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:
- Hemodynamic instability
- Expanding \ pulsatile perirenal mass
- Injury to renal pelvis \ pedicle \ UPJ
Indications for angio-embolization:
- Bleeding from segmental renal artery
- Unstable pts + grade III, IV
- AV fistula
- Pseudo aneurysm
- Persistent gross hematuria
- Loss of > 2 units of blood \ 24 hrs
Complications:Â
- 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
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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