UROGENITA

L
EMERGENCI
ES
T R A U M AT I C A N D N O N -
T R A U M AT I C
• A urologic emergency is a condition requiring rapid diagnosis and immediate
treatment.
• Classification-Traumatic and Non Traumatic causes
NON-TRAUMATIC

• These include conditions like

• Hematuria (blood in urine)

• Renal Colic
• Urinary Retention

• Acute Scrotum (sudden onset of scrotal pain/swelling), and

• Priapism (prolonged erection)

TRAUMATIC

• These involve injuries to the urinary system and include Renal Trauma

• Ureteral Injury
• Bladder Trauma

• Urethral Injury and

• Testicular Trauma
HEMATURIA
Definition:

Hematuria is defined as blood in the urine, with microscopic hematuria specifically

indicating the presence of more than 3 red blood cells per high-power microscopic field.

Types:
It can be categorized as
●macroscopic (frank or gross hematuria, visible to the naked eye),
●dipstick hematuria, or
●microscopic hematuria (requiring microscopic examination).
Symptoms & Timing:
Hematuria can be either painless or painful, and its presentation can be classified based on
timing as initial, terminal, or total.
Medical Causes:

These include glomerular and non-glomerular conditions like blood dyscrasias,

interstitial nephritis, and renovascular disease.

Surgical/Urological Non-glomerular Causes:

• These involve conditions such as renal and urothelial tumours (involving bladder,
ureter, renal collecting system), prostate cancer, bleeding from benign prostatic
enlargement, trauma, renal or ureteric stones, and UTIs.
Haematuria Characteristics:
• In these surgical/urological situations, haematuria is typically identified by the presence of
circular erythrocytes and the absence of proteinuria and casts.
• Presentation:

• Hematuria can manifest as visible blood in the urine, anemia (in rare cases of heavy
bleeding), or urine retention/ureteric colic due to clot retention.
• Workup:

• The diagnostic process involves taking a patient history, conducting a physical examination,
and performing investigations such as urine culture and cytology, renal ultrasound, flexible
cystoscopy, and in selected cases, IVU or CT scans.
• Treatment:

• The primary approach to managing hematuria is to identify and treat the underlying cause.
RENAL COLIC
Acute Flank Pain, also known as Ureteric or Renal Colic, is characterized by:

Being the most common urologic emergency and a frequent cause of “Acute
Abdomen”.

A sudden onset of severe pain in the flank.

• Typically caused by the passage of a kidney stone through the ureter.
Renal colic is characterized by a non-traumatic emergency and exhibits the following pain characteristics:

Sudden Onset and Colicky Nature:

The pain begins very suddenly and is colicky, meaning it comes in waves.

Radiation:

The pain radiates to the groin as a kidney stone passes into the lower ureter.

Location Changes:

The location of the pain may shift from the flank to the groin, though this change does not reliably indicate the stone’s
position.

Patient Discomfort:

Patients experiencing renal colic often cannot find a comfortable position and may roll around in agony.

Associated Symptoms:

Nausea and vomiting are commonly associated with renal colic.

Pain Severity:
• The pain caused by a ureteric stone is described as being more severe than labor pain.
• DIFFERENTIAL DIAGNOSIS

• Vascular emergencies: Leaking abdominal aortic aneurysms.

• Cardiac and Pulmonary conditions: Myocardial infarction and Pneumonia.

• Gastrointestinal issues: Acute appendicitis, Inflammatory bowel disease

(Crohn’s, ulcerative colitis), Diverticulitis, Burst peptic ulcer, and Bowel
obstruction.
• Reproductive system conditions: Ovarian pathology (e.g., twisted ovarian
cyst), Testicular torsion, and Ectopic pregnancy
• WORK-UP-

• History:

• Gathering the patient’s medical history.

• Examination:

• Observing the patient’s behavior, specifically their tendency to move around to find a
comfortable position.
• +/- Fever:

• Checking for the presence or absence of fever.

• Pregnancy test:

• Conducting a pregnancy test, presumably for female patients of childbearing age.

• MSU:

• Performing a Mid-Stream Urine test.

