Lower urinary tract injuries (bladder and ureter) accompany <2% of hysterectomies, with bladder injuries outnumbering ureteral injuries five to one (1). Ureteral injuries can result from devascularization, crushing, ligation, or transection and, most commonly, occur at the time of abdominal or laparoscopic hysterectomy (2). Although ureteral injury is a rare occurrence, many injuries are not recognized at the time of initial surgery and present as delayed complications with infection, hydronephrosis, urinoma with subsequent ileus, ureterovaginal fistulas, or silent kidney death. In cases of unilateral ureteral obstruction, patients may present with abdominal and flank pain, fever, and leukocytosis. An ultrasound or intravenous pyelogram showing a dilated renal collecting system will suggest the diagnosis, while cystoscopy with retrograde dye studies will confirm it. If the ureter has been transected, the patient can present with abdominal distention, nausea, vomiting, ileus, or clear vaginal discharge suggestive of a ureterovaginal fistula. Cystoscopy with retrograde ureteral stent placement, ureteroscopy, or percutaneous nephrostomy with antegrade stent placement aided by a fluoroscopic dye study will help localize the site of transection (3). Computed tomography with intravenous contrast material is helpful in assessing an intra-abdominal or retroperitoneal process that may be involved in extrinsic ureteral obstruction or compression. After localization of the ureteral leak or site of obstruction, placement of a percutaneous nephrostomy drainage or transvesical ureteral stenting allows for nonoperative diversion and salvage of the remaining renal function. Complete transections of the ureter require definitive repair (ureteroneocystostomy or bladder reimplantation of the ureter, ureteroureterostomy or end-to-end anastomosis, and bladder mobilization and extension). The choice of method is based on the location of the injured ureteral segment.

In cases when a urinary tract fistula is suspected, the emergency room (ER) provider can utilize the “tampon test” to aid in the diagnosis. This test can also help differentiate between a ureterovaginal and a vesicovaginal fistula. The bladder is filled with 250 mL of indigo carmine-dyed water or saline, and the vagina is inspected for leakage. If no leakage is visualized but the suspicion of a fistula remains high, a tampon can be placed into the vagina, and the patient is then instructed to ambulate for a minimum of 15 to 30 minutes. Observation of the blue dye on the tampon suggests vesicovaginal fistula which can be confirmed with cystoscopy. The presence of nondyed urine in the vagina suggests ureterovaginal fistula. The appearance of a ureterovaginal fistula is usually preceded by a pyelitis, including history of fever spikes and unilateral costovertebral angle tenderness. Intravenous pyelogram and ureteroscopy are diagnostic.

Only physicians with expertise should repair complex ureterovaginal or ureterovesicovaginal fistulas. Vesicovaginal fistulas are amenable to transvaginal repair, while ureterovesicovaginal fistulas require transabdominal or endoscopic
surgery with ureteral reimplantation and omental graft superimposition (4). The role of the ER physician is to recognize the possible symptoms of ureteral injury in a patient who has undergone pelvic surgery which may include abdominal distention with ileus and urine ascites; fever, chills, and flank pain; oliguria, pyuria, or hematuria; pyelonephritis or a urinary tract infection not responding to appropriate antibiotics; and a ureterovaginal fistula with continuous vaginal discharge. Treatment for an underlying infection as well as appropriate and prompt urologic consultation is necessary to avoid further loss of kidney function.

While many pelvic surgeries can lead to acute or subacute urinary retention, urogynecologic procedures, in particular anti-incontinence operations, have the highest incidence of this complication. Patients with urinary retention typically present to the ER with complaints of incomplete bladder emptying, poor urinary stream, dribbling or lower abdominal pain, and bladder distention. These symptoms usually occur in the first few days after the surgery, even though the patient may have documented normal voiding trials and post-void residual volumes. The ER provider must recognize this condition and should attempt to decompress the bladder with a transurethral catheter. An expeditious bladder decompression is necessary to prevent over-distention injury to the bladder. Urinalysis and cultures should be obtained when indicated. In rare instances, such as in the case of an overcorrected repair, a transurethral catheter cannot be passed, and the urologic service should be consulted for cystourethroscopic evaluation and possible suprapubic catheter placement. Transurethral catheters should be placed with caution especially with those who have undergone primary urethral surgery. Medications such as α-agonists and anticholinergics can aggravate urinary retention and should be discontinued when possible. In cases of mechanical obstruction, further surgical intervention to include urethrolysis or revision of a suburethral sling may be indicated. Patients with incomplete bladder emptying following urogynecologic surgery should be taught intermittent self-catheterization to avoid complications such as recurrent urinary tract infections and upper urinary tract damage.

Urethral caruncles, small polyps of urethral mucosa protruding through the meatus, are seen almost exclusively in postmenopausal females, whereas urethral prolapse, defined as an eversion of the urethral mucosa through the external meatus, can be found in both postmenopausal women as well as young girls. The two urethral pathologies may be difficult to distinguish from one another. They commonly present with irritative voiding symptoms. Furthermore, it is not uncommon for urethral prolapse to present with vaginal bleeding. Classically, urethral prolapse is described as a fleshy erythematous mass of tissue surrounding the meatus. It occurs in the setting of vaginal atrophy and may be related to repeated straining, trauma, the placement of periurethral bulking agents, or, rarely, urethral tumors (5). Urethral caruncles, in contrast, are focal and not circumferential. The primary treatment for both is topical estrogen cream. The ER provider must ensure that the patient is not obstructed, in which case a transurethral catheter needs to be placed. If the urethral mucosa appears ischemic due to strangulation or thrombosis is noted, then resection of exposed urethral mucosa may be indicated and urologic consultation is recommended.

Vaginal evisceration is a rare but serious condition. It has been reported to occur following trauma from intercourse, obstetrical tears, foreign bodies, and vaginal surgery. Most commonly, evisceration will occur following hysterectomy in patients with prolapse, enteroceles, urogenital atrophy, and history of radiation therapy (6). Other predisposing factors include a vaginal cuff left open at the time of hysterectomy and cuff cellulitis or hematoma (7). The distal ileum is most commonly involved in vaginal evisceration (8).

When the patient presents with vaginal evisceration in the ER, the bowel should be wrapped in sterile gauze soaked in saline, and an immediate surgical consultation should be made. Prompt and appropriate surgical intervention is necessary to prevent mortality, which can occur in 6% to 10% of cases due to septicemia and thromboembolism. In general, emergent laparotomy with inspection of the bowel and resection of any compromised areas with reanastomosis is recommended (9

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