Some common causes of genitourinary trauma

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The urinary bladder occupies the deep pelvic cavity and is well protected. This is why it is rarely traumatised. However, it can suffer traumas which can cause extraperitoneal and intraperitoneal ruptures.Genitourinary trauma is seen in both sexes and in all age groups but is more common in males. The kidney is the most commonly injured organ in the genitourinary system and renal trauma is seen in some trauma cases and especially in abdominal trauma cases.

Genital trauma is much more common in males, due to anatomical considerations and more frequent participation in physical sports, violence and war-fighting. In young children the bladder is an abdominal organ especially when full and is more prone to blunt trauma injuries having only relatively thin abdominal musculature protecting much of it.

Blunt trauma
Deceleration injuries usually produce both bladder trauma (perforation) and pelvic fractures. The most common mechanisms of blunt trauma are road traffic accidents, falls and assaults. Because the bladder is located within the bony structures of the pelvis, it is protected from most external forces. Approximately 4% of patients with pelvic fractures also have significant bladder injuries. The likelihood of the bladder to sustain injury is related to its degree of distention at the time of trauma. The injury may occur if there is a blow to the pelvis that is severe enough to break the bones and cause bone fragments to penetrate the bladder wall. Generally the bladder injury in these cases is associated with other injuries as well, the most common being to the spleen and rectum.

Penetrating trauma
The most common cause of penetrating trauma is gunshot wounds and stabbings. Penetrating trauma tends to be more severe and less predictable than blunt trauma. Bullets have high kinetic energy and have the potential for greater destruction. They are most often associated with multiple organ injuries. The combination of penetrating trauma to both rectum and the urinary system can be associated with high morbidity and mortality.

Obstetric trauma
During prolonged labour or a difficult forceps delivery, persistent pressure from the fetal head against the mother’s pubis can lead to bladder necrosis. Also, direct laceration of the urinary bladder can occasionally occur in women undergoing a caesarean delivery. Adhesions from previous caesarean deliveries are a risk factor for bladder trauma. When bladder injuries remain unrecognised it can lead to vesicouterine fistulas and other problems. Gynaecological trauma Iatrogenic bladder injury may occur during a vaginal or abdominal hysterectomy. Laparoscopic hysterectomy is associated with higher risk of bladder or ureter injury. This is because blind dissection in the incorrect tissue plane between the base of the bladder and the cervical fascia may results in bladder injury. The main risk factors for bladder trauma are previous surgery, inflammation and malignancy.

Urological trauma
Perforation of the bladder can occur during a bladder biopsy, transurethral resection of the prostate (TURP) or transurethral resection of a bladder tumour (TURBT).[6]

Orthopaedic trauma
Orthopaedic pins and screws can perforate the urinary bladder, particularly during internal fixation of pelvic fractures. Thermal injuries to the bladder wall can occur during the setting of cement substances used to secure arthroplasty prosthetics.

Idiopathic bladder trauma
Alcohol-dependent people and those individuals whose drinking of large quantities of fluids has become chronic are susceptible to this type of injury. Previous bladder surgery is also a risk factor. This type of injury may result from a combination of bladder overdistension and minor external trauma.

Urethral trauma
The most common type of urethral trauma seen in urological practice is iatrogenic, due to catheterisation, instrumentation, or surgery. Radiotherapy can also lead to urethral strictures. Iatrogenic injuries to the urethra can be a complication of major pelvic procedures. The posterior urethra or urinary bladder may be injured in patients who sustain fractures of the bony pelvis. The anterior urethra is most commonly injured by blunt or ‘fall-astride’ trauma. Penile fractures can occur during sexual intercourse. The urethra is involved in around 20% of these cases. Urethral injuries are extremely rare in females.