To evaluate the efficacy and functional outcomes of bulbospongiosus muscle (BSM) flap interposition in the repair of urethral stenosis combined with urethrorectal fistula (USURF) or anterior rectal wall weakness (USRW).

Between January 2016 and December 2023, 36 patients underwent transperineal posterior urethroplasty with BSM flap interposition. 36 patients with traumatic posterior urethral stenosis who underwent perineal urethroplasty without interposition of the BSM as the control group, matched by propensity score analysis during the same period. Pre- and intra-operative clinical data were collected. Functional outcomes, including voiding, erectile, and ejaculatory function, were compared between the two groups.

A total of 36 males were included, of whom 19 (52.8%) had USURF and 17 (47.2%) had USRW. The mean follow-up time was 31.3 ± 17.7 months. The overall success rate was 94.4%. The median operating time was 3.0 (2.0, 3.0) h. The mean stricture length was 4.2 ± 1.2 cm. The mean postoperative maximum urinary flow rate was 24.2 ± 12.9 mL/s. Postoperative functional outcomes did not significantly differ between BSM interposition and BSM non-interposition group as assessed by Incontinence Questionnaire Male Lower Urinary Tract Symptoms (5.0 vs 3.0; P = 0.399), the International Index of Erectile Function 5 (3.0 vs 6.5; P = 0.183), Erection Hardness Score (P = 0.801), the Male Sexual Health Questionnaire 4 (1.0 vs 1.0; P = 1.00), European Quality of Life-5 Dimensions (0.9 ± 0.1 vs 0.9 ± 0.1; P = 0.139), EQ-VAS scores (75.9 ± 20.0 vs 79.9 ± 18.7; P = 0.428), urine dribbling (2.0 vs 1.5, P = 0.727), ejaculation volume (2.0 vs 2.0, P = 0.631) and ejaculation intensity (3.0 vs 4.0, P = 0.645).

Transperineal BSM flap interposition combined with anastomosis urethroplasty and urethrorectal fistula repair is a safe and effective treatment. BSM can strengthen the anterior rectal wall and separate the urethral anastomosis from the repaired rectal fistula, which should improve the success rate of fistula repair.

Our aim was to update evidence-based and consensus-based recommendations for the initial surgical management of urogenital injuries in patients with polytrauma and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Polytrauma and/or Severe Injuries.

MEDLINE and Embase were systematically searched to June 2021. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared surgical and/or therapeutic interventions for urogenital injuries in the hospital setting. We considered patient-relevant clinical outcomes such as mortality and bleeding control, or coagulation parameters as surrogate outcomes. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

Two new studies were identified. The topics covered were the comparison of outcomes after surgical and nonsurgical management as well as the use of surgical repair versus catheter drainage in patients with extraperitoneal bladder injuries. Three recommendations were modified, one of which for editorial reasons. All achieved strong consensus.

The following key recommendations are made. 1. Renal artery injuries can be managed using an endovascular approach. 2. Depending on the type and severity of the injury and concomitant injuries, renal injuries should be managed with the intent to preserve the organ. 3. Extraperitoneal bladder ruptures without involvement of the bladder neck should be conservatively treated with catheterisation.

Open pelvic fractures are a rare yet catastrophic injury pattern, often resulting from high-energy trauma such as motor vehicle collisions, motorcycle accidents, and pedestrian impacts. They account for only 2%-4% of all pelvic fractures, but their severity lies in the complex anatomy of the pelvis and its associated structures, including the vasculature, bowel, bladder, and genital organs. Mortality rates range from 15% to 50%, with some studies reporting rates as high as 70% in cases involving severe perineal or rectal injuries. These injuries pose two main risks to survival: hemorrhagic shock in the acute phase and pelvic sepsis during the later phases of recovery. Acute hemorrhage can occur from arterial injury (eg, internal iliac arteries), venous plexuses, or bony sources. Delayed deaths are often caused by sepsis due to fecal contamination of wounds or infected hematomas. Additionally, these fractures are often associated with other life-threatening injuries, including intra-abdominal trauma, genitourinary disruptions, and neurovascular compromise, further complicating their management. Management of these injuries has evolved significantly with advancements in hemorrhage control techniques such as preperitoneal pelvic packing and resuscitative endovascular balloon occlusion of the aorta. A multidisciplinary approach is essential to address the multifaceted challenges posed by these injuries.

Pelvic fractures are often associated with significant morbidity, including injuries to the urinary tract. Understanding the incidence and risk factors for urinary tract injury in these patients is crucial for prompt diagnosis and management. This meta-analysis aims to synthesize existing evidence to determine the overall incidence and identify specific risk factors associated with urinary tract injuries in patients with pelvic fractures.

To determine the incidence and risk factors for urinary tract injuries in patients with pelvic fractures.

