finding, unless severe crush injury to the ureter causes ischaemia and delayed fistualization. A retrograde pyelogram is needed to determine the exact site of injury: this will help in planning of the surgical repair. Ureteral injuries may be very subtle and long delays in diagnosis and treatment may result in the loss of a kidney.

Primary surgical repair should be undertaken as soon as the diagnosis is made, if it is to be successful. The operative technique varies with the site and extent of the ureteral injury. High-velocity missiles create more tissue injury than might be apparent on simple inspection. Adequate debridement of the injured tissues, an infection-free area of surgery, watertight closure with fine chromic sutures, tension-free anastomosis, and good urinary drainage with ureteral stents and/or nephrostomy tubes are essential. If the above principles are not adhered to, ischaemia, necrosis, and disruption of the ureteral anastomosis may result. Nephrectomy may then become necessary.

Antireflux reimplantation of the ureter in the standard Leadbetter-Politano fashion is the preferred repair. An end-to-end ureteral anastomosis may be possible if the healthy ends of the ureter allow for a tension-free repair. If the length of the ureter after debridement and mobilization does not lend itself to reimplantation or primary anastomosis, transureteroureterostomy is the technique of choice.

The injured midureter is best repaired by primary anastomosis (Fig. 10) 1553. This segment of ureter is the most mobile and, therefore, more readily approximated. Downward mobilization of the kidney may give the surgeon several extra centimetres of ‘ureteral’ length.

The preferred technique of repairing the upper ureter is primary anastomosis. Mobilization of the kidney and use of the various pyeloplasty methods aid in diminishing the gap between the healthy ends of the ureter.

The formation of an ileal ureter or kidney autotransplantation should be considered when the damage to the ureter is so extensive that the other repairs are technically impossible. A discussion of iatrogenic ureteral injuries is not in the scope of this chapter.

Blunt trauma causes 75 per cent of bladder injuries; penetrating missiles cause the remainder. A direct blow over a full bladder may cause it to rupture as a result of a sudden increase in intravesical pressure. If there is a tear in the anterior bladder wall the extraperitoneal rupture results in the extravasation of urine into the paravesical tissues (space of Retzius) ( Fig, 11 1554, A). When the tear is in the posterior wall, retrovesical extravasation occurs (Fig. 11, B). If the rent in the bladder is at the dome or vortex the urine passes into the peritoneal cavity (Fig. 11, C). Anterior bladder perforation by spicules occurs in about 10 per cent of patients with severe pelvic fractures (Fig. 11, D).

Fractured pelvis is the injury most commonly associated with a ruptured bladder (at least 80 per cent of patients). There is no apparent correlation between the type of bladder injury and the type of pelvic fracture. However, the greater the compression or disruption of the pelvic ring the more likely bladder and urethral injuries are to occur. Only 10 per cent of patients with pelvic fractures sustain significant bladder injuries and 5 per cent have posterior urethral damage. It is not unusual for intra-abdominal injury to be associated with bladder rupture. Penetrating missiles involve colon, rectum, and small bowel in at least 80 per cent of patients. About 40 per cent of patients with injury to the bladder also sustain injuries to the liver, spleen, and colon.

Complications arise mainly from associated injuries, rather than from isolated bladder rupture. Respiratory failure, sepsis, dysfunctional voiding, abscess formation, and pulmonary embolism are the most common. The overall mortality rate is 20 per cent. In patients with contusion it is 15 per cent, in intraperitoneal rupture, 25 per cent, and in extraperitoneal rupture, 40 per cent. Factors associated with mortality are: age greater than 60 years; Type I fractures (comminuted, involving 3 or more parts of the pelvic ring); four to five associated organ injuries; presentation in shock; and pedestrian injuries.

Patients with extraperitoneal extravasation caused by rupture of the anterior bladder wall develop suprapubic pain, tenderness, and swelling. Ecchymosis of the skin overlying the bladder is also common. A posterior wall tear and extraperitoneal urine leak causes pararectal pain and a boggy mass effect on digital rectal examination. Intraperitoneal rupture produces the desire to void but the inability to do so. Lower abdominal pain is another symptom that, in the later phase, develops into the findings of peritonitis. Uraemia may result when urine comes into contact with the peritoneum: this acts as a semipermeable membrane, dialysing the high urea nitrogen in the urine and causing a rapid rise in blood urea nitrogen levels. Fever and shock result if a long period of time has elapsed since the bladder rupture, and if the urine is infected.

