G e n i t o u r i n a r y I m a g i n g • R ev i ew

Ramchandani and Buckler

Genitourinary Trauma

Genitourinary Imaging
Review
FOCUS ON:

Imaging of Genitourinary Trauma

1
Parvati Ramchandani OBJECTIVE. Blunt and penetrating abdominal trauma can cause significant injury to the
Philip Michael Buckler genitourinary organs, and radiologic imaging plays a critical role both in diagnosing these in-
juries and in determining the management. In this article, we describe and illustrate the spec-
Ramchandani P, Buckler PM trum of injuries that can occur in the genitourinary system in order to facilitate accurate and
rapid recognition of the significant injuries.
CONCLUSION. Imaging plays a crucial role in the evaluation of the genitourinary tract
in a patient who has suffered either blunt or penetrating trauma because multiorgan injury is
American Journal of Roentgenology 2009.192:1514-1523.

common in such patients. Contrast-enhanced CT is the primary imaging technique used to

evaluate the upper and lower urinary tract for trauma. Cystography and urethrography re-
main useful techniques in the initial evaluation and follow-up of trauma to the urinary blad-
der and urethra.

Keywords: blunt trauma, genital trauma, genitourinary
trauma, kidney, penetrating trauma, scrotum, testicle,
ureter
DOI:10.2214/AJR.09.2470
Received January 30, 2009; accepted without revision
January 30, 2009.
1
Both authors: Department of Radiology, University of
Pennsylvania Medical Center, 3400 Spruce St.,
Philadelphia, PA 19104. Address correspondence to
P. Ramchandani (ramchanp@uphs.upenn.edu).
AJR 2009; 192:1514–1523
0361–803X/09/1926–1514
© American Roentgen Ray Society
W
ide-impact blunt abdominal
trauma is responsible for most
closed injuries of the genitouri-
nary organs, with motor vehicle
crashes being the most common cause in the
Western hemisphere [1, 2]. The incidence of
penetrating trauma is also increasing, which
is seen particularly in inner city trauma cen-
ters, and is becoming a major cause of renal
injury [3, 4]. A European registry of road
traffic crash victims compiled between 1996
and 2001 recorded trauma to the genitouri-
nary system in 0.46% of cases (199 of 43,056
cases) [2]. Motor vehicle crashes were most
frequently associated with renal and bladder
injuries (43% and 16% of cases, respective-
ly), whereas accidents involving two-wheeled
motorized vehicles were associated with in-
jury to the male external genital organs in
64% of cases, with testicular injury account-
ing for two thirds of cases, and renal injury
in 28% of cases [2]. Other series have report-
ed renal trauma in 1.2% of 500,000 patients
hospitalized for trauma in the United States
[5], and a 3% incidence of renal and testicu-
lar trauma in 14,763 children evaluated in a
U. S. emergency department [6]. In victims
of penetrating trauma, renal injury may be
seen in 3–5.7% of cases [3, 7].
Associated multiorgan injury is common
with both blunt and penetrating renal trauma
and may be seen in many as 80–95% of pa-
tients with blunt and penetrating renal trau-
ma [1, 3]; the liver and the spleen are the
most common intraabdominal organs to be
injured with blunt trauma [8]. Patients who
present with either gross hematuria or shock
are apt to have nongenitourinary intraab-
dominal injury in 24% and 65% of cases, re-
spectively [9], attesting to the severity of
the trauma.
In this article, we discuss the role of imag-
ing in the management of patients with geni-
tourinary trauma.
Adrenal Trauma
Incidence and Significance
Trauma to the adrenal glands is unusual
because of their relatively well-protected po-
sition deep in the retroperitoneum, so injury
to these organs occurs in the setting of mas-
sive trauma [10, 11]. The incidence of adre-
nal injury in patients with blunt trauma is
reported to be 0.15–4% in different series
[10–13]. Rana et al. [11] reported traumatic
adrenal hemorrhage in 5% of patients with
an injury severity score (ISS) greater than
40 compared with a 0.4% incidence in pa-
tients with an ISS of 0–19, whereas Stawicki
et al. [10] reported that mean ISS scores were
more than two times higher in patients with
adrenal injury than in those without. Patients
with adrenal gland trauma have a higher mor-
tality rate than do trauma patients without