A systematic search of PubMed, EMBASE, Scopus, and the Cochrane Library was conducted without date restrictions. Studies examining the incidence and risk factors of urinary tract injuries in patients with pelvic fractures were included. Data extracted included demographics, injury mechanism, pelvic fracture type, urinary tract injury incidence, mortality, and discharge disposition. Review Manager 5.4 was used for data analysis.

Ten studies comprising 22700 patients were included. The pooled incidence of urinary tract injury associated with pelvic fracture was 6.88% (95%CI: 6.20%-7.55%). Vehicle, motorcycle, and pedestrian accidents were identified as risk factors for urinary tract injury, with relative risks (RR) of 1.08 (95%CI: 1.06-1.11), 1.89 (95%CI: 1.78-2.00), and 1.53 (95%CI: 1.20-1.95), respectively. Pubic fracture and pelvic ring disruption were significantly associated with urinary tract injury [odds ratio (OR) 1.94, 95%CI: 1.09-3.44 and OR 5.53, 95%CI: 4.67-6.54, respectively)]. Patients without urinary tract injury were more likely to be discharged home (RR 0.79, 95%CI: 0.67-0.92). Mortality was higher in patients with urinary tract injury (OR 1.92, 95%CI: 1.77-2.09).

Urinary tract injury occurs in nearly 7% of patients with pelvic fractures. Motorcycle accidents, pubic fractures, and pelvic ring disruptions are significant risk factors. Urinary tract injury following pelvic fracture is associated with increased mortality.

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Vaginal pessaries are widely considered to be a safe and effective non-surgical management option for women with pelvic organ prolapse. Complications may occur, and are more frequent with improper care and certain device designs and materials. It is imperative to provide information to patients about potential complications. We present the case of a woman in her 70s who presented to the Emergency Department with increasing groin and abdominal pain following a vaginal pessary insertion 2 days prior for grade 3 vaginal vault prolapse. On presentation, her abdomen was markedly distended with guarding. Laboratory investigations showed a significant acute kidney injury with a metabolic acidosis. An initial non-contrast CT showed fluid and inflammatory changes surrounding the bladder, and bladder perforation was suspected. A subsequent CT cystogram showed extravasation of contrast from the bladder into the peritoneal cavity, in keeping with an intraperitoneal bladder rupture. The patient underwent an emergency bladder repair in theatre.

To determine the incidence of infection in nonoperative versus operative management of extraperitoneal bladder ruptures in patients with pelvic ring injuries.

A retrospective cohort study of 2 prospectively collected trauma registries.

Two Level 1 trauma centers.

Patients with operative pelvic ring injuries, 68 (6%) had extraperitoneal bladder ruptures.

The primary outcome was the incidence and associated risk factors of deep pelvic infection requiring return to OR for surgical debridement. Secondary outcomes included quality of reduction, other complications, and radiographic union. Comparisons were made based on the status of any associated bladder injury.

Of 1127 patients with operative pelvic ring injuries, 68 patients had extraperitoneal bladder ruptures, 55 had bladder repair and 13 did not. Of those 13 without repair, none had ORIF of the anterior pelvic ring. Patients without bladder repair had an increased odds of infection 17-fold compared to patients who did have a repair performed (OR 16.9, 95% CI 1.75 - 164, P = 0.01). Other associated factors for deep pelvic infection included use of suprapubic catheter ( p < 0.02) and a closed reduction of the anterior ring ( p < 0.01). Patients undergoing anterior ring ORIF and bladder repair had improved reductions and no increased infection risk.

Operative repair of extraperitoneal bladder ruptures decreases risk of infection in patients with pelvic ring injuries. Additionally, ORIF of the anterior pelvic ring does not increase the risk of infection and results in better reductions compared to closed reduction. Treatment algorithms for these combined injuries should consider recommending early bladder repair and anterior pelvic ORIF.

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The appropriate timing of surgical intervention for bladder injuries is not well-defined. The effect of time to surgery on the outcomes of patients with a bladder injury was assessed using data from the Trauma Quality Improvement Program.

Patients with dominant or isolated bladder injuries who underwent surgical repair from 2017 to 2019 were studied. Mortality, infection (surgical site infection or sepsis), acute kidney injury, overall length of stay, and length of stay after surgery were compared between patients who underwent bladder repair within and after 24 hours of arrival at the emergency department. The role of time to surgical repair in the outcomes of patients with a bladder injury was evaluated.

A total of 1,507 patients with a mean time to bladder repair of 14.0 hours were studied. In total, 233 (15.5%) patients with a bladder injury underwent bladder repair more than 1 day after emergency department arrival. These patients had significantly more infections (5.6% vs 2.5%, P = .011), more acute kidney injuries (7.8% vs 1.8%, P < .001), and a longer length of stay after surgery (16.0 vs 12.3 days, P = .001) than patients who underwent bladder repair within 1 day. A time to bladder repair longer than 24 hours after emergency department arrival did not significantly affect mortality (P = .075) but significantly increased the risk of infection/acute kidney injury (odds = 1.823, P = .040). However, the infection/acute kidney injury risk did not increase with increasing time to surgery in patients who underwent bladder repair within 24 hours (P = .120).

