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CME

Genitourinary Trauma in Women - Emergency Management

General Information

General InformationGeneral Information

Description

Anatomy

  • External: skin has minimal soft tissue4
    • Perineum: area inferior to the pelvic floor which includes the urethra to the anus
      • 2 layers of the urogenital triangle
        • Superficial layer: superficial perineal muscles, Bartholin glands, and suspensory ligaments for clitoris
        • Deep layer: urethral and vaginal sphincters, as well as deep perineal muscles
  • Internal4
    • Pelvis: most commonly damaged structures include inferior and superior pubic rami, pubic symphysis, and sacrum
  • Lower urinary4
    • Urethra: connects vulva with bladder, is adhered to the vagina and short (2-3 cm)
      • Function is dependent on sphincters and strength of supporting muscles of the perineum
    • Bladder: midline, posterior to pubic symphysis, separated by the retropubic space
  • Lower genital4
    • Vulva: labia majora, labia minora, clitoris, vaginal opening, and external urethral meatus
    • Vagina: hollow muscular tube that connects the cervix/uterus to the vaginal opening/vulva

Etiology

  • Bladder injury most commonly occurs from blunt abdominal trauma, 80% associated with pelvic fractures1,4,5
    • 4% of abdominal gunshot wounds are associated with bladder injury
  • Most urethral injuries are from blunt trauma1,4,5
    • 5%-10% of urethral injuries in women are caused by pelvic fractures
  • Rapid deceleration is a high-risk mechanism1,4,5
  • Vaginal injuries are most common with blunt or crushing-type injuries and highly related to anterior pelvic fractures1,4,5
  • Worldwide the most common cause of genital trauma in reproductive-age women is injury during childbirth6
  • In a large pediatric review of genital injuries presenting to the emergency department (ED), bicycles were the most common consumer product associated with injury7
  • Pediatric TIP: children lack periadipose tissues, and are at higher risk for urethral and bladder avulsion in blunt trauma1,3,4,5

Epidemiology

  • 10% of trauma patients sustain injuries to genitourinary (GU) tract2,4,8
    • 80% due to blunt injury, motor vehicle collisions (MVC), direct blunt force, or auto vs. pedestrian
  • Pelvic fractures are responsible for 3% of skeletal injuries2,4,8
    • Open pelvic fractures, which are about 4% of all pelvic fractures, have an associated 45% mortality rate
  • In one recent military study 2% of injured female service members had genitourinary injuries and among these women, severe multisystem trauma was common9

References

References

General references used

  1. Brunett PH, Cameron PA. Trauma in adults. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011
  2. Copeland CE, Bosse MJ, McCarthy ML, et al. Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function. J Orthop Trauma. 1997 Feb-Mar;11(2):73-81
  3. Hauda WE, II. Trauma in children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011
  4. McManus J, Gratton MC, Cuenca PJ. Genitourinary trauma. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011
  5. Goldman HB, Idom CB Jr, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol. 1998 Mar;159(3):956-9
  6. Lopez HN, Focseneanu MA, Merritt DF. Genital injuries acute evaluation and management. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:28-39
  7. Casey JT, Bjurlin MA, Cheng EY. Pediatric genital injury: an analysis of the National Electronic Injury Surveillance System. Urology. 2013 Nov;82(5):1125-30full-text
  8. Durrant JJ, Ramasamy A, Salmon MS, Watkin N, Sargeant I. Pelvic fracture-related urethral and bladder injury. J R Army Med Corps. 2013 Mar;159 Suppl 1:i32-9
  9. Reed AM, Janak JC, Orman JA, Hudak SJ. Genitourinary Injuries Among Female U.S. Service Members During Operation Iraqi Freedom and Operation Enduring Freedom: Findings from the Trauma Outcomes and Urogenital Health (TOUGH) Project. Mil Med. 2018 Jul 1;183(7-8):e304-e309
  10. Pode D, Shapiro A. Traumatic avulsion of the female urethra: case report. J Trauma. 1990 Feb;30(2):235-7
  11. Inaba K, Okoye OT, Browder T, et al. Prospective evaluation of the utility of routine postoperative cystogram after traumatic bladder injury. J Trauma Acute Care Surg. 2013 Dec;75(6):1019-23
  12. Mani NB, Kim L. The role of interventional radiology in urologic tract trauma. Semin Intervent Radiol. 2011 Dec;28(4):415-23full-text
  13. Kwok MY, Yen K, Atabaki S, et al. Sensitivity of plain pelvis radiography in children with blunt torso trauma. Ann Emerg Med. 2015 Jan;65(1):63-71
  14. Rathaus V, Grunebaum M, Konen O, et al Minimal pelvic fluid in asymptomatic children: the value of the sonographic finding. J Ultrasound Med. 2003 Jan;22(1):13-7

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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T909723, Genitourinary Trauma in Women - Emergency Management; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T909723. Registration and login required.

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