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 Genitourinary Trauma

adrenal injury, attesting to the severity of
the trauma. In the series by Stawicki et al.,
patients with adrenal injury had a five times
higher mortality rate than those without ad-
renal injury, and Rana et al. reported a 10%
mortality rate with adrenal injury compared
with 4% without. It follows that multiorgan
injury is common in these patients, although
isolated adrenal injury may be seen in 2–6%
of cases [11–15].
Imaging Features
Traumatic adrenal injuries tend to affect
the right adrenal gland disproportionately,
with only the right adrenal gland being af-
fected in more than 70% of cases [10–15]
(Fig. 1A). Isolated left adrenal injury is less
common, and bilateral adrenal injury is the
least common, occurring in fewer than 1% of
cases. It is speculated that the right adrenal
gland is more vulnerable to injury for sev-
American Journal of Roentgenology 2009.192:1514-1523.
binger of a delayed adrenal hematoma [17].
On follow-up CT examinations, hematomas
should decrease in size or resolve [11] (Figs.
1A and 1B). Adrenal masses that remain un-
changed over several weeks may represent a
disorder other than trauma—most often an
adenoma—and should be further evaluated
as deemed clinically appropriate [11]. Con-
versely, it is important to recognize that an
adrenal abnormality in the absence of a his-
tory of significant trauma is unlikely to rep-
resent a traumatic adrenal injury [11, 13].
Bilateral adrenal hemorrhage, particular-
ly in the setting of minimal trauma, should
prompt a search for an underlying coagula-
tion abnormality. A preexisting adrenal dis-
order can predispose the adrenal gland to in-
jury and hemorrhage with relatively minor
trauma [18].
Sonography is a particularly useful tech-
nique to evaluate children who have sus-
assess for other associated injuries. Contrast-
enhanced MDCT is the imaging technique
of choice to evaluate the entire urinary tract,
including the renal vasculature, renal paren-
chyma, and the collecting system [4, 22, 23].
The role of IV urography (IVU) is currently
relegated to situations in which CT may not
be available, or as a one-shot study in the op-
erating room, where a film is obtained 10–15
minutes after contrast injection to grossly as-
sess symmetry of excretion and to look for
contrast extravasation that would indicate in-
jury to the collecting system [24]. The low
sensitivity of IVU for detecting or character-
izing injuries limits its usefulness in the rou-
tine evaluation of a trauma patient [25].
Grading Injuries
The severity of renal injuries is graded
from 1 to 5 (least to most severe) accord-
ing to a classification system developed by

eral reasons: Its confined position allows di-
rect compression of the right adrenal gland
between the liver and the spine, and the di-
rect entry of the short right adrenal vein into
the inferior vena cava (IVC) contributes to
an acute rise in intraadrenal venous pressure
during the abdominal compression associat-
ed with blunt trauma [16].
The typical appearance of a traumatic ad-
renal injury is an expansile, hyperattenuat-
ing, round or oval hematoma with a mean
diameter of 2.8 cm and mean attenuation of
52–54 HU [11, 13] (Fig. 1A). Other findings
seen are irregularity or obliteration of the
gland by hemorrhage, periadrenal fat strand-
ing, and mild to moderate enlargement of
the gland due to edema or contusion. Active
adrenal hemorrhage may be seen. Mild en-
largement of the adrenal gland may be a har-
tained trauma. The adrenal gland may be
enlarged and may show hypoechoic areas of
hemorrhage [19] (Fig. 1C).
Unilateral adrenal injury is of little clin-
ical significance, with therapeutic interven-
tions required only for the associated injuries
that commonly accompany adrenal trauma.
Bilateral adrenal injury may rarely cause en-
docrine abnormalities such as adrenal insuf-
ficiency or posttraumatic pheochromocyto-
ma-like syndrome [20, 21].
Renal Trauma
Role of Imaging
The primary role of imaging in renal trau-
ma is to accurately assess the severity and
extent of injury, evaluate the injured kidney
for underlying disorders, evaluate the anato-
my and function of the opposite kidney, and
the Organ Injury Scaling Committee of the
American Association for the Surgery of
Trauma (AAST) and is called the organ in-
jury scale (OIS) [26–28]. The grading sys-
tem was primarily devised as a clinical re-
search tool for 32 different organs and organ
systems, including the different parts of the
urinary tract, to ensure accurate and repro-
ducible classification of injury severity. The
grading system for renal injuries is yet to be
modified to better integrate abnormalities
seen only on imaging, such as arterial con-
trast extravasation and quantification of he-
matoma size [27].
Renal injuries are graded as follows [26–
28]: Grade 1 injuries are characterized by

A B C
Fig. 1—Traumatic adrenal hematoma.
A, 52-year-old man after motorcycle collision. Unenhanced CT scan reveals high-density right adrenal mass (arrow) suspected to be hematoma.
B, Follow-up contrast-enhanced CT scan obtained approximately 10 weeks later in same patient as in A shows resolution of right adrenal hematoma.
C, 12-year-old boy after motor vehicle collision who has right adrenal hemorrhage. Sagittal sonogram shows right adrenal gland to be enlarged and predominantly
hypoechoic, consistent with acute hemorrhage.

