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Imaging of genitourinary trauma

Departments of
Diagnostic Radiology and
Urology, Georg-August-University, Go ttingen, Germany
The kidney, bladder and male urethra are the organs typically injured by blunt and penetrating trauma to the urinary tract,
whereas the ureter is only rarely injured. The staging of genitourinary tract trauma has recently gained tremendous
significance due to improvements in ultrasound, CT and MRI, including contrast-enhanced magnetic resonance
angiography, and has become a helpful tool for decision making with regard to conservative and surgical management.
Furthermore, interventional radiology may be helpful to control hemorrhage from vessels in the pelvic region that may not
be easily accessed by open surgery. Therefore, this pictorial essay gives examples of the radiological presentation of
genitourinary trauma and describes technical details of the diagnostic imaging modalities used.
The urogenital tract is involved in :/10% of all
patients exposed to blunt and penetrating trauma
[1,2]. In general, the kidney, bladder and male
urethra show distinct trauma patterns, whereas the
female urethra and ureter are infrequently injured.
Decision making regarding conservative or operative
management of urologic trauma depends primarily
on the presence or absence of hemodynamic in-
stability due to ongoing blood loss, and this may
force the urologic specialist to proceed to the
operating room without performing adequate ima-
ging studies. However, in the majority of trauma
patients, diagnostic imaging is mandatory for an
exact staging of genitourinary trauma [1,2]. This
pictorial essay gives examples of the radiological
presentation of renal, vesical and urethral trauma
and briefly describes the therapeutic consequences
of various findings. All patients were investigated in
the course of routine diagnostic work-up.
Material and methods
CT images were performed on an eight-slice multi-
detector CT system (LightSpeed Ultra; GE, Mil-
waukee, WI). Normally, a non-contrast scan was
performed, together with a contrast scan with CT
angiography and venous and excretion phases. MR
angiography was done using a 1.5-T MR unit
(Symphony; Siemens, Erlangen, Germany) as con-
trast-enhanced MR angiography with 3D gradient
echo sequences. Subtraction images were available
Renal trauma
Clinically, patients with renal trauma present with
micro- or macrohematuria and flank pain. The
severity of renal trauma is classified according to
the American Association for the Surgery of Trauma
Organ Injury Score [2,3] into five different grades.
The assignment of an injury to a specific severity
grade in this grading system depends on the presence
of single or multiple parenchymal ruptures, the
depth of parenchymal rupture, lesions of the renal
pelvis with extravasation of urine and trauma to the
major renal vessels. Grades IIII can be clearly
established by means of appropriate studies, but
there are areas of overlap between grades IV and V
(e.g. vascular and parenchymal injury can be present
in both) [2]. Contrast-enhanced CT in the renal
excretion phase is the imaging technique of choice
Correspondence: Silvia Obenauer, MD, Department of Diagnostic Radiology, Georg-August-University, Robert-Koch-Strasse 40, 37099 Go ttingen,
Germany. Tel: /49 551 398965. Fax: /49 551 399606. E-mail: soben@med.uni-goettingen.de
Scandinavian Journal of Urology and Nephrology, 2006; 40: 416422
(Received 1 December 2005; accepted 4 April 2006)
ISSN 0036-5599 print/ISSN 1651-2065 online # 2006 Taylor & Francis
DOI: 10.1080/00365590600796642
for the staging of renal ruptures and for the planning
of renal reconstruction, whereas excretory urography
and angiography are only used in special cases
(Figures 13) [3]. For the detection of urine leaks,
delayed CT imaging after application of contrast
medium is essential. Urinomas may be confined,
encapsulated fluid collections or may manifest as
free fluid. However, most urinomas leak into a
subcapsular location or into the perirenal space
within Gerotas fascia. If extensive, a urine leak
may cross the midline within the perirenal space
anterior to the aorta and inferior vena cava and
extend into the contralateral perirenal space. Indica-
tions for renal exploration after trauma can be
separated into absolute and relative. Absolute
indications include evidence of persistent renal
bleeding, expanding perirenal hematoma and pulsa-
tile perirenal hematoma. Relative indications are
urinary extravasation, non-viable tissue, delayed
diagnosis of arterial injury, segmental arterial injury
and incomplete staging [4]. The operative manage-
ment of renal rupture includes delayed or immediate
reconstruction of the renal pelvis and sutures of the
parenchyma (Figure 4). In the case of vascular
lesions, arterial reconstruction or bypassing may be
necessary if the duration of warm ischemia does not
exceed 8 h [47].
