What is Lower Genitourinary Trauma (Injury to the Groin Area)?
Trauma or injuries can vary in severity – they can be minor wounds or could be serious enough to cause shock and failure of multiple organ systems. Among individuals aged between 15 and 24, trauma or injuries are the main cause of death. Roughly, trauma patients account for 30% of all admissions to the intensive care unit every year.
The lower part of the urinary and genital system, also known as the lower urogenital (GU) tract, is made up of organs like bladder, urethra, vagina, uterus, ovaries, penis, scrotum, and testes. This part is usually shielded by the pelvic bone structure. This structure is shaped like a ring and consists of the sacrum, coccyx, and innominate bones such as the pubis, ischium, and ilium. These bones meet at the pubic symphysis, towards the front of the body.
The bladder is a sort of storage tank for urine. But its size, shape, and position relative to nearby organs change depending on how full it is. When empty, the bladder sits inside the protective bony pelvis. But as it fills, it moves up into the abdominal cavity where it’s more exposed to injury. The bottom part of the bladder is close to the vagina in females and the rectum in males. This bottom part, known as the bladder neck, is the most stationary part of the bladder. In both sexes, ligaments, called the pubovesical ligaments, attach this part to the pubic bones. Blood supply to the bladder mainly comes from the superior and inferior vesical arteries which arise from the internal iliac artery. The bladder is also controlled by nerves from the sympathetic (T10-L2) and parasympathetic (S2-S4) nervous systems that come from the pelvic plexus. The bladder is composed of 4 layers: the lining (urothelium), a layer beneath the lining (lamina propria), the muscle layer (muscularis propria), and an outer layer (serosa).
The male urethra, a tube that goes from the bladder to the external opening of the urinary system, is about 18 to 20 cm long. The female urethra is about 4 cm long and is held in place by different ligaments towards the front and beneath the pubic bone. The blood supply and nerves controlling the urethra in both sexes are quite similar.
The female external genitalia include the mons pubis, labia majora and minora, clitoris, vestibule, and vestibular bulb. The vagina is a tube made up of muscle and fibrous tissue that goes from the genital area to the uterus. The uterus, an organ that’s between the bladder in the front and rectum at the back, is a muscular organ that can change position based on how full the bladder and rectum are. The blood supply, drainage, and nerves of these organs also come from specific sources.
What Causes Lower Genitourinary Trauma (Injury to the Groin Area)?
Injuries to the urinary and reproductive system, also known as the genitourinary tract, usually happen due to a strong or sharp blow rather than a puncture or cut. In the Western Hemisphere, car accidents are the main reason people get injured in this part of the body.
Motorcycle and other two-wheel vehicle accidents are often linked to injuries to the outer part of men’s genitalia. Meanwhile, penile fractures, which are breaks in the penis, almost always happen during sexual intercourse.
Injuries to women’s genitalia often happen to victims of sexual assault.
Risk Factors and Frequency for Lower Genitourinary Trauma (Injury to the Groin Area)
Urogenital trauma, or injuries to the urinary and genital organs, accounts for roughly 10%-20% of all abdominal trauma cases. Typically, these injuries are three times more likely to happen to males. High amounts of force, such as what can occur during a pelvic fracture, often cause these injuries. In fact, 60%-90% of adults with bladder injuries have had a pelvic fracture. Because such large force is needed, other injuries commonly happen alongside genitourinary trauma; particularly to the liver, spleen, and kidneys. Furthermore, if a patient arrives with visible blood in their urine, there’s a 24% chance they also have other injuries within their abdomen.
- Urogenital trauma makes up about 10%-20% of all abdominal trauma cases.
- This type of injury is three times more common in males.
- High-level forces, such as from a pelvic fracture, often cause these injuries. Bladder injuries are connected to pelvic fractures in 60%-90% of cases in adults.
- Other injuries often co-occur with genitourinary trauma, particularly affecting the liver, spleen, and kidneys.
- If a patient has visible blood in their urine, it’s likely (24% chance) they also have other injuries within their abdomen.
Signs and Symptoms of Lower Genitourinary Trauma (Injury to the Groin Area)
The Advanced Trauma Life Support (ATLS) course lays out a step-by-step plan for dealing with trauma patients. This plan helps medical personnel quickly identify and handle life-threatening injuries. It’s important to note that a complete medical history of the patient isn’t immediately necessary when dealing with acute injuries. The medical team that brings the patient to the trauma unit will provide a brief overview of the patient’s current condition. After the patient is stable, a more comprehensive history can be obtained. Useful information would include the source of injury, if the patient was able to walk at the scene of the incident, any loss of bowel or bladder control, and if the patient is experiencing any numbness or weakness. Presence of blood in the urine or at the exit of the urethra could signal injury to the urinary and reproductive systems.