AJR:192, June 2009 1515

 Ramchandani and Buckler

undergo radiographic evaluation if they have

gross hematuria or microhematuria and a
systolic blood pressure < 90 mm Hg [27];
12.5% of such patients have a major renal in-
jury [30]. Adult patients with blunt trauma
who have microhematuria and systolic blood
pressure > 90 mm Hg have only a 0.2% inci-
dence of major renal injury [30] and do not
require imaging evaluation. Additional pa-
tients in whom imaging evaluation should be
considered even in the absence of hematuria
are those with vertical deceleration injuries
A B (falls), those who were in high-speed motor
Fig. 2—Renal contusion and segmental arterial injury in two patients with blunt trauma.
vehicle collisions, and those with multiple
A, 43-year-old woman after fall from height. Enhanced CT scan reveals bilateral ill-defined foci of diminished associated injuries [27, 30, 31]. Radiologic
enhancement, consistent with renal contusions (arrows). Note perinephric hematoma on right (arrowheads). evaluation of all patients suffering penetrat-
B, 22-year-old man after fall from height. Enhanced CT scan reveals sharply demarcated perfusion defect, ing injury is recommended because there is
presumably due to segmental arterial injury. Note retroperitoneal hematoma in retrocaval region (arrow).
poor correlation between hematuria and se-
verity of injury [30].
Imaging abnormalities—Renal contusions
are seen as areas of ill-defined decreased en-
American Journal of Roentgenology 2009.192:1514-1523.

hancement (Fig. 2A), whereas areas of seg-

mental infarction due to laceration, thrombo-
sis, or dissection of segmental arteries appear
as sharply demarcated linear or wedge-
shaped nonenhancing areas (Fig. 2B). Lacer-
ations appear as irregular or linear parenchy-
mal defects that may contain clot (Fig. 3A).
In a shattered kidney, foci of active arterial
extravasation should be distinguished from
islands of viable renal parenchyma that are
A B
still enhancing (Fig. 3B). Subcapsular hema-
Fig. 3—Deep parenchymal injuries in two patients with renal trauma. tomas are seen as round or elliptical high-at-
A, 50-year-old woman after motor vehicle collision. Enhanced CT scan in nephrographic phase reveals deep left tenuation (40–70 HU) collections of clotted
renal lacerations and perinephric hematoma.
B, 28-year-old woman after gunshot wound. Nephrographic phase CT scan reveals linear cleft in medial blood [22, 23].
aspect of right kidney and surrounding hematoma. Densities in hematoma (black arrows) reflect active arterial When a renal laceration is detected on CT,
bleeding. Small locules of gas in right paraspinal muscles (white arrows) are related to track of shotgun wound. a 10-minute delayed scan should be obtained
to assess the collecting system and evaluate
renal contusion without a parenchymal lac- patients with renal trauma, Wessels et al. [5] for urinary extravasation (Figs. 4A–4C and
eration, and a nonexpanding subcapsular he- found contusions or hematomas in 64.4% of 5). Delayed images are also helpful for char-
matoma. Grade 2 injuries show superficial patients, lacerations in 26.3% (Fig. 3), paren- acterizing the nature of a perinephric fluid
cortical lacerations that are < 1 cm deep (and chymal disruption in 5.3%, and vascular in- collection and for distinguishing a hematoma
thus do not involve the collecting system) juries in 4% of cases (Figs. 2–6). Penetrating from a urinoma [32] (Fig. 5). UPJ injuries are
and a nonexpanding perinephric hematoma. trauma resulted in more severe renal injuries discussed later with other ureteral injuries.
Grade 3 injuries have deeper lacerations, > 1 than did blunt trauma, with a higher propor- Segmental arterial injuries may cause areas
cm deep, that do not extend into the collect- tion of lacerations, parenchymal disruption, of segmental infarction, pseudoaneurysms, or
ing system, and nonexpanding perinephric and vascular injury [5]. arteriovenous fistulae. Global infarction can
hematoma. Grade 4 injuries show lacera- be due to renal artery thrombosis related to
tions that extend into the collecting system Imaging Findings intimal dissection from a deceleration inju-
and injury to the main and segmental renal Indications for imaging—The degree of ry, or to renal artery avulsion, in which case
vessels. Grade 5 injuries show shattering of hematuria that should lead to radiologic eval- a perinephric hematoma should be present
the kidney and dispersion of the avulsed por- uation of the urinary tract in a victim of blunt (Fig. 6A). Venous injuries with blunt trauma
tions, avulsion, laceration or thrombosis of trauma is controversial because there is no are rare and usually occur in association with
the main renal vessels, hilar injury, and ure- absolute correlation between the presence or arterial pedicle injuries and severe parenchy-
teropelvic junction (UPJ) avulsion. degree of hematuria and the amount of re- mal injuries, although isolated renal venous
Most renal injuries are minor; contusions nal injury that is present [29]. Consensus re- injury without arterial or parenchymal injury
account for 64–81% of all renal injuries [5, view of experts indicates that hemodynami- has been reported with trauma sustained dur-
28] (Fig. 2A). In a multicenter study of 6,231 cally stable adults with blunt trauma should ing martial arts [33] (Fig. 6B).