Gross haematuria occurs in most patients who are able to void: bloody urine is found at the time of urethral catheterization, or the bladder may be empty if there is a large intraperitoneal tear. Urethral injury should be excluded prior to insertion of a Foley catheter. If this is not possible, a retrograde urethrogram should be performed first. When the catheter has been inserted a static cystogram can be obtained, using oblique as well as anteroposterior views. Intraperitoneal rupture is indicated by the presence of contrast material within the abdominal cavity. A teardrop deformity of the bladder occurs classically with an extravesical, space of Retzius, collection of blood and urine. A postdrainage film sometimes shows minor extravasation of contrast material. In patients with clinical evidence of a ruptured bladder, a static cystogram may be normal if the small tear has ‘sealed’. Distension of the bladder may therefore be needed: this is achieved with a ‘stress’ cystogram, whereby an extra 60 ml of contrast material is put into the bladder after the pressure has equalized on the standard static cystogram. A plain radiograph of kidney, ureter, bladder prior to the cystogram is essential in determining the presence of pelvic fractures or foreign bodies. An intravenous pyelogram allows the upper urinary tracts to be assessed for associated ureteral or renal injuries. However, it diagnoses bladder ruptures in no more than 20 per cent of known bladder injury. Table 2 464 presents an algorithm that will aide the physician in assessing the patient with pelvic and suspected urological injuries.

Bleeding from a contused bladder usually resolves with urethral catheter drainage. However, bladder rupture necessitates surgical exploration and primary repair. Up to 80 per cent of patients require a laparotomy to treat associated intra-abdominal injuries. The bladder needs to be approached from the midline in order to avoid lateral dissection into pelvic haematoma. The cystotomy should also be in the midline, since disturbing the haematoma may cause a tamponade effect and may also introduce infection. Once the bladder is entered more than one area of injury is usually found. The damaged tissues are debrided and closed in two layers with absorbable sutures. A suprapubic tube and a urethral catheter are used to allow minimal bladder distension and adequate urinary drainage. The associated pelvic haematoma should not be drained. The suprapubic tube is removed when the urine clears and the Foley catheter is removed after 7 to 10 days, when cystography shows no extravasation.

Extraperitoneal rupture of the bladder may be treated by suprapubic exploration. Foreign bodies and bony spicules are removed. The bladder rent is then debrided to healthy tissue and closed in the standard fashion. Multiple drains, suprapubic tube, and a Foley catheter are inserted.

Broad-spectrum antibiotics must be administered postoperatively, since this is a fertile area for infection. Successful non-operative management of small tears, using urethral catheter drainage to decompress the bladder, may be appropriate in a few patients.

The mortality rate in patients with bladder rupture approaches 20 per cent. This is not due to the bladder injury itself but is related to associated injuries. Uncontrolled bleeding from torn pelvic vessels is managed by selective angiography and emobilization with autologous clots.

Trauma to the urethra can be divided into posterior and anterior injuries. The posterior urethra encompasses the urogenital diaphragm with the external sphincter and the prostate. It is fixed to the pubic bone by the puboprostatic ligament. The anterior urethra is distal to the urogenital diaphragm and contains the bulbar and pendulous urethral segments (Fig. 12) 1555. The care of various injuries may be markedly different, depending on the locality of the urethral injury.

Most posterior urethral injuries are motor vehicle accidents and they are usually caused by pelvic fracture. Gunshot and stab wounds account for less than 10 per cent of these injuries. Five per cent of patients with pelvic fractures have urethral injury; this figure rises to 50 per cent when there is disruption of the pelvic ring. Fracture of the pubic rami and pubic symphysis causes rupture of the puboprostatic ligaments. As blood collects in the retropubic and perivesical space the prostate is displaced cephalad, causing partial or complete tear of the membranous urethra (Fig. 13) 1556.

The injury should be suspected in any patient with a pelvic fracture. He may be unable to void and may present with blood at the urethral meatus and a palpable bladder. Digital rectal examination will reveal a boggy mass anteriorly and the prostate may be mobile and displaced upwards. A retrograde urethrogram with water-soluble contrast material will show periprostatic extravasation and no contrast media within the bladder if the urethral tear is complete. An incomplete rupture will show some contrast material within the bladder as well as periprostatic or periurethral extravasation. An intravenous pyelogram is necessary to allow full evaluation of the upper urinary tracts and the bladder. In patients with complete posterior urethral disruption there is a typical teardrop deformity of a high-riding bladder caused by perivesical accumulation of blood. Urine will also extravasate if the bladder neck is not in spasm.