Urethral injuries commonly present with the following symptoms:
- Blood at the opening of the urethra
- Cuts or bruises around the area between the anus and genitals
- Swelling of the scrotum caused by blood accumulation
- Inability to urinate
- Prostate gland pushed upward, felt during a rectal exam
- Difficulty or inability to insert a tube into the urethra to allow urination (foley catheter)
Testing for Lower Genitourinary Trauma (Injury to the Groin Area)
When evaluating a patient after a trauma, healthcare professionals follow specific steps to assess your health. To make it easier remember, they use a helpful order titled ABCDE:
- A stands for ‘Airway and cervical spine protection’: The doctor will ask you to speak to see if your airway is clear.
- B stands for ‘Breathing’: They will listen to your breathing and look at your chest to see if it moves properly when you breathe.
- C stands for ‘Circulation’: This helps them see if you’re in shock.
- D stands for ‘Disability’: They assess your consciousness using the Glasgow scale.
- E stands for ‘Exposure and environmental control’: They will undress you but also make sure you’re warm by covering you with a blanket.
After these steps, they will do a complete head-to-toe check-up, looking for any signs of injuries. They’ll check for blood from your urethra (the tube where urine comes out), which may suggest an injury. They’ll also check your rectum (your back passage) – blood here can indicate a digestive system injury. They are also likely to check your pelvis (your lower belly area) for any signs of damage.
Lab tests can be of great help in this situation too if you have been in a traumatic situation. Certain blood tests, like serum lactate and base deficit, can show if you have been bleeding a lot. Several blood clotting tests can indicate the risk of bleeding complications.
They may also use different imaging techniques like ultrasound, X-rays, or CT scans, depending on the situation and urgency. The ultrasound can be used to look for any free fluid in your pelvis. It can spot the bleeding but can’t distinguish bowel contents from blood. An X-ray can help identify potentially life-threatening injuries, and a CT scan can provide a more detailed picture of your injuries.
In cases of visible blood or suspected bladder injury, they might fill the bladder with a contrast solution for a CT scan. If that solution is found outside the bladder, it would confirm bladder injury. In case of suspected urethral injuries, they can do a special X-ray where they insert a catheter and slowly inject a contrast solution until it gets to the bladder. They also look for injuries to the female genitals, which can be a sensitive situation if caused by abuse. Here, evidence for potential legal cases can also be gathered. They will examine both inner and outer genitalia for any signs of injury.
For male patients, an injury to the penis, often referred to as ‘penile fracture’, is usually identifiable from the medical history and physical examination. If doctors need more information, they might use an ultrasound or MRI as well.
Treatment Options for Lower Genitourinary Trauma (Injury to the Groin Area)
If you have a bladder contusion or a simple bladder injury that isn’t severe, your doctor will usually opt for non-surgical treatment. This involves using a catheter, which is a tube inserted into the bladder, for 10 to 14 days to drain it. Then, an imaging test like a CT scan or an x-ray is conducted to check if your bladder is healing properly. If the test shows no leakage of contrast dye (a special dye used in imaging tests to highlight certain areas), the catheter can be removed. If there is still some leakage, the catheter is left in place and the test is repeated weekly. If after 4 weeks leakage still persists, then a surgery may be necessary to repair the bladder.
If you’re already having surgery for other injuries, the doctor will typically repair the bladder injury at the same time. During this process, a cut is made into the front of your bladder to access the laceration, which is then stitched using a type of thread that dissolves after a period of time. A catheter is used to drain the bladder, and a scan is performed after a week to check if the bladder is healing properly.
Certain injuries to the bladder require surgery. These can involve either a major open surgery or laparoscopic surgery, which uses smaller incisions and a tiny camera to guide the operation. The surgeon checks inside the bladder for any other injuries, particularly to the areas where the ureters (tubes that carry urine from the kidneys to the bladder) join the bladder. If any injuries are found, they are repaired promptly. The surgeon also makes sure urine is flowing out of both ureters normally. Afterwards, a catheter is used to drain the bladder for about a week, while antibiotics are given to prevent infection.
Minor injuries to the urethra, the tube that allows urine to pass out of the body, often don’t require treatment. But for more serious injuries, catheterization (inserting a tube into the urethra to allow urine to flow) is typically used. Penetrating injuries to the anterior (front) part of the urethra need surgical repair. If surgery can’t be done right away due to other injuries, a suprapubic catheter, which is inserted into the bladder through the lower abdomen, may be used to divert urine away from the urethra.