Patients with dominant or isolated bladder injuries may have a poor outcome (ie, increased infection rate, acute kidney injury, longer overall length of stay, and longer length of stay after bladder repair) if they undergo surgical repair more than 24 hours after arrival at the emergency department.

Pelvic ring injuries are often associated with vascular and intrapelvic organ injuries including damage to the genitourinary system. The purpose of this study was to examine the relationship between surgically treated pelvic ring injuries and genitourinary injuries. The primary outcome was to determine the rate of post-operative complications including infection, urinary dysfunction, and sexual dysfunction. The secondary outcome was to determine if the time to surgery was associated with post-operative complications.

Retrospective chart review from September 1, 2015 to December 31, 2019 of patients who sustained a pelvic ring injury which required surgical intervention. All patients with closed triradiate cartilage were included.

A total of 115 patients met the inclusion criteria, 12 patients with an associated genitourinary (GU) injury were included in the GU group and 103 without GU injury were placed in the non-GU group. The median (range) age of patients in the GU group was 49.5 years (20, 64) and 48 years (15, 92) in the control group (p = 0.92). Demographic characteristics including age, Injury Severity Score and Elixhauser comorbidity score were similar between groups. Within the GU group, five patients had an injury to their bladder, four to their urethra and three had an injury to their kidney. In the GU group, one patient developed a wound dehiscence and one developed a urinary tract infection with subsequent sepsis (17%), while in the non-GU group, one patient (1%) developed erectile dysfunction (p = 0.028). Regression analysis demonstrated that having concomitant pelvic ring and GU injuries, as well as the number of surgeries were variables associated with post-operative complications, while time to surgery was not.

Pelvic ring injuries with concomitant genitourinary injuries were associated with increased odds of post-operative complications. No differences were noted in complication rates due to the time to surgery between groups.

High-quality imaging is crucial for orthopedic traumatologists in the evaluation and management of pelvic and acetabular fractures. Computed tomography (CT) plays an essential role in the diagnosis and treatment of patients with these complex injuries. A thoughtful evaluation of associated soft tissues can reveal additional details about the patient and their injury that may impact treatment. This review aims to highlight soft tissue findings that should be identified when evaluating the initial diagnostic imaging after pelvic and acetabular trauma.

Urological injuries can occur in patients with pelvic fractures. Treatment recommendations lack solid evidence and is often pragmatical. There is a continuous need to describe short- and long-term morbidity following lower urinary tract trauma.

To describe incidence, diagnosis, treatment, and morbidity following lower urinary tract injuries in pelvic fractures.

Retrospective study including patients with pelvic, including acetabular, fractures admitted to a Level I Trauma Centre covering 2.8 million citizens between 2009 and 2020. Outcome measurements comprised primary management, treatment trajectory, short- and long-term complications and outcomes.

A total of 39 (5%) patients with pelvic fractures had concomitant urethral and/or bladder injuries, and one patient with an acetabular fracture had a bladder injury. The management of urethral injuries varied vastly, and complete urethral ruptures were associated with severe short- and long-term complications. Only one patient with bladder injury experienced severe long-term complications.

Management of lower urinary tract injuries in patients with major pelvic fractures remains a major challenge. Special attention should be focused on urethral injuries where we uncovered an unsystematic treatment and follow-up even in a highly experienced centre, although this is also attributed to complicated multidisciplinary patient trajectories. There is a continuous need to reduce long-term complications following urethral trauma which should be addressed in multicenter studies.

While the impact of female sexual dysfunction (FSD) on mental health and overall health-related quality of life (HrQOL) has been previously documented, no prior work has evaluated this relationship in women following traumatic pelvic injuries.

This study aims to understand the relationship of FSD with HrQOL and depression in women with a history of traumatic pelvic fracture.

Data were collected with an electronic survey that included queries regarding mental and sexual health. Inverse probability weighting and multivariate regression models were utilized to assess the relationships between sexual dysfunction, depression and HrQOL.

Study outcome measures included the Female Sexual Function Index (FSFI) to evaluate sexual functioning, the 8-item patient health questionnaire (PHQ-8) to assess depression symptoms, and the visual analog scale (VAS) component of the EuroQol 5 Dimensions Questionnaire (EQ-5D) to determine self-reported HrQOL.

Women reporting FSD had significantly higher PHQ-8 scores with a median PHQ-8 score of 6 (IQR 2, 11) relative to those without FSD who had a median score of 2 (IQR 0, 2) (P < .001). On multivariate linear regression, presence of FSD was significantly associated with higher PHQ-8 scores (β = 4.91, 95% CI 2.8-7.0, P < .001). FSFI score, time from injury, and age were all independently associated with improved HrQOL, with FSFI having the largest effect size (β = 0.62, 95% CI 0.30-0.95, P < .001).

