Genitourinary trauma

Upper Tract Injuries (kidney + ureter)

• Majority of blunt trauma injuries present w/ hematuria
• Renal pedicle injuries and penetrating injuries to ureter may not cause hematuria
• Renal injuries are a/w flank hematoma, lower rib fx, penetrating wounds to flanks

Diagnosis

• 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 pt

Renal Injuries

AAST Grading System for renal injuries

• Non-operative management
  • Grade I: Cortex contusion
  • Grade II: Cortex laceration
• Possible operative management
  • Grade III: Corticomedullary junction laceration
    • Grade IV: Collecting system laceration
• Operative management
  • Grade V: Shattered kidney, thrombosis of renal artery, avulsion of hilum

Treatment

• Absolute indications for renal exploration and intervention:
  • Life-threatening hemorrhage
  • Expanding, pulsatile, or non-contained retroperitoneal hematoma
  • Renal avulsion injury

Disposition

• Admit
  • All penetrating renal injuries
  • All gross hematuria
  • All grade II and higher injuries
• Discharge
  • Microscopic hematuria and no indication for imaging
  • Isolated renal trauma and contusion-type grade I injury
    • Instruct no heavy lifting; f/u in 1-2wk to document resolution of the hematuria
  • Grade I subcapsular hematoma can d/c'd w/ 24hr f/u

Ureter Injuries

• 90% of injuries occur from penetrating injury
• Isolated ureter injury is rare
• Absence of hematuria does NOT rule out ureteral injury

Management

• If CT is nondiagnostic but high index of suspicion perform IV urography or retrograde pyelography
• Treatment
  • Surgery
• Disposition
  • Admit

Lower Tract Injuries (bladder + urethra + genitalia)

• Often accompany pelvic fracture

Bladder Injury

Presentation

• Suprapubic pain, blood at meatus, inability to void
• Gross hematuria is present in 95% of significant bladder injuries
  • Pelvic fracture + gross hematuria = bladder rupture
  • <1% of all blunt bladder injuries p/w UA w/ <25 RBCs/HPF
• Bladder Rupture
  • Extraperitoneal
    • Assoc w/ pelvic fx and laceration by bony fragments
    • Leakage of urine into perivesicular space
    • "Tear drop" shape on imaging
  • Intraperitoneal
    • Assoc w/ compresive force in presence of full bladder

Management

• Imaging
  • Retrograde cystogram (CT or plain film) indicated for:
  • Gross hematuria
    • Inability to void
    • Pelvic fx in assoc w/ microscopic hematuria
    • Clinical suspicion of bladder injury
  • CT A/P w/ IV contrast NOT sensitive enough for bladder rupture
• Treatment
  • Extraperitoneal rupture - nonoperative management with bladder cathether drainage
  • Intraperitoneal rupture - primary surgical repair

Urethral Injury

Types

• Anterior
  • Located anterior to the membranous urethra
  • Straddle injuries, self-instrumentation
• Posterior
  • Located in the membranous and prostatic urethra
  • Due to blunt trauma from massive deceleration
  • Often accompanies pelvic fx

Presentation

• Hematuria, dysuria, inability to void, blood at meatus
• Vaginal bleeding
• Perineal hematoma
• High-riding or detached prostate
  • Associated w/ complete posterior urethral disruption

Management

Imaging

• Retrograde urethrogram
  • Must perform before catheterization to prevent further urethral injury
  • 60 mL of water soluble contrast in toomey syringe
  • Inject into urethra, shoot KUB during last 10 mL
  • No bladder filling with extravasation - complete tear
  • Bladder filling with extravasation - partial tear

Treatment

• • Posterior urethral injury
    • Suprapubic cathether placement
    • Surgery is usually performed weeks later
  • Anterior urethral injury
    • Penetrating injuries require surgical exploration and repair

Genitalia Injury

Testicular Injury

• Presentation
  • Blunt trauma due to impingement against symphysis pubis
    • Will have contusion or rupture based on whether tunica albuginea is disrupted
    • Large, blue, tender scrotal mass (hematocele),
• Imaging
  • Scrotal ultrasound required for all blunt testicular injuries
    • Reliable in diagnosing ruptured testes
• Treatment
  • Most testicular injuries are managed conservatively
    • Analgesia, ice, elevation, scrotal support, urology f/u
  • Tesicular rupture requires early surgical intervention

Penile Injury

• General
  • Any pt w/ trauma to genitalia w/ a prothesis in place should be seen by a urologist
  • All penetrating trauma to the penis requires surgical consultation
  • Avulsed penile skin should not be reapplied (invariably becomes necrotic and infected)
• Penile fracture
  • Results from rupture of corpus cavernosum
    • Cracking sound followed by pain, detumescence, swelling, discoloration, deformity
  • Obtain retrograde urethrogram to r/o urethral injury
  • Requires operative removal of blood cut and repair of tunica albuginea
• Penile contusion
  • Treat conversevely ice, rest, elevation, foley placement if pt unable to void
• Zipper Injury
  • Mineral oil and lidocaine infiltration can be used to free the penile skin
  • Wire-cutting or bone-cutting pliers can be used to cut the median bar of the zipper
• Traumatic epididymitis
  • Noninfectious inflammatory condition that occurs w/in few days after trauma to testis
    • Treatment is similar to that for nontraumatic epididymitis

Vaginal Injury

• Perform speculum examination when vaginal hemorrhage or hematoma is present to exclude vaginal laceration

Source

Tintinalli