• INVESTIGATIONS

• Radiological investigations used for diagnosing conditions, likely related to the

urinary system, specifically focusing on ureteric stones and flank pain:
• KUB/Abdominal US, IVP (previously used), Helical CTU, and MRI: are listed as
methods for radiological investigation.
• Helical CTU offers significant advantages over IVP, including higher specificity
and sensitivity for diagnosing ureteric stones, the ability to identify non-stone
causes of flank pain, no need for contrast, faster procedure time, and comparable
cost to IVU.
• MRI is a highly accurate method: for detecting ureteric stones
• ACUTE MANAGEMENT-

• Pain Relief: Utilizing NSAIDs (administered via injection, orally, or rectally) and
potentially opiate analgesics like pethidine or morphine.
• Hyperhydration: Listed with a question mark, indicating potential or debated
use.
• Watchful Waiting: Recommended for stones 5mm or less, as 95% pass
spontaneously with analgesic supplements
URINARY RETENTION
• Urinary Retention is classified info

• Acute Urinary Retention

• Chronic Urinary Retention

Acute Urinary Retention is a non-traumatic emergency characterized by the painful
inability to void, with pain relief achieved through bladder catheterization. Its
pathophysiology involves:

Increased urethral resistance: Often due to bladder outlet obstruction (BOO).

Low bladder pressure: Indicating impaired bladder contractility.

• Interruption of bladder innervation: Affecting either sensory or motor nerves.
• CAUSES

• Men:

• Causes include benign prostatic enlargement (BPE) due to BPH, carcinoma of the
prostate, urethral stricture, and prostatic abscess.
• Women:

• Causes include pelvic prolapse (cystocele, rectocele, uterine), urethral stricture,

urethral diverticulum, complications following surgery for ‘stress’ incontinence,
and pelvic masses like ovarian masses.
• Both sexes

• Mechanical obstruction:

• Haematuria leading to clot retention, pain, radical pelvic surgery, and pelvic
fracture rupturing the urethra.
• Neurological issues:

• Sacral nerve compression or damage (cauda equina compression), neurotropic

viruses (herpes simplex or zoster) affecting sensory dorsal root ganglia of S2-S4,
multiple sclerosis, transverse myelitis, diabetic cystopathy, and damage to dorsal
columns of the spinal cord (e.g., tabes dorsalis, pernicious anaemia) leading to
loss of bladder sensation.
• MANAGEMENT

• Initial management

• This involves immediate relief of urinary retention through either

urethral catheterization or the insertion of a suprapubic catheter (SPC).
• Late Management:

• This phase focuses on identifying and treating the underlying cause of the acute
urinary retention.
ACUTE SCROTUM
Acute scrotum

An emergency situation that requires immediate medical attention.

Involves prompt evaluation and differential diagnosis to determine the cause.

• May necessitate immediate surgical exploration, particularly in cases of non-
traumatic emergencies.
• Differential Diagnosis

• Torsion of the Spermatic Cord (Intravaginal):

• This is identified as the most serious cause of acute scrotum.

• Torsion of the Testicular and Epididymal Appendages:

• Another potential cause of acute scrotum.

• Epididymitis:

• This is noted as the most common cause of acute scrotum.

• TORSION OF SPERMATIC CORD(INTRAVAGINAL)

• Testicular torsion (intravaginal) is a severe medical condition characterized by the

twisting of the spermatic cord, which can lead to irreversible damage to the testicle if
not treated promptly.
• Surgical Emergency:

• It is considered a true surgical emergency requiring immediate intervention.

• Time-Sensitive Injury:

• Irreversible ischemic injury to the testicular tissue can begin as soon as 4 hours after
the onset of torsion.
• Decreased Salvage Rate:

• The likelihood of saving the testicle significantly decreases as the duration of the
torsion increases.
• PHYSICAL EXAMINATION FINDINGS-

• Key physical examination findings include:

• The affected testis is high-riding and in a transverse orientation.

• Presence of acute hydrocele or massive scrotal edema.

• The cremasteric reflex is absent.

• The affected testis is tender and larger than the other side.

• Prehn’s sign is positive, meaning elevation of the scrotum does not relieve pain.

• Manual detorsion may be attempted as a treatment measure.

• Adjunctive test-

• Purpose of Adjunctive Tests:

• To assist in the differential diagnosis of acute scrotum.

• To confirm the absence of spermatic cord torsion.

• Doppler Examination:

• Doppler examination of the cord and testis is mentioned as an adjunctive test.

• However, it’s noted to have high false-positive and false-negative results.

