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.]]
[[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)
 
==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 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
*Renal injuries are associated with flank hematoma, lower rib fracture, penetrating wounds to flanks


===Diagnosis===
===Lower tract injury===
*Often accompanied by signs of [[pelvic fracture]]
 
==Differential Diagnosis==
{{Lower GU trauma DDX}}
{{Abdominal trauma DDX}}
 
==Evaluation==
===Workup===
*Who to image?
*Who to image?
**Penetrating Trauma
**Penetrating Trauma
Line 10: Line 27:
**Blunt Trauma
**Blunt Trauma
***Gross hematuria
***Gross hematuria
***Hypotension and any degree of hematuria
***[[Hypotension]] and any degree of hematuria
***Child with >50rbc/HPF
***Child with >50rbc/HPF
***High index of suspicion for renal trauma
***High index of suspicion for renal trauma
****Deceleration injuries even with no hematuria
****Deceleration injuries even with no hematuria
****Multiple trauma pt
****Multiple trauma patient


===[[Renal Injuries]]===
===Diagnosis===
===Ureter Injuries===
*CT with IV contrast is the gold standard in assessing renal and GU trauma
*90% of injuries occur from penetrating injury
**More sensitive and specific than IVP, ultrasound, or angiography
*Isolated ureter injury is rare
**However, can miss significant injuries to the renal pelvis, collecting system and ureter given CT generally obtained before contrast is excreted in the urine.
*Absence of hematuria does NOT rule out ureteral injury
**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>
 
**Exception to using IVP over CT is perioperatively in unstable patients requiring immediate operation for other injuries
====Management====
**Note, CT A/P with IV contrast NOT sensitive enough for [[bladder trauma|bladder rupture]], requires CT cystography
*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=====
==Management==
**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====
==Disposition==
*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====
==See Also==
*Perform speculum examination when vaginal hemorrhage or hematoma is present to exclude vaginal laceration
*[[Traumatic Foley Catheter Removal]]
*[[Abdominal trauma]]
*[[Trauma (main)]]


==Source==
==External Links==
Tintinalli


==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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