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Pelvic Fractures & Genitourinary Trauma

Name: Pelvic Fractures & Genitourinary Trauma
Creator: Veli Bakalov, MD

Close the ring, image before the catheter, repair what leaks

Surgery·Trauma·5 min read·8 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Unstable pelvic ring fracture (open book, vertical shear) in shock → binder centered over the greater trochanters, massive transfusion, and FAST to exclude an abdominal source.
About 85% of pelvic fracture bleeding is venous or bony; arterial bleeding (~10–15%) is treated with angioembolization, venous bleeding with preperitoneal packing plus external fixation.
Unstable pelvic fracture with a positive FAST → laparotomy first (with preperitoneal packing).
Posterior (membranous) urethral injury accompanies pelvic fracture (high-riding prostate); anterior (bulbar) injury follows straddle falls (butterfly perineal hematoma).
Blood at the meatus or inability to void → retrograde urethrogram before any Foley; a disrupted urethra is drained with a suprapubic catheter.
Pelvic fracture + gross hematuria → retrograde (CT) cystogram with ≥300 mL; extraperitoneal rupture → catheter drainage 10–14 days, intraperitoneal (dome, urinary ascites, rising creatinine) → operative repair.
Renal trauma: CT with a delayed phase for gross hematuria or microhematuria with SBP <90; stable patients, even with high-grade injuries, are managed nonoperatively.
Penile fracture (pop, detumescence, eggplant deformity) → emergent surgical repair; testicular rupture on ultrasound → prompt exploration.

Pelvic ring fractures and hemorrhage

Fracture patterns. Anteroposterior compression produces the "open book": diastasis of the pubic symphysis with widening of the sacroiliac joints, which enlarges pelvic volume and tears the posterior venous plexus. Vertical shear, typically from a fall onto extended legs, displaces a hemipelvis cephalad and is the most unstable pattern. Lateral compression from side impact is the most common pattern and reduces pelvic volume, so it usually bleeds less. An unstable ring in a patient in shock means life-threatening retroperitoneal hemorrhage until proven otherwise.

~85%of pelvic bleeding is venous (presacral plexus) or from fracture surfaces

~10–15%is arterial (superior gluteal, internal pudendal, obturator branches)

Binder first. Apply a pelvic binder, or a sheet wrapped tightly and clamped, centered over the greater trochanters rather than the iliac crests; internally rotating and binding the legs adds to the effect. Closing the ring shrinks pelvic volume and tamponades venous bleeding. Examine the pelvis gently once at most, because repeated springing dislodges clot.

Binder and bloodmassive transfusion protocol with balanced products
FASTpositive in an unstable patient → laparotomy, with preperitoneal packing at the same operation
Pelvic hemorrhage controlangioembolization for arterial bleeding (contrast blush on CT in a stable patient); preperitoneal packing with external fixation for venous bleeding or when angiography is not immediately available
Definitive fixationonce physiology is restored

Open pelvic fractures. Examine the perineum, rectum, and, in women, the vagina in every pelvic fracture. A laceration communicating with the fracture makes it an open fracture with high mortality; treat with broad-spectrum antibiotics, washout, and a diverting colostomy for rectal or perineal wounds.

Urethral injury

Mechanisms. Pelvic fractures shear the posterior (membranous) urethra at the prostatomembranous junction, while straddle falls crush the anterior (bulbar) urethra against the pubic symphysis. Urethral injury is uncommon in women because the urethra is short and mobile.

Posterior versus anterior urethral injury

Feature	Posterior (membranous)	Anterior (bulbar)
Mechanism	Pelvic fracture	Straddle injury, instrumentation
Exam	Blood at meatus, high-riding or boggy prostate, urinary retention	Blood at meatus, butterfly perineal or scrotal hematoma
Where blood tracks	Into the pelvis and retropubic space	Along the shaft (Buck fascia intact) or into the perineum (Colles fascia)
Initial drainage	Suprapubic catheter; endoscopic realignment in selected cases	Suprapubic or gentle urethral catheter, depending on extent

Urethrogram before catheter. Blood at the urethral meatus, inability to void with a distended bladder, a high-riding prostate, or a perineal or scrotal hematoma calls for a retrograde urethrogram before any catheter attempt, because a blind Foley can complete a partial tear or create a false passage.