Color Doppler Ultrasound-

Assesses anatomy and determines the presence or absence of blood flow.

Shows a sensitivity of 88.9% and a specificity of 98.8%.

• Is operator dependent.

• Radionucleotide imaging-

• It is used for the assessment of testicular blood flow.

• It demonstrates a sensitivity of 90% and a specificity of 89%.

• Hyperemia of the scrotal wall can lead to false impressions.

• It is not useful for diagnosing hydrocele and hematoma.

• SURGICAL EXPLORATION

• Surgical exploration for torsion of the spermatic cord, considered a non-traumatic

emergency, involves:
• Incision and Detorsion:

• A scrotal incision (median raphe or transverse) is made, the affected side examined, and the
spermatic cord detorsed.
• Testicular Viability Assessment:

• Testes with marginal viability are re-examined after warm sponges, while necrotic testes are
removed.
• Preservation and Fixation:

• If preserved, the testis is placed in the dartos pouch (suture fixation), and the contralateral
testis is fixed to prevent future torsion.
• EPIDIDYMO-ORCHITIS

• Presentation:

• Characterized by an indolent process, scrotal swelling, erythema, pain, and

commonly dysuria and fever.
• Physical Examination (P/E):

• Findings include localized epididymal tenderness, a swollen and tender

epididymis, or a massively swollen hemiscrotum with absent landmarks; the
cremasteric reflex should be present.
• Urine Analysis:

• May show pyuria, bacteriuria, or a positive urine culture, often indicating Gram-
negative bacteria.
• Management-

• Bed rest and activity restriction: Bed rest for 1 to 3 days, followed by relative
restriction of activities.
• Scrotal support: Scrotal elevation and the use of an athletic supporter are
recommended.
• Antibiotic therapy: Parenteral antibiotic therapy should be initiated if a Urinary
Tract Infection (UTI) is documented or suspected.
• Avoidance of urethral instrumentation: Urethral instrumentation should be
avoided
PRIAPISM
Definition:

Priapism is a persistent erection of the penis lasting over 4 hours, unrelated to

sexual desire.

Types:

It primarily occurs in two forms: ischaemic (veno-occlusive, low flow), which is

often painful and linked to diseases or drugs; and nonischaemic (arterial, high
flow), which is typically painless and caused by trauma.

Age Groups Affected:

• While it can affect any age, it is more commonly observed in 5- to 10-year-old
boys and 20- to 50-year-old men.
Causes of Priapism:

Primary (Idiopathic): Occurs in 30%-50% of cases without a known cause.

Secondary: Can be caused by various factors including:

Drugs

Trauma

Neurological conditions

Hematological diseases (e.g., sickle cell disease, leukemia)

Tumors
• Miscellaneous factors.
• Diagnosis-

• History:

• Assessing duration of erection (especially >4 hours), pain, previous episodes, and
identifying predisposing factors/underlying causes.
• Examination:

• Observing for an erect, tender penis (in low-flow priapism), rigid corpora
cavernosa with a flaccid glans, evidence of malignant disease in the abdomen,
and performing a DRE to check the prostate and anal tone.
• Investigations

• Blood tests:

• Complete Blood Count (CBC) with differential and reticulocyte count, and
Hemoglobin electrophoresis for sickle cell disease.
• Urinalysis:

• Including urine toxicology to rule out substance-induced priapism.

• Blood gases from corpora:

• To differentiate between low-flow (dark blood, acidic, hypoxic, hypercapnic) and

high-flow (bright red blood, normal pH, high oxygen, low carbon dioxide)
priapism.
Colour flow duplex ultrasonography

differentiates between ischaemic (low or absent inflow) and nonischaemic

(normal to high inflow) priapism.

Penile pudendal arteriography

• is another diagnostic method used to visualize blood flow in the penile
arteries.
Treatment approaches vary:

The treatment for priapism depends on its specific type and can involve
conservative, medical, or surgical interventions.

Underlying cause treatment:

Addressing the root cause of priapism is an essential part of the treatment strategy.

Warning about impotence:

• It is vital to inform all patients with priapism about the potential risk of impotence
as a long-term complication.
TRAUMATIC

• These involve injuries to the urological system, such as

• Renal injuries,

• Ureteral injuries,
• Bladder injuries,

• Urethral injuries, and

• Testicular injuries
RENAL INJURY
• RENAL INJURIES

• Kidneys are relatively protected from traumatic injuries.