The treatment of posterior urethral injuries remains controversial. It is our present opinion that a urethral catheter should not be passed when a rupture is suspected or established. The insertion of a Foley catheter can convert an incomplete tear to a complete rupture as well as introduce infection. It can also increase the gap between the apex of the prostate and the tear, thereby extending the resultant urethral stricture that almost always occurs. Initial treatment should consist of placement of a large suprapubic cystotomy tube only. Drainage of the retropubic space is not recommended, since this may lead to more fibrosis and possibly infection, increasing the already high incidence of permanent erectile impotence and urinary incontinence.

If the rupture is incomplete, the suprapubic tube may be clamped in 2 weeks to initiate voiding, if an antegrade cystourethrogram performed through the suprapubic tube shows no extravasation. The tube is removed after 3 weeks, when urothelialization of the injury is usually complete. This kind of injury may heal without stricture formation. When the rupture is complete, various methods of urethral anastomosis, with or without partial pubectomy, or scrotal inlay procedures described in standard urological texts can be carried out 6 months after the initial injury. This time lag allows the extent of the stricture to declare itself and periurethral induration to subside. Primary repair of the urethra at the time of injury produces an unacceptable rate of postoperative stricture and erectile impotence. The impotence rate following primary repair is reported to be 30 per cent; in patients undergoing delayed repair, this approaches 10 per cent. The stricture rate in most reports with primary urethral realignment is as high as 75 per cent and urinary stress incontinence affects 25 per cent of patients. Following a delayed procedure these figures drop to 10 per cent and 15 per cent, respectively.

Iatrogenic manipulation, gunshot wounds, and straddle perineal injuries are the most common causes of anterior urethral trauma. At the Massachusetts General Hospital 40 per cent of over 200 urethral strictures requiring urethroplasty were traumatic in origin; 55 per cent affected the anterior urethra, 38 per cent involved the posterior urethra, and the remainder occurred from combined rectourethral injury.

Trauma to the bulbous urethra usually results from a fall astride an object, causing the perineum and the underlying urethra to be crushed against the inferior edge of the pubic symphysis and bone. The most frequent injury is contusion and haemorrhage within Buck's fascia. If this fascia is torn there is subcutaneous extravasation of blood and urine which is enclosed within Colles' fascia (Fig. 14) 1557. This extravasation cannot extend out to the thighs because of the firm attachment of the fascia to the ischiopubic rami. The extravasated fluids travel downward into the scrotum and upward around the root of the penis. They then extend further upward beneath Scarpa's fascia, the superficial fascia of the abdomen (Fig. 15) 1558.

Pain and swelling at the site of injury with ecchymosis extending along the previously described fascial planes is the rule. Blood at the urethral meatus and difficulty in voiding are also common findings. When anterior urethral injuries are severe, voiding may produced marked pain and increase the swelling in the perineum and scrotum as urine and blood collect in the periurethral tissues.

A retrograde urethrogram with water-soluble contrast media should be performed prior to further manipulation. This can be accomplished under gentle pressure using a Brodney penile clamp or a 12 F Foley catheter inserted just far enough into the urethra to allow the catheter balloon to be inflated with 3 ml of fluid. The catheter will occlude the urethra at the fossa navicularis. The degree of injury is usually commensurate with the extent of contrast material extravasation. However, if a urethral catheter has been previously passed without prior radiographic determination of the urethral injury, a pericatheter urethrogram can be performed (Fig. 16) 1559.

Once the diagnosis of anterior urethral injury is made, the initial management is based on the prevention of infection, extravasation of blood and urine, and the prevention of loss or displacement of the urethral lining. If not attended to, all of the above, alone or in combination, may cause subsequent stricture formation.

If urethrography and urethroscopy demonstrate only contusion, observation is all that is required. The perineal, scrotal, and penile haematoma and ecchymoses usually absorb without incision and drainage. The dysuria and urethral bleeding dissipate in several days. However, delayed strictures do occur in patients in whom the urethral lining has been demonstrated to be intact at the time of initial injury. The patient should therefore be re-evaluated after 6 to 12 months, even if there are no symptoms of outlet obstruction.

Anterior urethral injuries with evidence of partial separation and minimal extravasation should be treated initially with urethral catheter drainage and broad-spectrum antibiotics. The catheter is left in place for 3 weeks, to allow the laceration to line itself with new epithelium. The urethral catheter should be coated with an inert material such as Silastic, and should be no larger than a 14F for an adult. A larger catheter may not allow adequate drainage of the extravasated fluids around it. If the periurethral tissues become infected or if the swelling increases, drainage and debridement are necessary.

