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!

• 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
• Who to image?
  • Penetrating trauma
  • Blunt trauma with gross hematuria
  • Blunt trauma with microscopic hematuria (>5 rbc/HPF) and hemodynamic instability
  • High-energy deceleration mechanism or suspected associated intra-abdominal injuries
• Disposition
  • 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
• Extraperitoneal
• Assoc w/ pelvic fx and laceration by bony fragments
• Leakage of urine into perivesicular space
• Intraperitoneal
• Assoc w/ compresive force in presence of full bladder
• 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

Reference: Harwood-Nuss