Ureteral Injury Algorithm

Based on Woodle et al., Genitourinary Trauma: What You Need to Know (J Trauma Acute Care Surg, 2026)

1 step

A: Suspected Ureteral Injury

Start

Ureteral injuries are uncommon and easily missed. Suspect with penetrating trauma to the flank, back, or abdomen (especially gunshot wounds with a transpelvic or retroperitoneal trajectory), high-energy blunt mechanisms with deceleration, or associated renal injury. Hematuria is an UNRELIABLE sign — it is absent in a substantial proportion of ureteral injuries.

Clinical Note

Delayed diagnosis is the principal hazard: missed injuries present days later with fever, flank pain, ileus, urinoma, or urine leaking from the wound. Maintain a high index of suspicion based on mechanism and trajectory.