Bladder trauma
Trauma to the urinary bladder includes contusions
and ruptures. Any macrohematuria in association
with pelvic or lower abdominal trauma may be
evidence of bladder injury. Whereas bladder contu-
sions do not require any treatment, a vesical
rupture must be treated by means of either
transurethral catheter drainage if urine is leaking
into the extraperitoneal paravesical space or surgical
closure if there is leakage of urine into the
peritoneal space. Bladder ruptures are diagnosed
by means of transurethral cystography. In trauma
patients the Foley catheter should be clamped
before CT imaging in order to reveal bladder
trauma. If a bladder injury is not demonstrated
on the initial CT scan and the pelvic injuries are
serious enough to cause concern about a bladder
injury, then a retrograde study must be performed
with adequate bladder filling. CT cystography may
reveal extra- or intraperitoneal rupture of the
bladder (Figure 5) [8,9].
Ureteral trauma
Ureteral injuries after a violent attack are rare and
their diagnosis is often delayed. However, if ureteral
injuries are found after blunt trauma, there is a high
probability of associated visceral injuries (bowel,
kidney, bladder). Thus, further diagnostic imaging
(CT) is recommended [10].
Urethral trauma
Traumatic urethral lesions are typically complete or
incomplete ruptures and occur mainly in males.
They are classified into infradiaphragmal and supra-
diaphragmal lesions according to the localization of
the defect in relation to the pelvic floor. Whereas
supradiaphragmal lesions are typically associated
with an indirect blunt trauma to the lower abdomen,
infradiaphragmal lesions are often seen after a
straddle trauma to the perineal region. Bladder
lesions are combined with urethral lesions in up to
Figure 1. (a) CT scan of a patient after a trauma to the left ank.
A small subcapsular uid collection (black arrow) can be seen
dorsally in the left kidney as a sign of renal contusion (grade 1).
(b) CT scan of a motorcyclist after a collision with a car showing a
right subcutaneous and perirenal hematoma (black arrow), rib and
vertebral body fractures, together with a rupture of the renal
parenchyma that did not extend into the collecting system (renal
injury grade 2/3) (white arrow). Conservative therapy was chosen.
Imaging of genitourinary trauma 417
Figure 3. (a) Typical grade 5 renal rupture due to blunt trauma with a big retroperitoneal hematoma in the native series without intravenous
contrast medium (black arrow). (b) After injection of contrast medium, a completely ruptured right kidney with multiple lacerations can be
seen (black arrow). (c, d) In an excretion series, highly concentrated contrast medium can be seen extravasating into the retroperitoneal
space, a typical sign of disruption of the renal pelvis (black arrows ). Delayed surgical reconstruction was done.
Figure 2. (a, b) CT scans of a young patient after blunt trauma. The radiological ndings are typical of intimal disruption of the left renal
artery with consequent thrombosis because the kidney does not take up contrast medium through the renal artery but only through small
capsular vessels (black arrow). Furthermore, a major medial hematoma is completely absent (white arrow), indicating that there is not
complete disruption of the renal artery or vein. (c, d) MRI scans of the kidney. (c) A T1-weighted image in the coronal view after contrast
medium injection reveals perfusion of the right kidney and no enhancement of the left kidney. (d) MR angiography after subtraction
technique in the maximum intensity projection conrmed the presence of renal artery intima disruption (white arrow). No revascularization
was possible due to the long period of ischemia of the kidney.
418 S. Obenauer et al.
20% of cases. Clinically, urethral disruption is
associated with the triad of blood at the urethral
meatus, inability to urinate and a palpably full
bladder. Retrograde injection of contrast medium
into the urethra is safe and has high sensitivity for
making the diagnosis of urethral rupture. Surgical
therapy consists of realignment of the ruptured
urethral segments and catheter drainage (Figure 6)
Vascular lesions to the urogenital tract
In a few cases of polytraumatized patients with
pelvic fractures, significant bleeding is seen resulting
from an injury to the internal iliac vessels and their
branches, e.g. the scrotal artery. In these cases,
surgical therapy may be difficult. Embolization, e.g.
with coils or with polyvinyl alcohol particles in the
feeding vessels, is a suitable alternative to open
surgery. According to Ben-Menachem et al. [12],
reliable occlusion of bleeding vessels may be
achieved in :/11% of all patients with pelvic
fractures. However, early stabilization of the frac-
ture remains the most effective way of decreasing
blood loss in these cases (Figure 7) [13]. CT and
magnetic resonance (MR) angiography are gaining
increasing importance for studying these lesions.