• A significant amount of force is typically needed to cause kidney damage.

Blunt Trauma:

This includes injuries resulting from a direct blow or acceleration/deceleration

forces, such as those sustained in road traffic accidents, falls from a height, or falls
directly onto the flank.

Penetrating Trauma:
• This category encompasses injuries caused by objects penetrating the body,
including knives, gunshots, and iatrogenic causes (injuries resulting from medical
intervention), such as percutaneous nephrolithotomy (PCNL).
• Indications for Renal Imaging

• Macroscopic hematuria: and penetrating wounds to the chest, flank, or abdomen.

• Microscopic or dipstick hematuria: in a hypotensive patient (SBP <90mmHg).

• A history of rapid acceleration or deceleration injuries.

• Any child: with microscopic or dipstick hematuria following trauma.

IVU (Intravenous Urogram):

It has largely been replaced by contrast-enhanced CT scans.

An “on-table IVU” might be performed if a patient is immediately

transferred to the operating theatre without a prior CT scan and a
retroperitoneal hematoma is discovered.

Spiral CT:
• This type of CT scan is noted as not allowing for accurate staging in the
context presented.
Renal USG Advantages:

Can establish the presence of two kidneys, identify retroperitoneal hematoma, and
assess blood flow in renal vessels using power Doppler.

Renal USG Disadvantages:

Cannot accurately identify parenchymal tears, collecting system injuries, or urine extravasations
until urine has accumulated.

Contrast-enhanced CT:
• Considered the imaging study of choice due to its accuracy, speed, and ability to
image other intra-abdominal structures.
Staging System:

The severity of renal injuries is graded using the American Association for the Surgery of Trauma (AAST) Organ
Injury Severity Scale.
• Grading:

• Grade I:

• Minor degrees of ureteral dilatation, with reflux limited to the ureter.

• Grade II:

• Reflux reaches the renal pelvis, but there is no dilatation of the collecting system, and the
fornices (the cup-shaped structures in the kidney that collect urine) remain normal.
• Grade III:

• Mild to moderate dilatation of the ureter and renal pelvis, with mild blunting of the fornices.

• Grade IV:

• Moderate dilatation and tortuosity of the ureter, with moderate blunting of the fornices and
calyces.
• Grade V:

• Severe dilatation and tortuosity of the ureter, renal pelvis, and calyces, often with loss of
Conservative Management:

Applicability: Effective for over 95% of blunt injuries, 50% of renal stab injuries, and
25% of renal gunshot wounds (in specialized centers).

Interventions: Includes a wide-bore IV line, IV antibiotics, bed rest, serial CBC

(Htc), and follow-up with US and/or CT scans.
• Duration: Typically requires 2-3 weeks of conservative management.
• INDICATIONS FOR SURGICAL EXPLORATION

• Persistent bleeding: Indicated by persistent tachycardia and/or hypotension that

doesn’t respond to fluid and blood replacement.
• Expanding perirenal haematoma: Suggests ongoing bleeding around the kidney.

• Pulsatile perirenal haematoma: A strong indicator of active arterial bleeding

around the kidney.
URETERIC INJURY
URETERIC INJURIES

Ureters are protected from external trauma by surrounding bony structures,

muscles, and other organs.

Ureteric injuries are considered a “Traumatic emergency.”

• Causes and mechanisms of ureteric injuries include both external and internal
trauma
• CAUSES

• DUE TO EXTERNAL TRAUMA-

• Ureteric injuries due to external trauma are rare and require severe force.

• Injuries can be blunt or penetrating (e.g., knife or bullet wounds).

• Blunt trauma severe enough to injure the ureters is typically associated with
multiple other injuries.
• Penetrating trauma to the abdomen or chest can damage the ureters and other
organs
• DUE TO INTERNAL TRAUMA

• It is uncommon but more frequent than external trauma.

• Various surgical procedures can lead to internal trauma, including hysterectomy,

oophorectomy, sigmoidcolectomy, ureteroscopy, Caesarean section, aortoiliac
vascular graft placement, laparoscopic procedures, and orthopedic operations.
Diagnosis of Ureteric Injuries:

Requires a high index of suspicion:

This emphasizes the need for careful consideration and awareness of the possibility of ureteric injury, especially in
relevant clinical scenarios.

