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

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)

 

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

 

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

 

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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

 

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Download the PDF version: here

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References:

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