The lower urinary tract is injured in less than 1% of all firearm woun
ds in men. In war medicine, blast wounds occur in 75% of the cases whi
le in civil medicine ballistic injuries are more frequent. When the bl
adder and the posterior urethra is involved, the projectile usually fo
llows a path through the gluteal muscles and pelvis. A perineal genita
l path is usually found for injuries to the anterior urethia. This exp
lains the frequency of associated vascular and colorectal lesions in p
elvic wounds and genital injuries in perineal wounds. Bone and muscle
injuries occur in both situations. A mental reconstruction of the proj
ectile path is required for a precise diagnosis of the lesions, togeth
er with the clinical examination (urine outlet, miction impossible wit
h or without bladder extension, urethral bleeding) and most importantl
y standard x-ray of the pelvis in search of bone lesions and the proje
ctile. Urethrography should always be performed whenever the urethra i
s injured in all civil wounds. However, the final diagnosis of the les
ions can only be made at surgery. Urology procedures, usually performe
d by polyvalent surgeons, should be simple, rapid and reliable. It is
important to preserve urinary and genital functions in these young sub
jects usually under 30 years of age. Cystostomy and drainage is the st
rict minimum. In addition, depending on the infectious and hemodynamic
status, conservative excision of damaged tissue is needed prior to pr
imary closure. Wounds involving the bladder can be closed in 95% of th
e cases. Closure is simple for wounds involving the superior portion o
f the bladder. For deeper wounds involving the trigone endovesical sut
ure is used after intubing the ureters. Ureteral drainage is mandatory
when the bladder is highly damaged and cannot be closed. Urethro-pros
tato-membranous wounds should also be repaired to avoid inevitable fib
rosis of fistulization. However, access to the apex of the prostate ca
uses major bleeding and there is a risk of injuring the sphincter or e
rection nerves, particularly by surgeons inexperienced in urogenital s
urgery. When massive bleeding cannot be controlled by clamping the two
hypogastrics, symphysiotomy, rather than symphysectomy, is recommende
d. In other cases, aligning the urethral extremities may be sufficient
. Short wounds to the anterior urethra should be cleaned and the extre
mities spatulated and anastomosed on a guide when they can be closed.
In other cases, a perineal or penile urethrostomy is created. Associat
ed wounds involving the anus and rectum require colostomy, emptying th
e excluded rectum and wide pelvic-perineal drainage. An attempt should
be made to repair the rectum or the sphincter. Genital lesions requir
e early repair : tight suture of the albuginea of the cavernous bodies
with or without a patch, preservation of viable testicular parenchyma
and adnexal tissues (but orchidectomy is necessary in 50% of the case
s).