Intraoperative:

Diagnosis can occur during surgery.

Late signs:

Several indicators can point to a ureteric injury in the later stages:

Ileus:

The presence of urine within the peritoneal cavity can lead to an ileus (bowel obstruction).

Infection:

Prolonged postoperative fever or overt urinary sepsis can be signs of infection related to the injury.

Fluid drainage:
• Persistent drainage of fluid from abdominal or pelvic drains, surgical wounds, or the vagina may indicate a leak from the injured ureter.
Flank pain:

If the ureter has been ligated (tied off), flank pain can occur.

Urinoma:

An abdominal mass representing a urinoma (a collection of urine outside the urinary tract) can also be a late sign.

Vague abdominal pain:

Non-specific abdominal pain can also be present.

Pathology report:
• In cases where an organ has been removed, the pathology report may reveal the presence of a
ureteric segment, confirming an injury.
• MANAGEMENT OPTIONS

• Minimally invasive options: DJ stenting.

• Surgical repair of the ureter: Primary closure, direct anastomosis,

reimplantation into the bladder (ureteroneocystostomy with psoas hitch or Boari
flap), and transureteroureterostomy.
• More complex reconstructive options: Autotransplantation of the kidney,
replacement of the ureter with ileum, and permanent cutaneous ureterostomy.
• Last resort: Nephrectomy (removal of the kidney).
BLADDER TRAUMA
BLADDER TRAUMA

• Bladder injuries can result from various causes, including both traumatic and
iatrogenic events. Traumatic injuries can be blunt or penetrating, while iatrogenic
injuries often occur during surgical procedures. Common causes include pelvic
fractures, rapid deceleration injuries (like seatbelt injuries), and surgical
procedures such as transurethral resection of bladder tumors (TURBT),
cystoscopic bladder biopsies, and transurethral resection of the prostate (TURP).
Additionally, Caesarean sections, especially emergency ones, can lead to bladder
injury.
Specific Causes of Bladder Injuries:

Iatrogenic Injuries:

These are injuries that occur as a result of medical procedures. Examples include:

TURBT: Transurethral resection of bladder tumor. This procedure involves removing tissue from
the bladder using a resectoscope passed through the urethra.

Cystoscopic bladder biopsy: A procedure where a small tissue sample is taken from the
bladder for examination.

TURP: Transurethral resection of the prostate. This procedure involves removing tissue from the
prostate gland using a resectoscope.

Cystolitholapaxy: A procedure used to break up and remove bladder stones.

• Caesarean section: Particularly in emergency situations, the bladder can be injured during this
procedure.
Penetrating Trauma:

Injuries caused by objects piercing the lower abdomen or back can damage the bladder.

Blunt Trauma:

This includes:

Pelvic fractures: Fractures of the pelvic bones can cause bladder damage.

Rapid deceleration injuries: Accidents like car crashes where the bladder is full can cause
bladder rupture, even without a pelvic fracture.

Minor trauma in the inebriated patient: Blunt trauma to the lower abdomen can rupture a full
bladder in individuals who are intoxicated.

Spontaneous Rupture:
• In rare cases, the bladder can rupture after bladder augmentation surgery.
• TYPES OF PERFORATION

• Intraperitoneal

• Extraperitoneal
• Intraperitoneal rupture-

• An intraperitoneal perforation of the bladder is a traumatic emergency where a

rupture in the bladder wall, specifically involving the peritoneum, allows urine to
leak into the abdominal cavity. This type of injury is characterized by a breach in
the peritoneum (the lining of the abdominal cavity) and the bladder wall itself,
leading to the escape of urine into the peritoneal space.
Intraperitoneal vs. Extraperitoneal:

Bladder ruptures can be broadly classified as intraperitoneal (within the abdominal cavity) or
extraperitoneal (outside the abdominal cavity).

Mechanism of Injury:

Intraperitoneal bladder ruptures often result from a sudden increase in bladder pressure, such as
from a direct blow to a distended bladder, or from deceleration injuries.

Anatomy:

The peritoneum only covers the dome of the bladder, making this area more susceptible to
rupture under pressure.