These results underscore importance of addressing not just sexual health, but also mental health in female pelvic fracture survivors in the post-injury setting.

This study is one of the first to examine women with traumatic pelvic fractures who did not sustain concomitant urinary tract injuries. Study limitations include low response rate and the inherent limitations of a cross-sectional study design.

Patients with persistent, unaddressed FSD after pelvic fracture are at unique risk for experiencing depression and reporting worse health-related quality of life due to complex biopsychosocial mechanisms. Gambrah HA, Hagedorn JC, Dmochowski RR, et al. Sexual Dysfunction in Women after Traumatic Pelvic Fracture Negatively Affects Quality of Life and Mental Health. J Sex Med 2022;19:1759-1765.

A consecutive series of 177 male patients, with high energy pelvic ring injuries, were treated operatively in our institution. The purpose of this study was to evaluate long-term sexual and urological dysfunction in these patients using validated disease specific patient reported outcome measures (PROMs), and identify if sexual and urological dysfunction is detectable from generic outcome scores used in the assessment of pelvic ring injury at a minimum of 10 years follow-up (range 10-22).

Surviving patients were contacted to complete validated PROMs to examine genitourinary and global functional outcome. Fifty-two male participants, had a mean age of 44-years-old (range,16-69) and ISS of 17 at time of injury. Mean duration follow-up of 15 years. The primary outcome measures were the Sexual Health Inventory for Men (SHIM) and the Modular Questionnaire for Male Lower Urinary Tract Symptoms (MLUTS). Secondary outcomes were the EQ-5D and Short Form 36. Responses were tested for correlation between generic and disease-specific PROMs and analyzed for association with genitourinary injury and age as risk factors of poor outcome.

Genitourinary injuries occurred in 7 patients (13%), and ten patients (19%) had documented neurological dysfunction following injury. Satisfactory general functional outcome was reported with EQ-5D-3L VAS score of 71. However, 80% report some level of sexual dysfunction with 37% reporting it as severe. MLUTS mean symptom score was 9 (range, 0 - 26) and bothersomeness score was 21 (range, 0-90). There was poor correlation between urological and sexual dysfunction scores and between the disease specific and generic scores.

In operatively treated pelvic ring injuries, validated disease specific PROMs, (SHIM and MLUTs) identified a significant impact to both sexual and urological patient health, with 37% reporting severe sexual dysfunction. Longstanding sexual and/or urological dysfunction can be a source of significant psychological impact that this study has shown is not identifiable using generic PROMs; EQ-5D-3L and SF-36. To gain a holistic understanding of the functional outcome of patients following a pelvic injury, urological and sexual dysfunction must not be overlooked.

To quantify the severity of urinary and sexual dysfunction and to evaluate the relationship between urinary and sexual dysfunction, injury, and treatment factors in patients with pelvic fracture.

Prospective cohort study.

Level 1 trauma center.

One hundred thirteen patients with surgically treated pelvic fracture (65.5% OTA/AO 61B fractures; 7 open fractures; 74 men).

Surgical pelvic stabilization.

The 36-Item Short Form Health Survey and International Consultation Incontinence Questionnaire responses were collected at baseline, 6 months, and 1, 2, and 5 years. Patients were scored on symptoms of voiding and incontinence, and filling (for women), to derive urinary function. Sexual function was scored as a single domain. Both genders reported urinary and sexual bothersome symptoms. Regression analysis was used to isolate the importance of predictive factors on urinary and sexual function, urinary and sexual bother, and their impact on quality of life.

Patients with pelvic fracture have significant urinary and sexual dysfunction, which is sustained or worsens over time. Male urinary function was predicted by Injury Severity Score (P = 0.03) and 61C fracture (odds ratio: 3.23, P = 0.04). Female urinary function was predicted by urinary tract injury at admission (odds ratio: 7.57, P = 0.03). Neurologic injury and anterior fixation were identified as significant predictors for male sexual function and sexual bother, whereas urological injuries were important in predicting female urinary and sexual bother (P < 0.01). Sexual function (P = 0.02) and sexual bother (P < 0.001) were important predictors of overall mental well-being in men.

Urinary and sexual dysfunction are prevalent and sustained in men and women and do not follow the prolonged slow recovery trajectory seen in physical function. Male urinary and sexual dysfunction was closely tied to neurologic injury, whereas female urinary and sexual dysfunction was predicted by the presence of a urinary tract injury. Urinary and sexual dysfunction were important to overall mental well-being in men.

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Rupture of the urinary bladder and extravasation of urine into the peritoneal cavity leading to urinary ascites is an uncommon event, usually caused by blunt trauma to the abdomen. A high index of suspicion is required for early accurate diagnosis, which avoids unnecessary investigations and interventions. The disappearance of ascites following indwelling Foley's catheterization and high peritoneal fluid urea and creatinine compared to serum values are keys for diagnosis. Sometimes, the diagnosis may be delayed as the features are mistaken for intrinsic renal disease. Here, we report a case of pseudo-acute kidney injury caused by urinary ascites due to intraperitoneal bladder rupture following blunt abdominal trauma in an alcoholic patient.

