IN THE NAME OF GOD

Genitourinary Trauma

Ali Ariafar. M.DUrology- Oncoloy FellowshipShiraz university of medical sciences

Renal Trauma

Three to 10% of trauma patients have GU involvement; 10-15% of trauma patients with abdominal injuries have GU involvement.

In patients with GU trauma, symptoms are nonspecific and may be masked by or attributed to other injuries.

In blunt trauma, history is obtained regarding the time and mechanism of injury, position of the patient, speed of the vehicle, and use of restraints.

In penetrating trauma, knowing the size of the stabbing weapon or the caliber of the gun and the distance from which it was discharged aids assessment..

Renal injuries are the most common injuries of the urinary System( 45% of all GU injuries)

Renal injuries are most commonly from motor vehicle accidents (MVAs).

Renal Trauma

The most important indicator of renal trauma is gross or microscopic hematuria. however the degree of hematuria and the severity of renal injury do not correlate consistently

Blunt trauma is cause 80% of renal injuries among patients with gross hematuria, notable renal trauma is present in 25%

less than 1% of patients with microhematuria have

substantial renal injury The absence of hematuria, although rare, does not

exclude renal injury because it is absent in 5% of patients and 36% renal vascular injury

Renal Trauma Flank ecchymosis or mass indicates a retroperitoneal

process but is not specific to renal injuries and rarely occurs acutely.

Suspect renal injury when fractures of lower ribs and/or spinal processes are observed and/or when a history of sudden deceleration or significant lateral force on the patient exists.

Trajectory of the bullet or penetrating object helps indicate the possibility of renal injury.

Presence of abdominal, visceral, solid organ, or vascular injury indicates renal injury, as these injuries coexist with renal injuries in 34% of patients with blunt trauma and in up to 80% of patients with penetrating trauma.

Renal Trauma Renal Injury ScaleGrade Injury Description I microscopic or gross hematuria, urologic studies

normal subcapsular hematoma, non-expanding without parenchymal laceration

II non-expanding perirenal hematoma confined to renal retroperitoneum, or laceration < 1.0 cm parenchymal depth of renal cortex without urinary extravasation

III laceration > 1.0 cm parenchymal depth of renal cortex without

urinary extravasation or collecting system rupture

IV parenchymal laceration extending through the renal cortex, medulla, and collecting system, or main renal artery or vein injury with contained hemorrhage

V completely shattered kidney or avulsion of renal hilum which devascularizing the kidney

Renal Injury Scale

Renal Trauma

Lab Studies:

Complete blood count (CBC) to obtain hematocrit level and platelet count

Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to check for coagulopathy; may be unnecessary in young, otherwise healthy patients

BUN and serum creatinine: Elevation of BUN without elevation in creatinine indicates urine reabsorption.

Urinalysis to diagnose hematuria Blood type and crossmatch

Renal Trauma

Indications for Radiographic Assessment in suspected renal trauma

penetrating trauma to flank or abdomen regardless of the degree of hematuria (microscopic or gross)

in all adult patients with blunt abdominal trauma with gross hematuria

in all adult patients with blunt abdominal trauma with microscopic hematuria and associated shock (<90 mm Hg)

deceleration injuries from history major intra-abdominal injuries with

microhematuria pediatric flank or abdominal trauma with any

degree of hematuria

Renal Trauma

Radiographic Staging IVP - double dose CT Scan - best method of staging -

radiographic study of choice Ultrasound Angiography - used for suspected

renovascular injury

Renal Trauma Most renal injuries (80%) are minor and do

not require surgical intervention Absolute Indications for Surgery Signs and symptoms of persistent bleeding

Unstable vital signs Decreasing hemoglobin Expanding flank mass

  Relative Indications for Surgery Urinary Extravasation Renovascular injury Incomplete staging Nonviable tissue

Renal Trauma

Complications Persistent urinary extravasation Delayed renal bleeding Perinephric abscess Hypertension Arteriovenous fistula Hydronephrosis

Grad 1

Grade 2

Grade 3

Grade 4

Grade 4-5

Grade 5(UP avultion)

Grade 5(shattered kidney)

Grade 5(devascularization)

Grade 5(devascularization)

Surgery

Ureteral trauma Ureteral injury is rare but may occur, usually during

the course of a difficult pelvic surgical procedure or as a result of stab or gunshot wounds

Occur in less than 4% of penetrating trauma and less than 1% of blunt trauma

Hystrectomy was responsible for the majority of surgical injury(54%) followed by colorectal surgury (14%)

Ureteral Injury

Diagnosis Hematuria (25-45% have no microhematuria)

fever flank pain nausea and vomiting acute peritonitis Paralytic ileus Watery discharge from the wound or

vagina

Ureteral Injury

Imaging No ideal study

IVP—non-diagnostic in 33-100% Finding subtle on both IVP and CT Delayed function Ureteral dilation/deviation

Retrograde—only to delineate extent of injury

Antegrade—only if retrograde not possible

Ureteral Injury Treatmen

LOWER URETERAL INJURIES MIDURETERAL INJURIES UPPER URETERAL INJURIES

Complications Stricture Urinoma Pyelonephritis fistula formation. peritonitis

Bladder Trauma

Bladder injuries mostly occur in blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures; 15% occur with penetrating trauma and blunt mechanism without a pelvic fracture (ie, full bladder blowout).