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 Genitourinary Trauma

A B C
Fig. 4—Collecting system injury in 18-year-old man with blunt abdominal trauma shown on delayed excretory phase imaging.
A, Nephrographic phase CT scan shows severely lacerated right kidney and large surrounding fluid collection of hematoma and urinoma.
B, Excretory phase of CT urogram shows extravasation of urine from right kidney (arrows).
C, Sagittal multiplanar reformation of same study as in B shows numerous lacerations (arrows) in right kidney as well as extravasated urine (arrowheads).

Underlying renal parenchymal abnorma­

American Journal of Roentgenology 2009.192:1514-1523.

lities can predispose the kidney to injury.

These abnormalities include cysts, tumors,
chronic hydronephrosis, and congenital anom­
alies such as a horseshoe kidney, ectop­ic kid-
ney, congenital UPJ obstruction, and poly-
cystic kidneys [25, 34] (Fig. 7). Trauma in
abnormal kidneys tends to be confined to the
kidneys, to occur with relatively minor trau-
ma, and to result in macrohematuria more
frequently. Children, particularly those with
congenital anomalies, have been considered
to be at greater risk for renal trauma, but in a
A B small published series [6] congenital anoma-
lies were not found to increase the incidence
Fig. 5—45-year-old woman with perinephric fluid who was involved in motor vehicle collision.
A, CT scan in early excretory phase shows right renal lacerations and perinephric fluid. of renal injuries.
B, Late excretory phase image shows that perinephric fluid is combination of hematoma and extravasated urine.
Management
Nonoperative management is the accepted
standard of care for minor injuries. No fol-
low-up imaging is recommended for grades
1 and 2 injuries (minor renal injuries). Pa-
tients with grade 3 lacerations who are hemo-
dynamically stable and show no devitalized
fragments also require no follow-up imag-
ing [27]. Delayed or secondary hemorrhage
may occur from 2 to 38 days later in patients
with deep lacerations, particularly those due
to stab wounds, likely because of pseudoan-
eurysm or formation of an arteriovenous fis-
A B
tula [35, 36]. These can usually be well man-
Fig. 6—Traumatic renal arterial and venous injury in two patients. aged with standard angiographic techniques.
A, 23-year-old man with vascular pedicle injury after motorcycle collision. Nephrographic phase CT scan
shows near total absence of enhancement in left kidney. Left renal artery (arrow) terminates abruptly. There
Grade 4 lacerations require follow-up CT at
was also left perinephric hematoma as well as hemoperitoneum from associated splenic injury (not shown). 36–72 hours to monitor extravasation from
B, 52-year-old man after blunt trauma during karate practice resulting in traumatic left renal vein thrombosis. the collecting system. Because urine extrava-
Contrast-enhanced CT scan shows large filling defect (white arrows) in left renal vein. Also note relatively sation resolves spontaneously in 80–90% of
delayed enhancement of left kidney, which is still in corticomedullary phase, compared with right kidney,
which already shows some contrast excretion into collecting system (black arrow). Left kidney is enlarged, and cases, expectant management is the appro-
perinephric fluid and stranding are present. priate therapy for most such patients [37]. If