To compare the long-term outcomes of initial management of pelvic fracture urethral injury (PFUI) in a large cohort of trauma patients undergoing urethral reconstruction.

119 patients underwent urethral reconstruction by a single surgeon for PFUI at our center between 1998-2018. We compared initial PFUI management - primary realignment vs suprapubic tube (SPT) insertion alone. Multivariable Cox proportional hazard analysis was used to assess the association between primary intervention and the risk of having a complication.

PFUI was initially managed with primary realignment (57%) or SPT alone (43%). Ultimately, all patients underwent a primary perineal urethral anastomosis after a median of 7 months (IQR: 5-14). Overall, 27 patients (23%) had 1 or more long-term complications after a median 25 months (IQR:7-66), including urethral stricture, de novo erectile dysfunction, and urinary incontinence. On multivariable analysis, initial PFUI management did not predict for complications.

No difference was found in long-term outcomes after urethral reconstruction when comparing initial PFUI management of primary realignment vs SPT insertion.

Pelvic ring injuries, frequently caused by high energy trauma, are associated with high rates of morbidity and mortality (5-33%), often due to significant blood loss and disruption of the lumbosacral plexus, genitourinary system, and gastrointestinal system. The aim of the present study is to perform a systematic literature review on male and female sexual dysfunctions related to traumatic lesions of the pelvic ring.

Scopus, Cochrane Library MEDLINE via PubMed, and Embase were searched using the keywords: "Pelvic fracture," "Pelvic Ring Fracture," "Pelvic Ring Trauma," "Pelvic Ring injury," "Sexual dysfunction," "Erectile dysfunction," "dyspareunia," and their MeSH terms in any possible combination. The following questions were formulated according to the PICO (population (P), intervention (I), comparison (C), and outcome (O)) scheme: Do patients suffering from pelvic fracture (P) report worse clinical outcomes (C), in terms of sexual function (O), when urological injury occurs (I)? Is the sexual function (O) influenced by the type of fracture (I)?

After screening 268 articles by title and abstract, 77 were considered eligible for the full-text analysis. Finally 17 studies that met inclusion criteria were included in the review. Overall, 1364 patients (902 males and 462 females, M/F ratio: 1.9) suffering from pelvic fractures were collected.

Pelvic fractures represent challenging entities, often concomitant with systemic injuries and subsequent morbidity. Anatomical consideration, etiology, correlation between sexual dysfunction and genitourinary lesions, or pelvic fracture type were investigated.

There are evidences in the literature that the gravity and frequency of SD are related with the pelvic ring fracture type. In fact, patients with APC, VS (according Young-Burgess), or C (according Tile) fracture pattern reported higher incidence and gravity of SD. Only a week association could be found between GUI and incidence and gravity of SD, and relationship between surgical treatment and SD. Electrophysiological tests should be routinely used in patient suffering from SD after pelvic ring injuries.

A multidisciplinary approach to the management of pelvic ring injuries has been shown to decrease mortality rates. The primary goals within the emergency room are to assess, resuscitate, and stabilize the patient. The Advanced Trauma Life Support protocol guides the initial assessment of the patient. A pelvic binder or sheet should be applied to help to provide reduction of the fracture and temporary stabilization. The trauma team becomes the primary service for the patient as he or she transitions away from the emergency department. The trauma team must effectively communicate with and serve as the liaison between other specialists as injuries are identified. emodynamic stability should be closely monitored in patients with pelvic ring injuries, involving the assessment of vital signs, imaging findings, and clinical judgment. Angioembolization and peritoneal packing may play a role in helping to control hemorrhage. Urologists should be consulted if a Foley catheter cannot be passed or there is concern for urethral or bladder injury. Further imaging or urologic intervention may be necessary. Orthopaedic surgeons can help to assess the patient, classify the injury, and assist in temporary stabilization while planning definitive fixation.

We present 2 cases of traumatic testicular dislocation associated with a pelvic ring injury after a motorcycle collision. Case 1 describes bilateral testicular dislocation discovered intraoperatively. Urology was consulted, and the testicles were manually reduced under general anesthesia. Case 2 describes unilateral testicular dislocation discovered at the 1-month follow-up after pelvic ring fixation. Concern for infarction prompted urology to take the patient for surgical reduction. Both cases resolved uneventfully without genitourinary complaints at the follow-up.

Testicular dislocation is rare but should be considered in the setting of pelvic injury due to a motorcycle collision. Detection warrants urgent urologic consultation.

Traumatic lower urinary tract injuries are uncommon and mainly occur in patients with severe trauma and multiple abdominopelvic injuries. In the presence of other substantial injuries, bladder and urethral injuries may be overlooked and cause significant morbidity and mortality. Therefore, it is important that radiologists are familiar with mechanisms and injuries that are high risk for bladder and urethral trauma. We review the imaging findings associated with these injuries and the appropriate modalities and techniques to further evaluate the patient and accurately diagnose these injuries. Computed tomography cystography and conventional retrograde urethrography are effective tools in identifying injuries to the lower urinary tract and play a crucial role in patient care and prognosis.

