Most patients with significant genitourinary injuries require prompt urologic consultation. The majority of these patients will have additional injuries within the chest, abdomen, or pelvis, which will also mandate immediate surgical evaluation. It is extremely rare for the genitourinary tract to be injured in isolation. Therefore, the initial management of genitourinary trauma should not be in isolation either. General trauma management, as explained in other chapters in this book, should be implemented upon arrival in order to identify and treat all life-threatening injuries.
In the intensive care unit (ICU), life-threatening injuries, such as traumatic shattered kidney or urosepsis from bladder rupture, are encountered much more frequently than an isolated injury to the external genitalia. Although situations such as a zipper injury or priapism might be considered a genitourinary emergency in the emergency department (ED), it would be extremely rare for someone to be admitted to an ICU solely under those circumstances. However, attention must be paid to the entire genitourinary system in the ICU. For example, it is more common in the ICU to have a patient with an injury to the external genitalia that accompanies a pelvic fracture. Timely recognition and appropriate treatment of all genitourinary emergencies are vital to minimizing associated morbidity, which may include renal insufficiency, sepsis, incontinence, decreased sexual function, impotence, and infertility. In addition, these less frequently encountered injuries are important because they will be relevant in some way, such as when not to place a Foley catheter in a trauma patient or when to complete a rape kit in a patient with pelvic injuries secondary to physical abuse.
Finally, it is always important to remember that even though the human body and medicine are broken down into systems, such as the genitourinary system, there is considerable overlap among them. Many topics pertaining to the genitourinary system are addressed elsewhere in this book, such as the management of renal failure and sepsis.
A 45-year-old man with a history of hypertension presents after being involved in an automobile accident. It is reported that he was not wearing a seat belt, but the air bag did deploy. Standard advanced trauma life support is initiated. He is drowsy from being intoxicated and intubated for airway protection. Initial vital signs include a heart rate of 102 bpm and blood pressure 115/75 mm Hg. On physical examination, no lacerations or abdominal distension can be appreciated. Significant bruising is noted along the left flank and back. A Foley catheter is passed without difficulty and initial urine collection shows no hematuria. Postintubation chest radiography shows fractures of the 11th and 12th ribs on the left as well as a mild pulmonary contusion also on the left. It is noted that despite aggressive crystalloid resuscitation, the patient's heart rate is now 112 bpm and blood pressure is 100/60 mm Hg, and a stat chest, abdomen, and pelvic computed tomographic (CT) scan with contrast is ordered. As the scan finishes, his heart rate is 125 bpm and blood pressure is 75/48 mm Hg. The CT scan result shows a grade IV kidney laceration on the left.