Injuries to female reproductive organs and surrounding areas, like perineal lacerations (cuts in the area between the vagina and the anus) or injuries to the vulva (the external part of the female genital organs), can often be treated at the hospital’s emergency department. They are usually cleaned, any dead tissue is removed, and then the injured area is stitched back together with dissolvable sutures. Deeper cuts to the vagina or cervix (the lower part of the uterus that connects to the vagina), especially those associated with pelvic fractures, may require more complex treatment. These injuries are usually repaired during surgery, and any injuries to the urinary system or rectum are also addressed at the same time.
Injuries to the uterus, fallopian tubes, or ovaries are typically repaired during surgery. If an injury is too severe, the uterus, fallopian tube, or ovary may have to be removed. Male genital organ injuries, specifically to the penis, are usually treated with surgery as soon as possible.
What else can Lower Genitourinary Trauma (Injury to the Groin Area) be?
There are several injuries and conditions that could be linked to trauma or certain diseases, and they might include:
- Injury to the kidneys
- Injury to the ureter (a tube that carries urine from the kidneys to the bladder)
- Pelvic fracture
- Injury to the rectum
- Tears or cuts in the vagina
- Injury to the abdomen
- Bleeding in the area at the back of the abdomen (retroperitoneal hemorrhage)
- Narrowing of the urethra (the tube that allows urine to pass outside the body)
- Urinary stones
- Fournier gangrene, a severe infection of the genital area
- Domestic abuse
What to expect with Lower Genitourinary Trauma (Injury to the Groin Area)
The future health outlook for patients suffering from damage to the lower genital and urinary systems differs widely. This difference depends on the specific injury and any other injuries the patient might have. Typically, these patients have multiple injuries. Damage to the genital and urinary systems rarely threatens life directly but often leads to long-term health problems. Overall, the patient’s future health is largely determined by the injury itself and any existing health problems.
Possible Complications When Diagnosed with Lower Genitourinary Trauma (Injury to the Groin Area)
Noticing and addressing complications related to the urinary and genital tract are crucial since, if left unattended, they can cause serious health problems and potentially death. These complications can either be early or late depending on when they are observed after an event like surgery. Early problems can include bleeding, infection or an overlooked injury which can lead to symptoms like increased levels of waste products in the blood, inflammation of the abdominal lining, or slowing of bowel movements. Late complications often involve functional issues like difficulty controlling or passing urine, narrow urethra, sexual problems, and issues with reproductive functions.
Early Complications:
- Bleeding
- Infections and sepsis
- Overlooked injuries
Narrowing of the urethra, also known as urethral strictures, is treated by a urologist initially with repeated dilations. If this does not work, a surgical procedure may be required which has a high success rate.
Incontinence and difficulty in holding or passing urine are also initially treated using simple methods. Strength training for pelvic muscles and electronic signals to amplify the body’s signals can be highly effective. Certain medications along with physiotherapy can also be helpful. If all else fails, a sphincter-like device may be implanted which has shown success in the past.
Trama to the genitals can result in sexual and reproductive problems. Microscopic repair of blood vessels and nerves within the penis can restore sensation in most cases. However, skin can still die even after this and would require multiple cleanings and skin transfers. To aid recovery, high-pressure oxygen therapy can also be used. Sexual problems can be handled with medications, vacuum devices, or surgically implanted devices.
Injuries to the vagina that extend to the rectum can result in lack of control over bowel movements. Changes to diet, fiber supplements, slowing bowel movements through medication, and strengthening exercises for the pelvic floor can be initial treatments. If these methods do not work, surgical procedures to repair the natural sphincter or implant artificial ones can be considered.
A possible serious complication is the development of an abnormal connection between the vagina and rectum, known as rectovaginal fistula. These have a major impact on the affected person’s social and sexual lifestyle. However, multiple surgical solutions are available. For instance, procedures may involve tissue flaps, mesh repair, or special glues.
In addition to the physical complications, there are also potential psychological ones to consider, which can arise from the residual scars, embarrassment from sexual issues, or from the trauma that triggered the genital injuries. In such cases, early psychological support is strongly recommended.
Preventing Lower Genitourinary Trauma (Injury to the Groin Area)
When coming in for treatment, particularly for issues like pelvic fractures, it’s essential to understand what the process might look like. There may be a lengthy period of rehabilitation and physical therapy involved for full recovery. It’s also important to be aware that there may be ongoing discomfort or pain, so you should be aware of different ways to manage this pain. This process might also have psychological impacts, such as depression or anxiety, and there are options available to manage these feelings as well.
For patients with a catheter— a flexible tube used for removing fluids from the body—it’s key to learn how to use and maintain it safely. Pelvic fractures may also affect sexual functions. If this is the case, a referral can be provided to a gynecologist (a doctor specialized in the female reproductive system) or a urologist (a doctor specialized in the male and female urinary-tract system, and the male reproductive organs), to take care of these concerns.