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

In this review, we will discuss and illustrate the pathophysiology, presentation, and multidetector computed tomography findings associated with emergent bladder conditions, limiting our discussion to traumatic, infectious, and obstructive etiologies. After reviewing computed tomography cystographic technique, the commonly utilized classification systems for bladder trauma will be presented with illustrative examples of associated typical and more infrequent secondary injuries and complications. Next, the pathogenesis and imaging appearance of both mechanical and neurogenic acute urinary retention will be addressed, including less common though potentially pathognomonic obstructive etiologies including urethral calculi and ectopic ureteroceles. Finally, we will review and illustrate the imaging features of both inflammatory and infectious cystitis, including hemorrhagic and emphysematous variants, as well as the potentially encountered secondary complications.

Limited data exist on the characteristics, risk factors, and management of blunt trauma pelvic fractures causing genitourinary (GU) and lower gastrointestinal (GI) injury. We sought to determine these parameters and elucidate independent risk factors.

The National Trauma Data Bank for years 2010-2014 was queried for pelvic fractures by ICD-9-CM codes. Exclusion criteria included age ≤ 17 years, penetrating injury, or incomplete records. Patients were divided into three cohorts: pelvic fracture, pelvic fracture with GU injury, and pelvic fracture with GU and GI injury. Between-group comparisons were made using stratified analysis. Multivariable logistic regression was used to determine independent risk factors for concomitant GI injury.

In total, 180,931 pelvic fractures were found, 3.3% had GU, and 0.15% had GU and GI injury. Most common mechanism was vehicular collision. Injury severity score, pelvic AIS, and mortality were higher with combined injury (p < 0.001), leading to longer hospital and ICU stays and ventilator days (p < 0.001) with more frequent discharges to acute rehabilitation (p < 0.01). Surgical management of concomitant injuries involved both urinary (62%) and rectal repairs (81%) or diversions (29% and 46%, respectively). Male gender (OR = 2.42), disruption of the pelvic circle (OR = 6.04), pubis fracture (OR = 2.07), innominate fracture (OR = 1.84), and SBP < 90 mmgh (OR = 1.59) were the strongest independent predictors of combined injury (p < 0.01).

Pelvic fractures with lower GU and GI injury represent < 1% of pelvic fractures. They are associated with more severe injuries and increased hospital resource utilization. Strongest independent predictors are disruption of the pelvic circle, male gender, innominate fracture, and SBP < 90mm Hg.

To present our updated experience and discuss potential benefits of early endoscopic realignment (EER) for patients with pelvic fracture urethral injuries (PFUIs).

A retrospective review of patients treated with EER after blunt PFUIs was performed. EER was performed with a retrograde or a combined antegrade or retrograde approach with a cystoscope. Treatment success was defined as no secondary procedure or the ability to pass a cystoscope across the area of injury or surgical anastomosis.

Thirty-two patients (mean age 38 years, range 17-73) underwent EER between 2004 and 2016 with a mean follow-up of 26 months (range 1-102). Median time to realignment was 2 days (range 0-6) and was performed concomitantly with another surgical service in 72% of cases. Median operative time for EER was 38 minutes (range 8-100). Using an intent-to-treat analysis, 29 patients (91%) failed EER. Nine patients underwent a subsequent endoscopic procedure with 22% success rate. Excision and primary anastomotic urethroplasty was performed in 24 patients as a primary or secondary treatment with 96% success rate.

Our overall success rate for EER was 9%, but did not hinder subsequent urethroplasty success. The decision for performing EER should not be based on success alone. Secondary benefits of EER exist and may assist with the multidisciplinary care of a patient with complex trauma. The management of PFUI is challenging and these patients should be referred to tertiary centers.

To evaluate the tadalafil effect in the treatment of erectile dysfunction as a consequence of posterior urethral injury.

This is a retrospective study that included patients with posterior urethral injury caused by previous pelvic fracture; our patients received emergency urethral alignment and urethroplasty between 8 to 10weeks after trauma. To assess the degree of erectile dysfunction pre- and post-treatment, we applied the questionnaire of International Index of Erectile Function (IIEF-5). Statistics Wilcoxon test and descriptive statistics were performed.

Eight patients were included in this study, with an average age of 32.5years; the IIEF scale prior to treatment was on average 8.5 points and increased to 12.36 points with a value of P=.011.

These eight patients showed erectile dysfunction at the time of IIEF assessment, this due to emergency urethral realignment arising from the trauma caused by pelvic fracture. Treatment with inhibitors of 5-phosphodiesterase (iPDE5) is the first-line treatment in patients with erectile dysfunction because it is efficient, non-invasive and well tolerated. In this study we found results indicating good response to this treatment in 7 out of the 8 patients (87.5%). Only one patient showed no improvement after treatment, due to the presence of risk factors such as age (65years), tobacco use, and high blood pressure.