AJR:192, June 2009 1517


Fig. 7—42-year-old woman with bleeding from left
renal angiomyolipoma after motor vehicle collision.
Contrast-enhanced CT scan shows large exophytic
mass containing fat (white arrow) and multiple
foci of contrast extravasation (black arrows). Note
surrounding hematoma and anterior displacement
of kidney.
urine leaks persist, retrograde or antegrade
stenting may help to promote resolution of the
American Journal of Roentgenology 2009.192:1514-1523.
extravasation and avoid surgery [25]. Urino-
mas that form as a complication of urine ex-
travasation can also be successfully managed
by percutaneous drainage [25]. Angiography
is used largely to treat complications detected
on CT, such as suspected renal artery throm-
bosis or segmental arterial injury, in patients
in whom stenting or embolization is feasible
[38]. Surgical management is considered in
patients with renal pedicle injury or a severe-
ly damaged and shattered kidney [27].
Sequelae of Renal Trauma
Minor renal injuries (grades 1 and 2) heal
completely and leave no residual change in
the kidney on follow-up CT [39]. Higher-
grade injuries can cause permanent scars
in the affected kidney [39, 40]. Most (64%)
grade 3 and all grades 4 and 5 injuries re-
sult in permanent parenchymal scarring of
the kidneys.
Ureteral Trauma
Causes
Ureteral injuries from external trauma are
unusual but when they occur are usually re-
lated to penetrating trauma, primarily gun-
shot wounds [41, 42]. As with all cases of
penetrating trauma, multiple associated in-
traabdominal organ injuries are often pres-
ent [42]. Missile paths that are in proximity
to the ureter can also cause significant tissue
damage and may have a delayed presentation.
Blunt trauma usually affects the UPJ and is
related to rapid deceleration injury [41].
Iatrogenic ureteral injuries can occur dur-
ing gynecologic, obstetric, urologic, colorec-
1518 AJR:192, June 2009
Ramchandani and Buckler
tal, general, or vascular surgery [43]; gyne-
cologic surgery accounts for more than half
of all iatrogenic injuries [41]. The pelvic ure-
ters are the most commonly affected, and
preoperative imaging or ureteral stenting to
facilitate intraoperative ureteral identifica-
tion appear not to be helpful in preventing
injury [41]. Patients may present with flank
or abdominal pain, elevated serum blood
urea nitrogen and creatinine levels, vaginal
urinary leakage, fever, or other nonspecific
symptoms. If the injury is recognized intra-
operatively, the ureter can be repaired im-
mediately. Unfortunately, the diagnosis of
an iatrogenic ureteral injury can be delayed
for several weeks until the patient becomes
symptomatic.
Hematuria is an unreliable indicator of
ureteral trauma and may be absent in many
patients [41, 42].
Imaging Features
The AAST-OIS grades of ureteral injuries
are as follows: grade 1, ureteral contusion;
grade 2, less than 50% partial transection;
grade 3, more than 50% partial transection;
grade 4, complete transection; and grade 5,
complete transection and extensive devascu-
larization [44]. To our knowledge, no studies
have compared imaging findings with opera-
tive findings to determine whether the grades
of ureteral trauma can be recognized on ra-
diographic imaging.
Preoperative imaging may not be per-
formed in patients with penetrating trau-
ma because these patients are often rapidly
transferred to the operating room for explo-
ration [42]. One-shot preoperative or intra-
operative IVU may show contrast extravasa-
tion, but it is often not performed because of
poor diagnostic performance and the delays
inherent in performing the examination in an
unstable patient [24, 41, 42]. In the delayed
setting, complete IVU or contrast-enhanced
CT with imaging in the delayed phase may
show contrast extravasation from the ure-
ter or partial or complete ureteral obstruc-
tion in patients with ureteral injury. CT may
also show urinary ascites or urinoma; a high
index of suspicion should be maintained in
postoperative patients with intraabdominal
fluid collections to accurately assess the uri-
nary tract for urine leaks and to characterize
any fluid collections (Fig . 8).
In patients with blunt trauma and sus-
pected UPJ injury, CT with excretory phase
imaging is a reliable tool for evaluation.
Features that suggest UPJ injury include pre-
dominantly medial perirenal contrast ex-
travasation in the absence of renal paren-
chymal injury [45]. If the UPJ is lacerated,
contrast material will be present in the distal
ureter; and with transection, the distal ure-
ter will not be opacified. In equivocal cases,
retrograde pyelography can be helpful in dis-
tinguishing partial laceration from complete
transection [41]. The distinction is important
because lacerations are managed with a ure-
teral stent, whereas transections require sur-
gical repair.
Urinary Bladder Trauma
Classification
Bladder injuries are classified by the
AAST-OIS scale into five grades [44]; grade
1, which includes contusion, intramural he-
matoma, and partial thickness laceration;
grade 2, extraperitoneal wall lacerations < 2
cm; grade 3, extraperitoneal lacerations > 2
cm and intraperitoneal lacerations < 2 cm;
grade 4, intraperitoneal lacerations > 2 cm;
and grade 5, intraperitoneal or extraperito-
neal lacerations that extend into the bladder
neck or trigone. A second classification sys-
tem endorsed by a consensus panel of the So-
ciete Internationale D’Urologie [46] classifies
bladder injury into four types, which do not
take into account the length or extent of the
bladder wall laceration: type 1 is bladder con-
tusion; type 2, intraperitoneal rupture; type 3,
extraperitoneal rupture; and type 4, combined
injury. Radiologic imaging is better suited to
conform to the latter classification and is di-
rected toward determining whether there is a
full-thickness tear of the bladder as judged by
contrast extravasation on CT cystography or
Fig. 8—Right ureteral injury as a complication of
hysterectomy in 51-year-old woman. Delayed axial
image from CT urography shows jet of contrast
material (arrow) extending from injured right ureter.
Large amount of urinomatous ascites is present,
with some layering of contrast material present
dependently in pelvis.
 Genitourinary Trauma

