Definition

Urinary tract trauma refers to an injury that occurs in one part of the urinary tract, including the kidneys, ureters, bladder, or urethra. Ureteral trauma specifically occurs when the ureter, the tube responsible for carrying urine from the kidneys to the bladder, is injured by external forces, often due to abdominal wall injury.

The ureter, segmented into upper, middle, and lower parts, is relatively lengthy. Trauma most commonly affects its lower third. Compared to other organs in the urinary system, like the kidneys, ureteral trauma is less frequent, owing to its protection by pelvic bones, muscles, and skeletal structures.

Urinary tract trauma can compromise urination, necessitating therapy to restore urinary function. Treatment approaches are tailored to the severity and location of the injury.

Causes

Ureteral trauma can result from both blunt and sharp objects in the external environment, manifesting in the following ways:

• Blunt trauma

It occurs when the abdomen sustains a forceful impact, potentially injuring the ureter. Although relatively rare, this type of injury predominantly affects the upper third of the ureter and poses a low risk of harm.

• Sharp trauma

Penetrating injuries from sharp objects like stab wounds or gunshot wounds can breach the abdominal wall, potentially affecting the ureter. The severity and location of the injury largely determine the extent of ureteral involvement.

• Falls and accidents

Falling from a height, particularly onto the genital area or side of the body, can lead to ureteral injury. Similarly, accidents such as car crashes or motorcycle accidents pose a risk of ureteral trauma.

• Medical procedures

Complications from medical interventions can also cause ureteral trauma. For instance, surgical procedures may induce scar tissue formation in the surgical area, leading to ureteral injury.

Ureteral trauma primarily arises from medical procedures and rarely from external injuries due to the ureter's robust protection by pelvic bones, the psoas muscle, and the spine. Consequently, if ureteral trauma occurs alongside abdominal injuries, it typically signifies significant trauma affecting multiple abdominal structures.

Medical procedures posing a risk of ureteral trauma often involve the abdominal or pelvic regions, including tumor removal, prior surgeries, and procedures utilizing electrocautery or cryoablation techniques.

Risk factor

Several factors can increase the risk of ureteral trauma:

• History of previous medical procedures or examinations, particularly in the abdominal or pelvic regions.
• Unsafe driving practices and involvement in accidents.
• Experience of violence targeting the abdominal or pelvic areas.

Symptoms

Ureteral trauma, which often results from medical causes, typically presents symptoms immediately following procedures. The symptoms may vary depending on the location of the injury. Common signs and symptoms include:

• Pain in the lower back, side of the body, or pelvis.
• Presence of blood in the urine, appearing red or bloody.
• Pain during urination.
• Difficulty emptying the bladder.
• Bruising on the back or sides of the body.
• Abdominal bloating and discomfort.
• In females, urine leakage from the vagina instead of the usual opening.
• Fever.

Additionally, emergency symptoms indicating potential internal bleeding include:

• Altered mental status, such as confusion.
• Elevated heart rate.
• Pale and cold skin.
• Detection of high blood pressure in cases of kidney failure.
• Loss of consciousness, progressing to coma.

Diagnosis

Medical interview

The diagnosis of ureteral trauma begins with a comprehensive medical interview conducted by the doctor. Key aspects covered in the interview include:

• Main complaints and accompanying symptoms experienced by the patient
• Patient's medical history, including any prior injuries
• History of previous surgeries or medical procedures
• Details of treatments previously received
• Family medical history.

Physical examination

Following the medical interview, the doctor proceeds with a physical examination. In external injuries from sharp objects, visible scars may be observed on the abdomen, waist, or pelvis. Conversely, injuries caused by blunt force trauma may present with scars, bruises, or swelling on the abdominal and back walls.

Diagnostic tests

If there is suspicion of internal organ injury or bleeding, additional diagnostic tests may be recommended, such as:

• Urine examination to detect blood or signs of infection.
• Blood tests to assess for anemia, clotting disorders, and kidney function.
• CT scan with contrast to visualize the ureteral passage.
• Intravenous urography or pyelography to observe urine flow from the kidneys.
• Retroperitoneal exploration procedure, often performed concurrently with therapy, to assess ureteral and organ involvement.

Management

Management or treatment for ureteral trauma is as follows:

• Emergency Care

In cases of ureteral trauma, emergency care focuses on stabilizing the patient's condition and managing symptoms. Pain relievers and fever-reducing medication may be prescribed to address discomfort and fever.

• Surgical Procedures

Surgical intervention is often necessary to diagnose and treat ureteral injuries. Open surgery is commonly performed to repair the injured ureter, with procedures tailored to the location and severity of the injury. Surgical options may include stent placement, ureteral resection and anastomosis, or even nephrectomy in severe cases. However, surgery may not be suitable for all patients, especially those with unstable conditions, advanced age, or significant comorbidities.

• Laparoscopy

Laparoscopic procedures, involving the use of minimally invasive techniques and specialized instruments, are increasingly employed for ureteral trauma, particularly in cases related to medical procedures. Laparoscopy allows for precise visualization and repair of the injured ureter, with ureter reconstruction being a common application. This approach is favored for its high success rate and reduced postoperative complications.

Complications

Complications may arise from ureteral trauma when injury management is delayed or due to the effects of treatment. One common complication is urine leakage following surgery to reconnect the ureter, which can cause symptoms such as abdominal pain, infection, abscess formation, or the development of pus pockets.

Other potential complications include ureteral stricture (narrowing), hydronephrosis (kidney swelling), formation of abnormal connections between organs (fistula), and loss of kidney function if treatment is delayed.

Prevention

Preventing ureteral trauma is often possible when the cause is iatrogenic (resulting from medical procedures or conditions). To avoid getting hurt from external injuries, it's important to steer clear of hazardous activities and practice safe driving habits. 

When to see a doctor?

If you have sustained injuries to the abdominal area and continue to experience symptoms, it is important to seek medical attention promptly. Ureteral trauma requires immediate evaluation and treatment. Regular check-ups and vigilance for signs of danger, such as decreased consciousness, cold skin, sweating, or fainting, are advised.

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