The 87.5% of patients with urethral injury medicated with tadalafil were rehabilitated.

To assess the contemporary epidemiology of blunt trauma lower urinary tract injury (LUTI) and to evaluate outcomes in patients with and without associated pelvic fracture (PF).

Patients presenting to our level I trauma center with PF and/or LUTI from blunt trauma from 2000 to 2014 were identified in our institutional trauma registry. Demographics, mechanism of injury, fracture configurations, hospital course, and outpatient disposition were analyzed.

Of 5518 PF patients, 233 (4.2%) had LUTI. Thirty-four patients had non-PF LUTI. There were 3.2% of men and 3.3% of women with PF who had bladder injuries (P = .94). Urethral injury was more common in men (2.0% vs 0.05%; relative risk 43.1). Pubic arch fractures were present in 87% of patients with urethral injuries, although only 1.5% of patients with pubic arch fractures had urethral injury. Isolated acetabular fractures were never associated with urethral injury and associated with only 2.6% of bladder injuries. Extraperitoneal bladder ruptures were more common in the PF group as compared to the non-PF LUTI group (39.1% vs 14.7%, P < .01). Intensive care unit length of stay and hospital length of stay for PF vs non-PF patients were 7.1 ± 8.1 vs 2.8 ± 5.3 days (P < .01) and 13.5 ± 13.4 vs 7.7 ± 8.4 days (P = .01), respectively.

These data suggest that the contemporary incidence of PF LUTI is lower than previously reported. The presence of PF in patients with LUTI is associated with more severe overall injuries, longer hospital stays, and increased rates of inpatient complications.

This study was carried out to determine the incidence of bony injuries in trauma patients who had plain radiographs done at the Central Regional Hospital in Cape Coast.

This is a retrospective study based on plain radiographs taken by trauma patients who reported to the Central Regional Hospital.

The case notes of all patients with a discharge diagnosis of Road Traffic Accident or trauma of all aetiologies that presented to the hospital between January 2005 and December 2011 were retrieved, and those patients that had skeletal radiographic examinations were included in this study.

The total number of cases seen was 1,133. The ages of the patients ranged between 1 and 72 years. Sixty-nine (6.1%) of the patients were between 1 and 4 years old, with the majority between 20 and 49 years old, constituting 52.3%, with patients 60 years and above at 9.2%. There was statistically significant difference between male and female patients (p=0.001). A total of 912 (80.5%) patients had radiographic examination done out of which only 324 (35.5%) radiographs could be retrieved. There were 106 (32.7%) radiographs with various bony injuries which was statistically significant (p=0.001). Rib fractures represented 19/106 (17.9%) of which 62.5% had multiple rib fractures. Fifty-eight (54.7%) had long bone fractures. Other anatomical sites included the pelvis and the skull.

Trauma is a major public health problem in the country, involving mainly the productive age group. Unnecessary exposure to X-rays is common. Inadequate management of trauma patients negatively impacts on the outcome of trauma patients. Trauma prevention is the best way forward.

A forty-seven-year-old woman presented with recurrent urinary tract infections eleven years after open fixation of a pelvic ring injury. Cystoscopy revealed that the pelvic reconstruction plate had eroded into the bladder, likely the source of the recurrent infections. Following removal of the involved pelvic hardware and repair of the bladder, the patient had no further urinary tract infections.

Operative fixation of osseous pelvic injuries places metal implants in proximity to the bladder. Late erosion of hardware into the bladder can occur. A low threshold for urological work-up should be maintained for recurrent genitourinary symptoms in these patients.

To review the guidelines released in the last decade by several organisations for the optimal evaluation and management of genitourinary injuries (renal, ureteric, bladder, urethral and genital).

This is a review of the genitourinary trauma guidelines from the European Association of Urology (EAU) and the American Urological Association (AUA), and renal trauma guidelines from the Société Internationale d'Urologie (SIU).

Most recommendations are guided by the American Association for the Surgery of Trauma (AAST) organ injury severity system. Grade A evidence is rare in genitourinary trauma, and most recommendations are based on Grade B or C evidence. The findings of the most recent urological trauma guidelines are summarised. All guidelines recommend conservative management for low-grade injuries. The major difference is for haemodynamically stable patients who have high-grade renal trauma; the SIU guidelines recommend exploratory laparotomy, the EAU guidelines recommend renal exploration only if the injury is vascular, and the AUA guidelines recommend initial conservative management.

There is generally consensus among the three guidelines. Recommendations are based on observational or retrospective studies, as well as clinical principles and expert opinions. Multi-institutional collaborative research can improve the quality of evidence and direct more effective evaluation and management of urological trauma.