Clinical Significance:
• Intraperitoneal bladder rupture can lead to peritonitis (inflammation of the abdominal lining) if
not promptly addressed, and can result in delayed diagnosis and serious complications.
• Extraperitoneal rupture

• Extra peritoneal rupture of the bladder means the peritoneum, the lining of the
abdominal cavity, remains intact. However, urine leaks out of the bladder and
collects in the space surrounding the bladder, but not into the main abdominal
cavity.
• Symptoms

• The classic triad of symptoms and signs that suggests bladder rupture,
recognized intraoperatively, includes suprapubic pain and tenderness, difficulty
or inability to pass urine, and hematuria (blood in the urine). These signs are
often present when bladder rupture occurs due to trauma, especially during
surgery.
Suprapubic pain and tenderness:

Patients will often experience pain and tenderness in the lower abdomen,
specifically in the suprapubic region where the bladder is located.

Difficulty or inability to pass urine (dysuria or anuria):

The rupture can disrupt the normal flow of urine, making it difficult or
impossible to urinate.

Hematuria:

Blood in the urine is a hallmark of bladder rupture and is often the first sign
noticed.

Other potential findings:

• While less common, patients may also present with abdominal distention, signs
Intraoperative recognition:

During surgical procedures, a bladder rupture may be suspected if there is sudden

bleeding, appearance of the bladder catheter in the wound, or urinary
extravasation (urine leaking into surrounding tissues).

Pelvic fractures:
• Blunt trauma leading to bladder rupture is often associated with pelvic
fractures, especially those involving the pubic rami,
• Management

• Extraperitoneal bladder injuries:

• Primarily managed with bladder drainage, and open repair may also be
necessary.
• Intraperitoneal bladder injuries:

• Require open repair due to several factors:

• They are unlikely to heal spontaneously.

• They typically involve large defects.

• Leakage from these injuries can lead to peritonitis.

• They are often associated with injuries to other organs.

URETHRAL INJURY
• URETHRAL INJURIES

• Anterior Urethral Injury

• Posterior Urethral Injury

• ANTERIOR URETHRAL INJURIES-

• Anterior urethral injuries are rare and can result from various mechanisms,
including:
• Straddle injuries: The most common cause, particularly in boys and men.

• Direct trauma: Injuries to the penis or penile fractures.

• Medical procedures: Improper inflation of a catheter balloon in the anterior

urethra.
• Penetrating trauma: Injuries caused by gunshot wounds.
• Signs and symptoms

• Blood at the end of the penis.

• Difficulty in passing urine.

• Frank hematuria (visible blood in urine).

• Hematoma (bruising/collection of blood) around the rupture site.

• Penile swelling.
Key diagnostic criteria using retrograde urethrography include:

Contusion:

No extravasation of contrast.

Partial rupture:

Extravasation of contrast, with contrast also present in the bladder.

Complete disruption:
• No filling of the posterior urethra or bladder
• Management

• Contusion:

• Managed with a small-gauge urethral catheter for one week.

• Partial Rupture:

• No urethral catheterization; typically managed by suprapubic urinary diversion for one

week, or immediate repair for penetrating injuries.
• Complete Rupture:

• Management depends on patient stability; unstable patients receive a suprapubic

catheter, while stable patients may have immediate repair or a suprapubic catheter.
• Penetrating Injuries:

• Generally managed by surgical debridement and repair.

• POSTERIOR URETHRAL INJURIES-

• Posterior urethral injuries are commonly associated with pelvic fractures. Key
information includes:
• The majority of these injuries are linked to pelvic fractures.

• 10% to 20% of cases also involve a bladder rupture.

• Signs of injury include blood at the meatus, gross hematuria, perineal or scrotal
bruising, and a high-riding prostate.
Classification of posterior urethral injuries in traumatic emergencies:

Type I (rare):

A stretch injury where the urethra remains intact.

Type II (25%):

A partial tear of the urethra, but some continuity is maintained.

Type III (75%):

A complete tear of the urethra with no evidence of continuity.

In women:
• Partial rupture at the anterior position is the most common urethral injury
associated with pelvic fracture.
The management of urethral injuries depends on the type of injury:

Stretch injury (Type I) and incomplete urethral tears (Type II):

These are best treated by stenting with a urethral catheter.

Type III injuries:

Patients are at varying risk of complications such as urethral stricture, urinary

incontinence, and erectile dysfunction (ED).

Initial management involves a suprapubic cystotomy.

• Primary repair is typically attempted 7 to 10 days after the injury.