conventional cystography monitored by radi-
ography or fluoroscopy.
Causes
The most frequent causes of bladder trauma
are motor vehicle crashes (in which both seat
belt compression of the bladder and ejection
injuries may be responsible), falls, crush in-
juries, and blows to the lower abdomen [46].
Sixty percent to 90% (mean, 80%) of patients
with bladder injuries due to blunt trauma have
associated pelvic fractures [46], and approxi-
mately 30% of patients with pelvic fractures
will have some bladder injury, including blad-
der contusion [47]. Twenty-five percent of in-
traperitoneal bladder ruptures occur in patients
without a pelvic fracture [48]. Simultaneous
ruptures of the bladder and prostatomembra-
neous urethra can occur in 10–29% of males
undergoing trauma [49].
Bladder contusion is related to mucosal in-
American Journal of Roentgenology 2009.192:1514-1523.
peritoneal injury accounts for approximately
one third of bladder injuries. Extraperitoneal
ruptures account for approximately 60% of
major bladder injuries and are usually asso-
ciated with pelvic fractures, although the ex-
act mechanism of injury remains the subject
of debate. The bladder injury may be relat-
ed either to direct laceration by sharp bony
spicules of pelvic fractures or to a contra-
coup mechanism caused by ligamentous in-
jury and associated bladder tears. Extraperi-
toneal ruptures are further classified into two
groups, simple and complex, by Sandler et al.
[50]. In simple extraperitoneal rupture, con-
trast extravasation is confined to the pelvic
extraperitoneal space; whereas in complex
extraperitoneal rupture, extravasated con-
trast material can disperse widely into the
anterior abdominal wall, the penis, the scro-
tum, and the perineum as a result of disrup-
tion of the fascial planes of the pelvis by the
Imaging
Indications for imaging—Gross hematu-
ria with pelvic fracture is an absolute indica-
tion for evaluation of the bladder in a patient
with trauma [51, 52] because such patients
have a high likelihood of injury. Morey et
al. [52] reported that of their 53 patients with
bladder injury, all had hematuria, and 85%
had pelvic fractures. In the series by Quagli-
ano et al. [51], 32% of patients with pelvic
fracture and gross hematuria were found to
have bladder injury. Gross hematuria with-
out pelvic fracture, microhematuria with pel-
vic fracture, and isolated microhematuria are
considered relative indications for evaluation
of the bladder, with imaging recommended
in patients with clinical symptoms such as
suprapubic pain or voiding difficulties [52].
Both CT cystography and conventional
cystography are similar in their sensitivity
and specificity for detecting and character-

jury from trauma. No abnormalities are de-
tectable on imaging studies [50]. Intraperito-
neal rupture occurs when there is a blow to
or compression of the lower abdomen in a pa-
tient with a distended urinary bladder, caus-
ing a sudden rise in the intraluminal pres-
sure of the bladder and rupture of the dome,
which is the weakest portion of the bladder.
The dome of the distended bladder is cov-
ered by peritoneum, so an injury at this site
causes intraperitoneal extravasation. Intra­
injury. Complex injuries may result in con-
fusion during image interpretation, causing
confined extraperitoneal injuries to be mis-
interpreted as combined extraperitoneal and
intraperitoneal injuries or to be mistaken for
the presence of a coexisting urethral injury
[50, 51].
The presence of both intraperitoneal and
extraperitoneal bladder injuries is known as
a combined bladder injury and occurs in ap-
proximately 5% of major bladder injuries.
izing bladder injury [51, 53].
Conventional cystography—The identifi-
cation of contrast material outside the con-
fines of the urinary bladder confirms the
diagnosis of bladder rupture. With extraperi-
toneal leaks, the contrast agent remains con-
fined to the pelvis (Fig. 9); with intraperitone-
al leaks, contrast material may outline bowel
loops and extend into the paracolic gutters
and diffusely into the peritoneal cavity (Fig.
10A). In a patient with blood at the urethral

Fig. 9—34-year-old man with extraperitoneal bladder rupture after motor vehicle collision. Extraluminal
bladder contrast is not seen when there is passive filling of bladder with excreted IV contrast material but is
visualized well when bladder is actively distended on CT cystogram.
A, Delayed axial image from contrast-enhanced CT of pelvis shows excreted contrast material (and Foley
catheter balloon) in bladder as well as small amount of surrounding fluid (arrows), but no extraluminal contrast
material is detected. Note that bladder appears quite distended.
B–D, CT cystograms show extraperitoneal rupture and large amount of contrast material in prevesical space
and extending into superficial soft tissues.
A

B C D

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 Ramchandani and Buckler

meatus, there is a high likelihood of urethral
injury, and retrograde urethrography should
be performed before bladder catheterization
[54]. The bladder should be distended until
a detrusor contraction is obtained in order to
avoid a false-negative study.
Cystography has an accuracy rate of 85–
100% for detecting bladder injury [50–52].
Cystography should ideally be performed
with fluoroscopic guidance. The minimal se-
quence of films for cystography is prelimi-
nary radiography of the pelvis, a film of the
maximally filled bladder, and a postdrainage
film to detect extraluminal contrast leak from
a posterior wall injury that may be obscured
on the filled film. Because these patients of-
ten have associated pelvic fractures, oblique
views may not be feasible. Bladder injury
may be identified only on the postdrainage
film in approximately 10% of cases [48].
CT cystography—Active distention of the
American Journal of Roentgenology 2009.192:1514-1523.
tine diagnostic CT of the abdomen and pelvis
[57]. The absence of pelvic ascites is report-
ed to be quite helpful in excluding bladder
rupture [58].
In extraperitoneal injuries, contrast mate-
rial may be confined to the pelvis (a molar-
tooth appearance may be seen to the pattern
of contrast extravasation) or may extend be-
yond the perivesical space with a complex
extraperitoneal injury (Fig. 10B). Intraperito-
neal injuries outline bowel loops and diffuse
through the mesenteric folds (Fig. 10A).
Urethral Trauma
Classification
Male urethral trauma was originally clas-
sified by Colapinto and McCallum [59] on
the basis of the appearance of the urethra on
retrograde urethrography. This classification
was subsequently modified and expanded to
better predict continence [60]. Male urethral
of posterior urethral injuries [61]. A direct
blow to the perineum compresses the ure-
thra and corpus spongiosum between the ex-
ternal hard object and the inferior aspect of
the symphysis pubis. In most cases, no pelvic
fracture occurs. Straddle injuries can cause
either partial or complete rupture of the bul-
bous urethra [48] (Fig. 11A).
Posterior urethral injuries associated with
a pelvic fracture are classified into five types
[48, 59, 60]: type I, posterior urethra stretched
but intact; type II, urethra disrupted at the
membranoprostatic junction above the uro-
genital diaphragm (Fig. 11B); type III, mem-
branous urethra disrupted, with extension to
the proximal bulbous urethra or disruption of
the urogenital diaphragm (most common);
type IV, bladder neck injury with extension
into the urethra; type IVa, injury of the base
of the bladder and periurethral extravasation
simulating a true type IV urethral injury; and

