Genitourinary trauma: Difference between revisions
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==Upper Tract Injuries (kidney + ureter)==
==Upper Tract Injuries (kidney + ureter)==
*Majority of blunt trauma injuries present w/ hematuria
*Majority of blunt trauma injuries present w/ 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


===AAST Grading System for renal injuries===
===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
*Non-operative management
**Grade I: Cortex contusion
**Grade I: Cortex contusion
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**Grade V: Shattered kidney, thrombosis of renal artery, avulsion of hilum
**Grade V: Shattered kidney, thrombosis of renal artery, avulsion of hilum


===Diagnosis===
====Treatment====
Who to image?
*Absolute indications for renal exploration and intervention:
#Penetrating trauma
**Life-threatening hemorrhage
#Blunt trauma with gross hematuria
**Expanding, pulsatile, or non-contained retroperitoneal hematoma
#Blunt trauma with microscopic hematuria (>5 rbc/HPF) and hemodynamic instability
**Renal avulsion injury
#High-energy deceleration mechanism or suspected associated intra-abdominal injuries
 
====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


===Disposition===
====Management====
Majority of blunt renal injuries and all penetrating renal injuries require admission
*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)==
==Lower Tract Injuries (bladder + urethra + genitalia)==
*Often accompany pelvic fracture
*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 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
*Bladder Rupture
**Extraperitoneal
**Extraperitoneal
***Assoc w/ pelvic fx and laceration by bony fragments
***Assoc w/ pelvic fx and laceration by bony fragments
***Leakage of urine into perivesicular space
***Leakage of urine into perivesicular space
***"Tear drop" shape on imaging
**Intraperitoneal
**Intraperitoneal
***Assoc w/ compresive force in presence of full bladder
***Assoc w/ compresive force in presence of full bladder
**Pelvic fracture + gross hematuria = bladder rupture!
====Management====
*Fewer than 1% of all blunt bladder injuries present with urinalysis w/ <25 RBCs/HPF
*Imaging
*Signs: blood at meatus, inability to void, suprapubic pain
**Retrograde cystogram (CT or plain film) indicated for:
*Management
**Gross hematuria
**Bladder drainage via foley cather
**Diagnosic w/u indicated for patients with:
***Gross hematuria
***Inability to void
***Inability to void
***Pelvic ring fx in assoc w/ microscopic hematuria
***Pelvic fx in assoc w/ microscopic hematuria
*Retrograde cystography
***Clinical suspicion of bladder injury
**A "tear drop" shape suggests extraperitoneal bladder rupture
**CT A/P w/ IV contrast NOT sensitive enough for bladder rupture
*A routine abd/pelvis CT is not sensitive for bladder rupture!
*Treatment
**Need retrograde contrast
**Extraperitoneal rupture - nonoperative management with bladder cathether drainage
*Extraperitoneal rupture - nonoperative management with simple urinary drainage
**Intraperitoneal rupture - primary surgical repair
*Intraperitoneal rupture - primary surgical repair
 
*External Genitalia Injury
===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
=====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===
**Perform speculum examination when veginal hemorrhage or hematoma is present to exclude vaginal laceration
 
**If suspect testicular injury obtain ultrasound
**If suspect testicular injury obtain ultrasound
**Any pt with external genitialia trauma w/ hematuria, urinary retention or dysuria requires a retrograde urethrogram
**Any pt with external genitialia trauma w/ hematuria, urinary retention or dysuria requires a retrograde urethrogram
===Treatment===
Urinary extravasation alone is not an indication for exploration as it resolves spontaneously in the majority of cases. However, extravasation from a renal pelvis or ureteral injury does require repair.


==Source==
==Source==

Revision as of 21:07, 19 July 2011

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
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

    • Perform speculum examination when veginal hemorrhage or hematoma is present to exclude vaginal laceration
    • If suspect testicular injury obtain ultrasound
    • Any pt with external genitialia trauma w/ hematuria, urinary retention or dysuria requires a retrograde urethrogram

Treatment

Urinary extravasation alone is not an indication for exploration as it resolves spontaneously in the majority of cases. However, extravasation from a renal pelvis or ureteral injury does require repair.



Source

Harwood-Nuss

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