Never attempt a Foley catheter when there is blood at the meatus until a urethrogram shows the urethra is intact.

Later care. Complete disruptions scar into strictures that are repaired by delayed urethroplasty months later. Long-term risks include stricture, erectile dysfunction, and incontinence.

Bladder rupture

Diagnosis. Gross hematuria with a pelvic fracture requires a retrograde cystogram, by CT or plain film, after actively filling the bladder through a catheter with at least 300 mL of contrast; passive filling from IV contrast with a clamped catheter misses ruptures. Plain-film cystography includes a post-drainage image to catch posterior leaks. Exclude urethral injury first when there is blood at the meatus.

Extraperitoneal versus intraperitoneal rupture

Feature	Extraperitoneal	Intraperitoneal
Frequency	Most common	Less common; relatively more frequent in children
Mechanism	Pelvic fracture fragments lacerate the anterolateral wall	Blow to a full bladder bursts the dome, its only peritonealized surface
Cystogram	Flame-shaped contrast in the perivesical space	Contrast outlines bowel loops and paracolic gutters
Clues	Pelvic fracture with gross hematuria	Urinary ascites, peritonitis, rising BUN and creatinine from peritoneal absorption
Treatment	Catheter drainage ~10–14 days, cystogram before removal	Operative repair plus catheter drainage

Extraperitoneal ruptures are repaired surgically when the bladder neck is involved, bone fragments sit in the wall, the rectum or vagina is injured, or the patient is already undergoing laparotomy.

Children's bladders sit higher in the abdomen, so intraperitoneal rupture is relatively more common in them.

Renal injury

Who needs imaging. In stable blunt trauma patients, obtain CT with IV contrast and a delayed excretory phase for gross hematuria, microscopic hematuria with systolic BP <90 mmHg, or a rapid-deceleration mechanism, flank blow or ecchymosis, or lower rib fractures. The delayed phase shows extravasation from the collecting system, and absent enhancement of a kidney after deceleration suggests renal artery thrombosis from an intimal tear.

Management. Most renal injuries, including high-grade lacerations with urinary extravasation, are managed nonoperatively in stable patients: bed rest, serial hematocrit, and repeat imaging for worsening. Angioembolization treats active bleeding, and a ureteral stent or percutaneous drain handles a persistent urinoma. Exploration or nephrectomy is reserved for instability unresponsive to resuscitation, renal pedicle avulsion, or an expanding or pulsatile perirenal hematoma found at laparotomy.

Late complications. Delayed bleeding, urinoma, arteriovenous fistula, and hypertension. Page kidney is renin-mediated hypertension from a subcapsular or perirenal hematoma compressing the parenchyma.

Penile and testicular injury

Penile fracture. Forceful bending of the erect penis, usually during vigorous intercourse, ruptures the tunica albuginea of a corpus cavernosum. Patients describe an audible pop, rapid detumescence, and pain, followed by swelling and ecchymosis (eggplant deformity) with deviation away from the tear. The diagnosis is clinical; treatment is emergent surgical exploration and repair, which lowers the risk of erectile dysfunction and curvature. Blood at the meatus, hematuria, or retention suggests an associated urethral tear that needs a urethrogram or intraoperative cystoscopy.

Testicular rupture. Blunt scrotal trauma with a large hematocele or a tender, indistinct testis warrants scrotal ultrasound, which shows a disrupted tunica albuginea and heterogeneous parenchyma. Prompt exploration with debridement and closure of the tunica maximizes testicular salvage.