Trauma is one of the leading causes of death before the age of 40 years and approximately 5% of patients with trauma who require hospital admission have pelvic fractures. This article updates the emergency department classification of pelvic fractures first described in 2000. This information is of practical value to emergency physicians in identifying the potential vascular, genitourinary, gastrointestinal, orthopedic, and neurologic complications and further assists them in the initial evaluation and treatment of patients with pelvic fractures.

We describe the epidemiology, diagnosis, and management of adult civilian penetrating trauma to the ureter, bladder, and urethra. Trauma is a significant source of death and morbidity. Genitourinary injuries are present in 10% of penetrating trauma cases. Prompt recognition and appropriate management of genitourinary injuries, which are often masked or overlooked due to concomitant injuries, is essential to minimize morbidity. Penetrating trauma most commonly results from gunshot wounds or stab wounds. Compared to blunt trauma, these typically require surgical exploration. An understanding of anatomy and a high index of suspicion are necessary for prompt recognition of genitourinary injuries.

This article proposes a counter-argument to standard Advanced Trauma Life Support (ATLS) training--which advocates bladder catheterisation to be performed as an adjunct to the primary survey and resuscitation for early decompression of the bladder and urine output monitoring. We argue the case for delaying bladder catheterisation until after definitive truncal Computed Tomography (CT) imaging. To reduce pelvic volume and associated bleeding, our trauma team delay catheter insertion until after the initial CT scan. The benefits of a full bladder also include improved views on initial Focussed Assessment with Sonography in Trauma (FAST) scan and improved interpretation of injuries on CT. Our urinary catheter related infection rates anecdotally decreased when insertion was delayed and consequently performed in a more controlled, non-resuscitation setting following CT. Adult blunt multitrauma patients with pelvic ring fractures are at risk of significant haemorrhage. Venous, arterial and medullary injuries with associated bleeding may be potentiated by an increased pelvic volume with ring disruption, as well as a reduced pressure effect from retroperitoneal and intra-pelvic organs on bleeding sites. Various techniques are used to reduce intra-pelvic bleeding. For shocked patients who have sustained major pelvic injuries with no other signs of urinary tract trauma and minimal urine in the bladder on initial FAST scan, we advocate careful, aseptic Foley catheter insertion followed by bladder insufflation with 500-600 mL of Normal Saline (NS) and subsequent catheter clamping to tamponade pelvic bleeding.

The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries.

A systematic review of the literature using the MEDLINE® and EMBASE databases (search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria. These publications were used to inform the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

Guideline statements were created to inform clinicians on the initial observation, evaluation and subsequent management of renal, ureteral, bladder, urethral and genital traumatic injuries.

Genitourinary organ salvage has become increasingly possible as a result of advances in imaging, minimally invasive techniques, and reconstructive surgery. As the field of genitourinary reconstruction continues to evolve, clinicians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes.

To provide evidence on the midterm sexual-function- and health-related quality-of-life outcome of patients with a traumatic pelvic fracture, as recorded at least 12 months after their surgery.

Prospective noncomparative study.

Tertiary referral centre for pelvic-and-acetabular reconstruction.

Cohort of patients attending a dedicated pelvic-and-acetabular reconstruction clinic because of blunt pelvic trauma, at a minimum of a year after their injury.

Operatively treated pelvic fractures and concomitant surgical interventions for associated injuries, if any, sustained by the patients after blunt trauma.

Sexual function questionnaires: IIEF (international index of erectile function) and FSFI (female sexual function index). Quality of life was assessed with the EuroQol-5D questionnaire.

Of a cohort of 110 patients, 80 patients (48 males and 32 females) consented to participate with a median age of 46 years (range, 19-65 years). Of the above cohort, 62.5% were a result of road traffic accidents and 52.5% were classified as lateral compression type fractures. Assessment occurred at a median period of 36 months after injury (range, 12-96). Overall, significant decrease of their quality of life (P < 0.0001) and sexual function were recorded (males, P < 0.00014; females, P < 0.001). Sexual dysfunction was identified in 43.8% of the female and 52.1% of the male patients, as per the validated gender-specific sexual function scores (female sexual function index and international index of erectile function, respectively). Regression analysis identified the presence of urinary tract injury (P < 0.049) and open surgical treatment (P < 0.047) as independent risk factors for sexual dysfunction. A near significant association with injury severity score (P = 0.05) was seen. Male gender (P < 0.006), abdominal injury (P < 0.0001), pelvic fracture severity (P < 0.049), pain (P < 0.0001), and sexual dysfunction (P < 0.034) were identified as significant independent risk factors for decreased quality of life.

All domains of female and male sexual function were significantly decreased at a minimum of a year after pelvic fracture. Quality of life was also significantly decreased in this group with sexual dysfunction shown to be an independent risk factor for decreased quality of life after injury. Further pivotal clinical studies should follow based on the provided evidence. High clinical suspicion and prompt engagement of appropriate multidisciplinary pathways, including urological, gynecological, and psychiatric consultations, is recommended.

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.