urinary bladder with contrast material is es-
sential for a high-quality CT cystogram that
is reliable in excluding a bladder leak [50–
55]. It is important to recognize that passive
distention of the bladder, using excreted con-
trast material only, during a routine abdom-
inopelvic CT study cannot be relied on to
diagnose bladder rupture, even with clamp-
ing of a urethral catheter [50, 55, 56], even
if the bladder appears to be distended (Fig.
9). CT performed with excreted contrast ma-
terial only may show intraperitoneal or ex-
traperitoneal fluid but cannot differentiate
urine from ascites. A minimum of 300–350
mL of diluted contrast media should be in-
stilled into the bladder followed by axial CT
imaging of the pelvis [56]. Multiplanar ref-
ormation (MPR) may be helpful to better de-
lineate the site of the bladder rupture; Chan
et al. [53] found that additional sagittal and
coronal MPR images were particularly use-
ful in showing perforations at the dome of
the bladder. A postvoid or postdrainage film
is unnecessary and redundant in CT cystog-
raphy [53].
Quagliano et al. [51] reported sensitivity
and specificity of 95% and 100%, respective-
ly, for both CT cystography and convention-
al cystography. Other authors have reported
similar high sensitivity and specificity for
CT cystography [53, 57].
Quagliano et al. [51] distended the blad-
der with diluted contrast material before per-
forming routine abdominopelvic CT and re-
ported satisfactory results. Other authors
have reported performing CT cystography
on a second imaging series after initial rou-
injuries are primarily of two types, depend- type V, partial or complete pure anterior ure-
ing on the cause of the trauma. They may thral injury. A European consensus commit-
be associated with a fracture of the anterior tee [61] endorsed the Goldman classification
pelvic arch and affect about 5% of men who [60] but recommended simplification; they
sustain a pelvic fracture. These injuries usu- suggested that assessment be aimed at de-
ally involve the membranous urethra and are termining whether the injury is a partial or
due to shearing and rupturing of the pubo- complete disruption of the anterior or poste-
prostatic ligaments. A hematoma forms in rior urethra, and whether posterior urethral
the retropubic and perivesical spaces [48]; injuries are complicated by extension to the
identification of this hematoma on CT scans bladder neck or rectum [61].
is an important clue to the presence of a ure-
thral injury. Imaging
The second main type of injury results When a patient with pelvic trauma pres-
from a straddle injury, which directly in- ents with blood at the urethral meatus, or
jures the bulbous urethra. The frequency when urethral injury is suspected clinically,
of anterior urethral injuries is one third that retrograde urethrography is essential before
A B
Fig. 10—Intraperitoneal bladder injury and complex extraperitoneal bladder injury in two patients.
A, 75-year-old woman with intraperitoneal bladder rupture after motor vehicle collision. CT cystogram shows
defect in anterior bladder wall (arrow) as well as intraperitoneal contrast material outlining pelvic peritoneal
reflections.
B, 60-year-old woman after motor vehicle collision. Contrast extravasation from complex extraperitoneal
rupture is extending high into pelvis in space of Retzius.

