Urologic injury associated with pelvic trauma is a rare occurrence and even more infrequent in women who present with pelvic trauma. Yet it often represents a complex problem due to potential concomitant vaginal and rectal injury, and different considerations for the female urethral anatomy. Management often requires an interdisciplinary approach from urology, gynecology, general surgery, and orthopedics, and a different diagnostic and treatment algorithm than in patients with male anatomy. We present a discussion on the current urologic considerations and approaches to female pelvic trauma based on contemporary literature and our institutional experience at Harborview Medical Center, Seattle, Washington.

The female urethra is shorter, more protected by the pelvis, and less rigidly fixated to the pelvic bone compared to the male.¹ A recent analysis of National Trauma Data Bank showed that the incidence rate of female urethral injury was 10 times less than in patients with male anatomy.² The majority of female urethral injury was caused by blunt trauma. Of female cases, 56.7% had associated pelvic fracture, and there was a high rate of concomitant injuries (53.9% gynecologic injuries, 28.2% bladder injuries, 9.8% other genitourinary injuries).

Diagnosis of female urethral injury thus follows a different algorithm than in males given the female urethral anatomy. The physical exam will likely show either blood at the meatus or blood in the vaginal vault. A retrospective review of 130 women with pelvic fractures demonstrated that 100% (6/6) of women with an associated urethral injury also had blood at the introitus.³ Pelvic and rectal exams are indicated in these patients as vaginal or rectal injury will not only add complexity to urologic surgical treatment, but may also require the expertise from other specialties. While retrograde urethrography remains the standard diagnostic approach in men, this is not advisable in women. Most authors agree that an exam under anesthesia with cystoscopy and vaginoscopy is likely the best approach to diagnosing female urethral injury.⁴ One report showed that up to 40% of injuries may be missed by physical exam alone.⁵ If there remains any question of bladder or bladder neck injury, cystogram should also be performed (Figure). Most importantly, given the risk of missed diagnosis and the many reports of resultant complications secondary to infection or pelvic fibrosis from missed injuries, a high index of suspicion should drive investigation in female patients with pelvic ring fractures, blood in the urine, blood in the introitus or difficult catheter placement following pelvic trauma (Figure).

Figure. A, X-ray of the pelvis showing female pelvic trauma, with white arrows indicating displaced ischiopubic ramus and obturator ring. B, CT cystogram sagittal view shows bladder neck disruption with contrast extravasation and urethral catheter balloon posterior to bladder in the same patient.

The treatment algorithm for female urethral injury is guided by small case series. The largest review paper by Patel et al reports the best outcomes for immediate primary repair, within 7 days of injury, using an anastomotic approach.⁴ The authors found that primary realignment with urethral catheter alone has a much higher complication rate, including 60% of urethral stricture and 13% of urethrovaginal fistulization when compared to primary anastomotic repair (3% stricture, 6% fistula) and delayed repair (3% stricture, 4% fistula). However, immediate repairs, when compared with delayed repairs, were associated with a significantly lower rate of postoperative incontinence (6% vs 31%) and vaginal stenosis (0% vs 4%), and were much more likely to be completed via a vaginal approach. Both the ability to approach these injuries with a less invasive method and the improved long-term outcomes suggest that immediate repair may avoid the scaring and pelvic fibrosis inherent to a delayed repair. Our experience at Harborview Medical Center mirrors that of Patel et al. In a recent series of 10 female urethral or bladder neck injury patients, we found that only 2 of the 9 patients eligible for prompt surgical repair had a Clavien grade > 2 complication out to 15.2 months of median follow-up.⁶

The rate of blunt bladder injuries is similar in both women and men (3.37% vs 3.41%).⁷ Bladder and pelvic ureteral injuries follow the same diagnostic and treatment algorithms for men and women with the exception of concomitant vaginal injury, which puts the patient at higher risk for urovaginal fistulae. For concomitant bladder and vaginal injuries, patients should be explored and repaired when their stability allows. At our institution, repair may be deferred for up to 48 hours to ensure appropriate coordination with gynecology and orthopedic surgery when indicated. Cystorrhaphy is undertaken in an extraperitoneal manner, if possible, with standard closure of the bladder in at least 2 layers with absorbable suture. Simultaneously, the gynecology team will repair the vaginal laceration in a single layer. We routinely leave a closed-suction drain around the repair and obtain a cystogram after 2 weeks, prior to catheter removal. For concomitant ureteral and vaginal injuries, gynecology should be engaged for the vaginal laceration, and the mechanism and severity of injury determines the urologic treatment. In a series by Orcutt et al at our institution, we found that 89% of partial ureteral transections from blunt mechanisms were treated successfully with stenting alone.⁸ While none of these patients had a vaginal laceration, stenting is also the standard for the initial management of ureterovaginal fistulae, and thus it stands to reason that endoscopic approaches should be strongly considered for patients with a concomitant blunt ureteral and vaginal injury.⁹ For patients with complete ureteral transections or penetrating ureteral injuries, open surgical repair remains the gold standard.

Urologic injuries in female pelvic trauma are more complex because of concomitant vaginal injury and the female urethral anatomy. These injuries are less commonly encountered, and thus experience is often limited. The available data and our institutional experience indicate that urethral injuries should be thoroughly investigated and repaired primarily in a timely fashion whenever possible. Bladder and ureteral injuries should be treated using the same algorithms as in men except for associated vaginal injuries. Vesicovaginal injuries should be repaired primarily close to the time of diagnosis as long as the patient condition allows. Ureterovaginal injuries should be initially managed with endoscopic stent placement when possible. Regardless of the treatment plan, consultation with gynecology, general surgery, and orthopedics should be undertaken when evaluating and treating urologic injuries associated with pelvic trauma in women.