Genitourinary Trauma

Dr. Andrew McDonaldSept. 19, 2006

Group B rounds presentation

Goals

• Interactive discussion of GU trauma cases

• Review relevant anatomy and epidemiology as needed

• Review current diagnostic and management approaches

Learning objectives• When to suspect GU injury?• Significance of hematuria or pelvic #?• When to withhold a Foley catheter?• When to do a cystogram/CT cystogram?• Is CT grading of renal injuries helpful?• What are the management strategies

and when to call Urology?• How do we approach penetrating GU

trauma?

Case 1

• 21 year old man ejected from a car at high speed

• Hypotension at scene improves with fluids

• Has mild abdominal tenderness with left flank abrasions

• Does he likely have a GU injury?

Case 1 Epidemiology

• ~4% of trauma centre pts have GU injury

• 80% renal, 10% bladder, 10% other

• 72% minor, 17%moderate, 11% major

• 90+% conservative management

Case 1 Index of Suspicion

• Hx – deceleration injuries, abd blunt trauma, “straddle” injury

• Px – flank tenderness/bruising/abrasion, lower rib injury, abd tenderness, perineal hematoma, meatal blood, abn rectal exam

Case 1 Basic Investigations

• Pelvic xray

– ~90% bladder rupture have a pelvic fracture– 10% of pelvic fracture have bladder injury

– Anterior pelvic fracture think of post urethral injury

Case 1 Basic Investigations

• Urinalysis– Mee, S. J. Urology 141:1095 1989– All significant renal injuries had gross

hematuria OR microhematuria and hypotension

– Degree of hematuria not correlated to injury– Blunt trauma with shock usually get CT abd– We have stopped dipping urines

Case 1

• Pelvis xray– Stable pelvic fracture

• Catheter urine– Gross hematuria

• Further investigate?

Case 1 Renal Grading on CT

• I -contusion/subcapsular hematoma

• II -small cortical laceration/non- expanding retroperitoneal hematoma

• III -laceration >1cm or extravasation

• IV -laceration down to collecting system or vascular injury

• V -shattered kidney/avulsed hilum

Renal laceration

Case 1 Management

• Surgery for

– Ongoing hemorrhage– Major laceration/shattered kidney– Vascular pedicle injury

• Avoid contrast if going for CT if possible

Case 2• 44 year old man pedestrian struck and

thrown 10m

• Brief LOC, arm fractures, pain in pelvic area

• Prostate exam normal, pubic rami fractures

• Does he likely have a GU injury?

Case 2 Index of Suspicion

• Hx– Straddle or direct penile trauma– Pelvic pain or fracture

• Px– Perineal hematoma– Blood at meatus– Abnormal rectal exam

Case 2 Urethrogram

• Technique

• Problems – relate to dye

• Options if abnormal– One attempt if “channel” exists– Insert suprapubic catheter – Call Urology for suprapubic catheter

Urethrogram techniques

Case 2 Urethral injuries

• Posterior (75%) with pelvic fractures

• Anterior (25%) with straddle injury

• Penetrating

• Women (rare)

Urethrogram

Urethrogram

Urethrogram

Urethrogram

Case 2 Bladder injuries

• Intraperitoneal (20%)

• Extraperitoneal (80%)

• 95-100% have gross hematuria

• Presence of pelvic fracture not helpful in deciding whom to investigate

Case 2 Cystogram

• Plain cystogram– Technique– Advantages and Problems

• CT cystogram– Technique– Advantages

• Sequencing of tests

Cystogram

Cystogram

CT cystogram

CT cystogram

CT cystogram

Case 2 Management

• Surgical repair

– Intraperitoneal bladder rupture– Some Urethral repairs

Case 3

• 30 year old woman stabbed to flank and lower abdomen

• Hemodynamically stable

• Catheterized for clear urine

• Does she likely have a GU injury?

Case 3

• Need to also consider ureter injury

• Hematuria correlates poorly in penetrating GU injury

• Higher proportion go to operative repair

• Decision to work up based on anatomy and index of suspicion

Case 3

• Needs renal/ureter test e.g. CT/IVP

• Needs cystogram

• Low threshold for Urology referral

Other injuries

• Penis– Penetrating, skin avulsion and amputation

repaired surgically– “fracture” repaired and drained surgically

• Scrotum/testes– Hematocele and contusion (mild) or

rupture (severe, needs exploration)– Penetrating injuries need exploration

Pediatric trauma

• Low threshold for CT in blunt abd trauma due to difficult exam

• Don’t work up microscopic hematuria alone if reliable

Mgt Summary

• Urology consultation for– Ongoing renal hemorrhage– Major renal laceration/vascular inj on CT– Penetrating renal/ureteral trauma– Intraperitoneal bladder rupture– Urethral injury– Penile reconstruction/fracture– Testicular rupture

Learning objectives• When to suspect GU injury?• Significance of hematuria or pelvic #?• When to withhold a Foley catheter?• When to do a cystogram/CT cystogram?• Is CT grading of renal injuries helpful?• What are the management strategies

and when to call Urology?• How do we approach penetrating GU

trauma?