1520 AJR:192, June 2009

 Genitourinary Trauma

A B C
Fig. 11—Various types of urethral trauma in three patients.
A, 54-year-old man after straddle injury. Voiding cystourethrogram shows partial urethral transection and extravasation at bulbar urethra (type 5 injury, arrow).
B, 23-year-old man after motor vehicle collision. Pericatheter voiding cystourethrogram obtained a few days after admission shows leakage of urine above urogenital
diaphragm (type 2 injury, arrow). Note left pubic fractures and pear-shaped bladder caused by presence of surrounding hematoma.
C, 58-year-old male pedestrian struck by car. Enhanced CT scan shows balloon of Foley catheter positioned anterior to prostate and lateral to urethra (arrow). Note right
pubic fracture and urine and hematoma in periprostatic space.
American Journal of Roentgenology 2009.192:1514-1523.

attempting to catheterize the bladder [48, 60]
to avoid traumatizing the urethra further and
potentially converting a partial tear into a
complete injury [48] (Fig. 11C). Retrograde
urethrography is the diagnostic procedure of
choice to evaluate patients with suspected
urethral injury [48, 62, 63]. In patients with
significant trauma, a suprapubic catheter may
be placed for bladder drainage. However, it is
not rare in modern trauma centers for a Foley
catheter to be placed before retrograde ure-
thrography so that fluid intake and output can
be accurately monitored. CT may precede
retrograde urethrography by hours or even
days; it is therefore important to become fa-
miliar with findings on CT that are reportedly
seen with higher frequency in patients with
posterior urethral injuries than in those with-
out [64, 65]. These findings include obscura-
tion of the urogenital diaphragmatic fat
plane, hematoma of the ischiocavernosus
and obturator internus muscles, obscuration
of the prostatic contour, and obscuration of
the bulbocavernosus muscle. Obscuration of
the urogenital diaphragm fat plane was seen
in 88% of patients with pelvic fracture and
urethral injury versus only 3% of those with
pelvic fracture but no urethral injury. Hema-
toma of the ischiocavernosus muscle was
seen in 88% of patients with urethral injury
but in only 17% without urethral injury. Ob-
scuration of the prostatic contour was seen in
59% with urethral injury but in only 7%
without urethral injury. Obscuration of the
bulbocavernosus muscle was seen in 47%
with urethral injury but in only 10% without Testicular Trauma
urethral injury. Hematoma of the obturator The testes can be injured with sporting ac-
internus muscle was seen in 53% with ure- tivities, which account for more than half of
thral injury but in only 13% without urethral all cases of testicular injury [68]. Motor ve-
injury (Fig. 11C). hicle collisions are also an important cause,
Although MRI has no role in evaluating particularly two-wheeled motorized vehi-
the urethra in the acute setting, it is useful cles, when the testes are crushed between the
in assessing posttraumatic pelvic anatomy, bony pelvis and the fuel tank [2].
determining the position of the prostate and Imaging is useful in the triage of patients
the amount of pelvic fibrosis, and estimating for surgical or nonsurgical management.
the length of the prostatomembraneous de- Clinical examination may not be able to ac-
fect [62, 66]. curately determine the severity of injury be-
Injuries to the female urethra are uncom- cause the ecchymosis and the degree of he-
mon because of its short size and absence of matoma do not correlate accurately with the
firm attachment to the pubic bone. Female severity of testicular injury [69]. High-fre-
urethral injuries are often accompanied by quency sonography performed with a linear
vaginal and rectal injury [67]. array transducer is the imaging technique
A B
Fig. 12—44-year-old man who heard popping sound during sexual intercourse.
A, Transverse sonogram of penis shows defect in tunica albuginea of left corpus cavernosum (arrows) and large
surrounding hematoma.
B, Photograph of penis shows ecchymosis, giving “eggplant” appearance to penis.

AJR:192, June 2009 1521


of choice; MRI is helpful in patients with
equivocal findings.
Imaging is directed toward determining
whether testicular rupture is present. Sonog-
raphy has a reported sensitivity of 100% and
a specificity of 93.5% for the diagnosis of
testicular rupture [70]. Heterogeneous echo-
texture in the testis, testicular contour abnor-
mality due to extrusion of the testes through
a tunical defect, and disruption of the tunica
albuginea are indicative of testicular rupture.
Testicular fractures are surgically managed
with débridement of extruded seminiferous
tubules and closure of the tunical defect. The
rate of testicular salvage is 90% if surgery is
performed promptly. Testicular hematomas
may also cause the echotexture to be hetero-
geneous. The appearance of hematomas var-
ies with their age, but they show no internal
vascularity. Significant testicular hematomas
should be monitored because they may be-
American Journal of Roentgenology 2009.192:1514-1523.
come secondarily infected and necessitate
orchiectomy. Other findings that may ac-
company testicular trauma are a scrotal he-
matocele, scrotal wall hematoma, and trau-
matic epididymitis [68].
Penile Fracture
Fracture of the penis occurs exclusively
with an erection, with aggressive vaginal in-
tercourse being the most common cause. It
is related to excessive bending of the erect
penis and thrusting against the pubic sym-
physis. The patient usually reports a crack-
ing sound, immediate pain, and rapid detu-
mescence. On physical examination, there is
swelling and ecchymosis of the penile shaft,
causing the so-called eggplant deformity
(Fig. 12). A transverse tear occurs in the tu-
nica albuginea, usually of one corporal cav-
ernosal body, although both can be affected.
If the clinical findings are equivocal, sonog-
raphy or MRI [71–73] may help to show the
defect in the tunica albuginea as well as the
surrounding hematoma.
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