Urogenital Trauma

Renal Injury:

  • Blunt (80%), penetrating (20%)
  • Hematuria: best indicator of injury, but doesn’t correlate w\ severity
  • Presentation: flank pain\ecchymosis, rib fracture, shock

Imaging:

  • CT + IV contrast: gold standard!
  • IVP: high dose, single-shot -> mainly for pts in shock going to OR (no time for CT) -> to make sure the presence of both kidneys, if you’re planning to do nephrectomy
  • US: not for injury grading
  • Angio: rarely used, may be used for management (angio-embolization)

Management:

  • I, II, III -> conservative; bed rest, hydration, Foley, serial HCT\Hgb, periodic imaging
  • Operative management: early control of vessels is key, renal reconstruction, urinary diversion\nephrostomy, drainage of urinoma\abscess (+ Abx), nephrectomy

Urological trauma 2

Indications for OR:

  1. Hemodynamic instability
  2. Expanding \ pulsatile perirenal mass
  3. Injury to renal pelvis \ pedicle \ UPJ

Indications for angio-embolization:

  1. Bleeding from segmental renal artery
  2. Unstable pts + grade III, IV
  3. AV fistula
  4. Pseudo aneurysm
  5. Persistent gross hematuria
  6. Loss of > 2 units of blood \ 24 hrs

Complications: 

  • Renal artery stenosis, AV fistula, Page kidney (hematoma and scarring -> compression of the kidney -> renin secretion) -> HYPERTENSION (give ACEI)

Urological trauma 3

 

Ureteral Injury:

  • Usual scenario: penetrating trauma + multiple associated injuries
  • Most commonly is iatrogenic
  • Not necessarily presenting w\ hematuria

Imaging:

  • CT w\ delayed imaging: shows extravasation \ periureteral urinoma
  • Retrograde pyelogram: most sensitive
  • Intra-op: injection of methylene blue into the renal pelvis

Management: all repair is done over a stent

  • Upper -> direct uretero-uretero-stomy, trans uretero-uretero-stomy, auto-transplantation
  • Mid -> uretero-uretero-stomy, trans uretero-uretero-stomy
  • Lower -> reimplantation into the bladder, psoas hitch, Boari bladder flap

 

Bladder Injury:

  • Most commnly associated w\ blunt trauma + pelvic fractures, or iatrogenic (TURP, TURBT)
    • Most bladder injuries are associated w\ pelvic fractures, but not all pelvic fractures cause bladder injury
  • Presentation: hematuria (common), peritonitis (if ruptured)

Imaging:

  • Cystogram
  • CT cystogram

Urological trauma 5

 

Urethral Injury:

  • Mostly posterior urethra (prostatic + membranous) w\ blunt trauma
  • Anterior urethra (bulbous + penile) w\ straddle or penetrating trauma
  • Presentation: blood at uretheral meatus*, high-riding\boggy prostate*, scrotal\”butterfly” perineal hematoma*, urine retention, palpable full bladder. (*Contraindication to cath)

Imaging:

  • Retrograde urethrogram: showing extravasation

Management:

  • Suprapubic cath
    • If incomplete urethral tear -> attempt gentle cath (not to convert to complete transection)
    • If female -> primary repair (bc there’s usually concomitant vaginal injury)
    • If male -> delayed repair (urethroplasty) after 3-6 months, allows fibrosis and scar tissue to develop (after doing cystogram and repeating retrograde urethrogram)

 

Testicular Injury:

  • Usually w\ blunt trauma: hematoma, pain, N\V

Imaging:

  • US: to check hematoma vs testicular injury

Management:

  • If blunt trauma:
    • If hematoma -> conservative; scrotal support
    • If testicular rupture -> surgical exploration; either repair of the tunica albuginea + removal of devitalized testicular tissue + hematoma evacuation OR perform orchiectomy
  • If penetrating trauma -> surgical exploration immediately!

 

Penile Injury:

  • Usually blunt trauma to erect penis, during intercourse
  • Sx: pain, ecchymosis, hematuria, “popping sound”

Management:

  • Immediate surgical repair

 


General Approach to Urogenital Trauma

1) Start w\ the “ABCDE” and stabilize the pt

  • In “B” -> check the ribs; pt might have a rib fracture (leading to renal injury)
  • Do CXR and pelvic X-ray
  • Do FAST to check for hemorrhage

2) Otherwise; take history:

  • Ask about mechanism of injury, abdominal pain, gross hematuria, urine retension, fever, N\V, PMHx (urogenital ds, malignancy), Hx of urinary instrumentation

3) Physical exam:

  • Vital signs: signs of shock
  • Abdominal exam: any peritoneal signs, flank mass, palpable bladder
  • DRE: blood PR, sphincter tone, high-riding prostate
  • Genital exam: testicular swelling, scrotal\perineal hematoma, ecchymosis, blood at meatus

4) Labs:

  • CBC: check HCT\Hgb
  • BMP: check electrolytes and kidney function
  • UA: check presence of microscopic hematuria, pyuria

5) If no signs of uretheral injury -> place cath

  • If you encounter resistance -> might be a urethral injury -> pull back and do RUG + place a suprapubic cath instead

6) And then, based on the suspected organ injury -> image and manage accordingly

 


Download the PDF version: here


References:

  • Dr Alghazwani’s lecture
  • Dr Alkhayal’s clinical notes
  • The Washington’s Manual of Surgery

 

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