Anterior urethral injuries with separation of the urethra require perineal incision and drainage. The transected urethra is then debrided, mobilized, and obliquely spatulated. The urethra can be mobilized proximally and distally, allowing defects of 1.5 to 2 cm to be approximated without tension. Primary urethral anastomosis is carried out over a 24F catheter using fine absorbable sutures (Fig. 17) 1560. The catheter is then removed and a 14F Foley catheter is replaced for drainage. Insertion of a suprapubic cystocath further aids urinary drainage and removes the need for a catheter change if the Foley catheter fails to function. The urethral catheter is removed in 10 to 14 days and a voiding cystourethrogram is undertaken through the suprapubic tube to check for fistulae. If healing is incomplete the cystotomy tube should remain in place for another week without replacing the urethral catheter. When primary reapproximation is impossible because of the length of injured urethra, tube grafts, scrotal inlays, or other urethroplasty procedures can be used. One-stage operations are ideal, but multiple staged procedures are occasionally required. If the patient is critically ill from associated injuries the initial treatment is placement of a suprapubic cystotomy tube, with perineal drainage if the extravasation appears significant. Elective surgery may be carried out 3 to 4 months later, after the tissue reaction has abated.

Wounds of the penis, urethra, and scrotum caused by blunt trauma or penetrating missiles may be associated with injuries to thighs, perineum, bony pelvis, bladder, or rectum. Thermal, electrical, and chemical burns may also involve the genitalia. In civilian life, injuries usually result from industrial accidents. Fragmentation devices cause the majority of genital trauma in combat. Trauma can be either major or minor with contusion, laceration, or puncture. Major injury can result from burns. Partial or complete amputation of the penis is not uncommon in acts of self-mutilation.

Blunt trauma, with crushing of the genitals, may cause severe oedema and haemorrhage. Because of the elasticity of the tissues, scrotal and penile swelling is rapid. There is pain and occasionally difficulty in voiding. Traumatic conditions such as haemtocele, haematoma of scrotal layers, rupture of the tunica, and intratesticular haematoma, with or without actual rupture, can now be diagnosed by ultrasound. This modality greatly aids the urologist in determining which patients require surgical intervention. Those which can be treated non-surgically require application of icepacks, pressure, and scrotal elevation. Difficulty in voiding can be overcome by a suprapubic cystocath. Once the oedema begins to subside, in 4 to 5 days, heat, instead of ice, will accelerate tissue fluid absorption.

Testicular rupture is an unusual consequence of blunt trauma because the tunica albuginea covering the testicles is so tough. The patient experiences pain with nausea and vomiting; there may also be a fever. The expanding scrotal mass requires incision and drainage with adequate debridement of the extruded testicular tissues. The tunica is then closed with fine chromic sutures and a pressure dressing is applied. Scrotal elevation and bed rest for several days diminishes the pain. A testicular (nuclear) scan 1 month after the repair allows post-traumatic viability of the testicles to be assessed. Spermatogenesis is frequently impaired following severe injury, but endocrine function may be maintained.

Rupture of the penile corporal bodies is treated in a similar fashion to rupture of the testicle. Once the urethral injury has been repaired or ruled out, the tunica albuginea of the affected corpus cavernosum is debrided and closed. A urethral catheter is placed. Penile rupture may produce impotence, due to damage of the neurovascular bundle, or a chordee, as seen in some patients with Peyronie's disease. These problems can be overcome by using vasoactive drugs to achieve erection or by corrective surgery.

Degloving injuries of the penile and scrotal skin may occur with industrial accidents. The skin is usually very mobile and may, therefore, protect the deeper tissues from injury. Immediate repair after debridement with split-thickness skin grafts or primary closure decreases the chance of infection or sepsis. If the repair of the scrotum does not allow for the concomitant replacement of the testicles, they can be placed subcutaneously in the medial thigh until secondary repair becomes possible.

Most penetrating wounds of the genitals should be treated as potentially infected. The basic principles in management are therefore debridement, lavage, repair, drainage, and antibiotic administration. When primary closure is possible, a tension-free anastomosis with absorbable sutures is performed.

The severed penis requires microvascular repair. The dorsal arteries and the deep and superficial veins of the penis need to be reanastomosed to allow adequate tissue survival and function. The amputated penis is washed and prepared with betadine, wrapped in sterile gauze, and placed in a plastic bag submerged in ice water until the patient can be made ready for the operating room. Repair of this injury, as well as others of the external genitalia, requires a good knowledge of plastic surgical techniques.

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Blaisdell FW, Trunkey DD, McAninch, JW, eds. Urogenital Trauma. New York: Thieme-Stratton Inc., 1985.

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