However, the disadvantage of these non-invasive
techniques is the inability to stop bleeding with
interventional vaso-occlusive measures. In particu-
lar, intimal dissections and complete renal artery
disruptions may be diagnosed with these novel
techniques if the patient is stable enough to permit
diagnostic imaging.
Lesions to the penis vessels, e.g. after traumatic
amputation, can be surgically managed by micro-
scopic anastomosis of the dorsal artery and repair of
the profound dorsal vein after closure of the urethra
and suture of the tunica albuginea, whereas the
cavernosal arteries cannot be reanastomosed.
Figure 4. (ac) Trauma of the kidney with renal rupture grade 5. CT scans show multiple lacerations of the left kidney with a completely
shattered kidney, whereas the pieces of the kidney are well vascularized (black arrows ). (df) CT scans taken 8 months after surgical
reconstruction of the kidney reveal a few perfusion inhomogeneities due to scars, while the whole kidney is well reconstructed (black arrows ).
Imaging of genitourinary trauma 419
Technical aspects of imaging
The role of imaging has increased tremendously in
recent years, with important improvements in color
Doppler ultrasound and ultrasound contrast agents.
There have also been important improvements in
CT technology, such as multi-detector spiral CT,
which enables both CT angiography and parenchy-
mal imaging of urinary trauma patients. Imaging of
the kidney and renal arteries can be done in a few
seconds. Acquisition of multiple thin overlapping
slices provides excellent 2D and 3D visualization of
the urinary tract. CT is the study of choice for the
diagnosis of renal urine leaks and urinomas. CT
protocols in patients with a suspected urine leak
involve scanning the abdomen and pelvis prior to
and following the i.v. administration of 100150 ml
of contrast material. Delayed-phase images obtained
520 min after injection of contrast material are the
key to demonstrating a urine leak, because iodinated
urine increases the attenuation of the urinoma over
time. There have also been important improvements
in MRI, such as contrast-enhanced MR angiogra-
phy, as well as MR angiography without contrast
administration using the true FISP (Fast Imaging
with Steady state Precession) technique. These
techniques allow the non-invasive visualization of
vessels in traumatized patients. However, MRI is not
the method of choice for traumatized emergency
patients. Radiotracer excreted outside the genitour-
inary tract at either bone or renal scintigraphy may
Figure 5. (a) Normal cystogram. (b) Image from a patient after a motorcycle accident showing the typical pattern of an extraperitoneal
bladder rupture with leakage of contrast medium into the perivesical extraperitoneal space (black arrow). (c) Cystogram of a patient with an
intraperitoneal bladder rupture (black arrow). (d) CT scan of an extraperitoneal rupture of the bladder with contrast medium in the extra-
or retroperitoneal space (black arrow).
Figure 6. (a) Normal retrograde urethrogram. (b) Typical image of a supradiaphragmal urethral rupture (black arrow).
420 S. Obenauer et al.
also allow a diagnosis of urine leak. I.v. pyelography
is relatively insensitive for the diagnosis of renal
injuries and urine leaks and may demonstrate
normal findings in /30% of cases with significant
renal injury. Furthermore, i.v. pyelography cannot
be used in emergency patients. Cystography was
formerly the diagnostic test of choice for evaluating
the presence of a urinary bladder injury. However,
CT cystography is now performed at many institu-
tions. This method aids the detection of coexisting
injuries to the pelvis and is more sensitive for
determining the true extent of bladder injury.
Various factors have to be considered when deciding
between operative or conservative management of
urogenital trauma. In an unstable patient with
hypovolemic shock, even after appropriate resuscita-
tion measures, it will not be possible to perform
time-consuming diagnostic imaging, and the trauma
site will be surgically explored. In all other (stable)
patients, who represent the majority of cases with
relevant urological lesions, further diagnostic ima-
ging is extremely helpful before deciding how to
proceed. Renal, bladder and urethral injuries may be
exactly defined, and plastic reconstruction is facili-
tated. Moreover, hemodynamically relevant bleeding
may be stopped in areas, such as the pelvis, that are
difficult to access surgically. Therefore, the clinical
urologist should be aware of the available diagnostic
and interventional radiological repertoire.
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Figure 7. (a) Angiography of a polytraumatized patient with continuous bleeding after pelvic fracture and reconstruction. Subtraction
images were done. Bleeding of a branch of the internal iliac artery can be seen (black arrow). (b) Later angiography series showing a depot
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