Genitourinary trauma: Difference between revisions

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==Upper Tract Injuries (kidney + ureter)==
==Background==
*Majority of blunt trauma injuries present w/ hematuria
[[File:Urinary system.png|thumb|'''(1) Human urinary system:''' (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra. <Br>'''Additional structures:''' (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.]]
*Renal pedicle injuries and penetrating injuries to ureter may not cause hematuria!
[[File:Blausen 0592 KidneyAnatomy 01.png|thumb|Renal anatomy.]]
[[File:PMC5265200 13244 2016 536 Fig1 HTML.png|thumb|Perinephric space with exaggerated pararenal space to show retroperitoneal structures. Perinephric bridging septa are seen between the left kidney and the adjacent renal fascia.]]
*Typically divided into:
**Upper tract injuries (kidney + ureter)
**Lower tract Injuries (bladder + urethra + genitalia)


===AAST Grading System for renal injuries==
==Clinical Features==
*Non-operative management
===Upper tract injury===
**Grade I: Cortex contusion
*Majority of blunt trauma injuries present with [[hematuria]]
**Grade II: Cortex laceration
*Renal pedicle injuries and penetrating injuries to ureter may not cause hematuria
*Possible operative management
*Renal injuries are associated with flank hematoma, lower rib fracture, penetrating wounds to flanks
**Grade III: Corticomedullary junction laceration
 
***Grade IV: Collecting system laceration
===Lower tract injury===
*Operative management
*Often accompanied by signs of [[pelvic fracture]]
**Grade V: Shattered kidney, thrombosis of renal artery, avulsion of hilum
 
==Differential Diagnosis==
{{Lower GU trauma DDX}}
{{Abdominal trauma DDX}}
 
==Evaluation==
===Workup===
*Who to image?
**Penetrating Trauma
***Any degree of hematuria
**Blunt Trauma
***Gross hematuria
***[[Hypotension]] and any degree of hematuria
***Child with >50rbc/HPF
***High index of suspicion for renal trauma
****Deceleration injuries even with no hematuria
****Multiple trauma patient


===Diagnosis===
===Diagnosis===
Who to image?
*CT with IV contrast is the gold standard in assessing renal and GU trauma
#Penetrating trauma
**More sensitive and specific than IVP, ultrasound, or angiography
#Blunt trauma with gross hematuria
**However, can miss significant injuries to the renal pelvis, collecting system and ureter given CT generally obtained before contrast is excreted in the urine.
#Blunt trauma with microscopic hematuria (>5 rbc/HPF) and hemodynamic instability
**If initial CT shows high grade renal injury (grade IV of V), UPJ injury, or concern for ureteral injury, should obtain additional 10 minute delayed CT<ref>Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335.</ref><ref>33.* Holevar M, DiGiacomo C, Ebert J, et al. Practice management guidelines for the evaluation of genitourinary trauma. </ref>
#High-energy deceleration mechanism or suspected associated intra-abdominal injuries
**Exception to using IVP over CT is perioperatively in unstable patients requiring immediate operation for other injuries
**Note, CT A/P with IV contrast NOT sensitive enough for [[bladder trauma|bladder rupture]], requires CT cystography


===Disposition===
==Management==
Majority of blunt renal injuries and all penetrating renal injuries require admission


==Lower Tract Injuries (bladder + urethra + genitalia)==
*Often accompany pelvic fracture
*Urethral Injuries
**Anterior: Self-instrumentation, falls, straddle injuries
**Posterior: Accompany pelvic fx
*Perform pelvic exam in all women with pelvic fractures!
*Signs: Blood at meatus, high prostate, difficulty voiding
*Management
**Presence of urethral injury should be ruled out prior to foley insertion!
**Retrograde urethogram
**Suprapubic cystotomy to allow drainage of bladder


*Bladder Rupture
==Disposition==
**Extraperitoneal
 
***Assoc w/ pelvic fx and laceration by bony fragments
==See Also==
***Leakage of urine into perivesicular space
*[[Traumatic Foley Catheter Removal]]
**Intraperitoneal
*[[Abdominal trauma]]
***Assoc w/ compresive force in presence of full bladder
*[[Trauma (main)]]
**Pelvic fracture + gross hematuria = bladder rupture!
*Fewer than 1% of all blunt bladder injuries present with urinalysis w/ <25 RBCs/HPF
*Signs: blood at meatus, inability to void, suprapubic pain
*Management
**Bladder drainage via foley cather
**Diagnosic w/u indicated for patients with:
***Gross hematuria
***Inability to void
***Pelvic ring fx in assoc w/ microscopic hematuria
*Retrograde cystography
**A "tear drop" shape suggests extraperitoneal bladder rupture
*A routine abd/pelvis CT is not sensitive for bladder rupture!
**Need retrograde contrast
*Extraperitoneal rupture - nonoperative management with simple urinary drainage
*Intraperitoneal rupture - primary surgical repair
*External Genitalia Injury
**If suspect testicular injury obtain ultrasound
**Any pt with external genitialia trauma w/ hematuria, urinary retention or dysuria requires a retrograde urethrogram


==Source==
==External Links==
Harwood-Nuss


==References==
<references/>
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:GU]]
[[Category:Urology]]

Latest revision as of 17:16, 3 May 2023

Background

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.
Renal anatomy.
Perinephric space with exaggerated pararenal space to show retroperitoneal structures. Perinephric bridging septa are seen between the left kidney and the adjacent renal fascia.
  • Typically divided into:
    • Upper tract injuries (kidney + ureter)
    • Lower tract Injuries (bladder + urethra + genitalia)

Clinical Features

Upper tract injury

  • Majority of blunt trauma injuries present with hematuria
  • Renal pedicle injuries and penetrating injuries to ureter may not cause hematuria
  • Renal injuries are associated with flank hematoma, lower rib fracture, penetrating wounds to flanks

Lower tract injury

Differential Diagnosis

Genitourinary Trauma

Abdominal Trauma

Evaluation

Workup

  • Who to image?
    • Penetrating Trauma
      • Any degree of hematuria
    • Blunt Trauma
      • Gross hematuria
      • Hypotension and any degree of hematuria
      • Child with >50rbc/HPF
      • High index of suspicion for renal trauma
        • Deceleration injuries even with no hematuria
        • Multiple trauma patient

Diagnosis

  • CT with IV contrast is the gold standard in assessing renal and GU trauma
    • More sensitive and specific than IVP, ultrasound, or angiography
    • However, can miss significant injuries to the renal pelvis, collecting system and ureter given CT generally obtained before contrast is excreted in the urine.
    • If initial CT shows high grade renal injury (grade IV of V), UPJ injury, or concern for ureteral injury, should obtain additional 10 minute delayed CT[1][2]
    • Exception to using IVP over CT is perioperatively in unstable patients requiring immediate operation for other injuries
    • Note, CT A/P with IV contrast NOT sensitive enough for bladder rupture, requires CT cystography

Management

Disposition

See Also

External Links

References

  1. ↑ Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335.
  2. ↑ 33.* Holevar M, DiGiacomo C, Ebert J, et al. Practice management guidelines for the evaluation of genitourinary trauma.
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