Obstetric and gynecologic complications are the most common etiology of bladder injuries during open surgery

Bladder Trauma

Bladder injuries: classified into contusions, extraperitoneal and

intraperitoneal ruptures 

10% of patients with pelvic fractures will have a bladder injury 

>80% of patients with bladder injuries have an associated pelvic fracture 

gross hematuria in the trauma setting requires imaging of both upper and lower urinary tract

CLINICAL INDICATORS OF BLADDER INJURY

Suprapubic pain or tenderness Inability to void or low urine output Clots in urin Abdominal distention or ileus Free intraperitoneal fluid on CT or

ultrasound examination

Indication for cystography

Gross hematuria with pelvic fracture(29% have bladder rupture)

penetrating injuries of the buttock, pelvis, or lower abdomen with any degree of hematuria

cystography is nearly 100% accurate for bladder injury

Cystogram finding

Extraperitoneal rupture: Dense, flame-shaped collection of contrast material in the pelvis

Intraperitoneal rupture: contrast material surrounding loops of bowel

Extrapritoneal rupture of bladder

Intrapritoneal rupture of bladder

Bladder Trauma Intraperitoneal ruptures usually associated with full

bladder and seatbelt injury or sudden blunt injury to lower abdomen

Bladder injury occurs at dome of bladder where there is peritoneal covering

All intra-peritoneal bladder injures should be repaired operatively 

Extraperitoneal injuries usually associated with pelvic fractures - mechanism of action is secondary to shearing forces or bony spicules penetrating bladder 

Most extraperitoneal bladder injuries may be treated with catheter drainage alone however relative indications for surgery include:

Continued bleeding Presence of bone in bladder Concomitant laparotomy

Complications Unrecognized bladder injuries may

manifest as acidosis, azotemia, fever and sepsis, low urine output, peritonitis, ileus, urinary ascites, or respiratory difficulties.

Unrecognized bladder neck, vaginal, and rectal injury associated with the bladder rupture can result in incontinence, fistula, stricture, and difficult delayed major reconstruction.

Severe pelvic fractures may cause a transient or permanent neurologic injury and result in voiding difficulties despite an adequate bladder repair.

Urethral TraumaUrethral Injuries: divided into posterior and anterior urethral injuries

  anterior urethral injuries caused by blunt (straddle injury

to perineum) or penetrating injury - usually have scrotal penile swelling and blood at the meatus 

posterior urethral injuries occur in 2-5% of patients with pelvic fractures 

blood at the meatus is the best sign in both injuries however, must have high index of suspicion 

in posterior urethral injuries may also get inability to void, a high riding prostate, scrotal swelling and ecchymosis, and "butter fly" bruising in perineum  

in suspected urethral injury - must do retrograde urethrogram prior to inserting catheter

Urethral Trauma posterior urethral injuries occur

commonly at bulbomembranous junction 

penetrating anterior urethral injuries usually best dealt with debridement and possible immediate reconstruction 

blunt anterior urethral injuries usually best dealt with catheter stenting +/- suprapubic tube insertion 

Urethral Trauma

Imaging Studies: Plain radiograph of the pelvis to assess presence

and extent of bony injury Retrograde urethrogram

This is indicated prior to the insertion of a Foley catheter when urethral injury is suspected.

Retrograde cystogram 250 cc are introduced through the Foley

catheter. If the patient reports no discomfort, another

150 cc are introduced, and the catheter is clamped.

Urethral Trauma

Urethral Trauma

Management of urethral injuries - Related to type of injury sustained, but basic principles apply Drain the bladder with a suprapubic catheter

percutaneously or open to prevent further extravasation.

Initial urethral repair is not recommended because of risk of hemorrhage, impotence, and infection of pelvic hematoma.

Commence definitive management of urethral injuries after stabilizing the patient and attending to associated injuries, if present.

Repair can be performed as immediate primary closure, delayed primary closure (10-14 d), or late primary closure (>3 mo).

Complication

Stricture incontinence Erectile dysfunction

Penile Trauma

Penis fracture Penis amputation Gun-shot Animal and Human

Bites

Penis Fracture Mechanism buckling injury to rigid penis The tunica albuginea is a bilaminar

structure (inner circular, outer longitudinal)

The outer layer determines the strength and thickness of the tunica

When the erect penis bends abnormally, the abrupt increase in intracavernosal pressure cause transverse laceration

Etiology

Sexual intercourse(94%) Masturbation Rolling over or falling on to the erect

penis Self-inflicted fractures during

masturbation (69%in Kermanshah)

Diagnosis and sign/symptom

The diagnosis of penile fracture is made by history and physical examination

Popping sound, followed by pain, rapid detumescence, and discoloration and swelling of the penile shaft.

Eggplant deformity (Buck's fascia remains intact)

Deviates to the side opposite the tunical tear.

“Rolling sign” firm, mobile, discrete, tender swelling over which the penile skin can be rolled

Imaging

Cavernosography urethrography Ultrasonography MRI (highly accurate )

False fracture

Rupture of the dorsal penile artery or vein

Tear of suspensory ligament

Penis fracture

Penis fracture

Outcome and Complications.

Immediate surgical reconstruction results in faster recovery, decreased morbidity, lower complication rates, and lower incidence of long-term penile curvature

Conservative management of penile fracture results in penile curvature in more than 10% of patients, abscess or debilitating plaques in 25% to 30%, and significantly longer hospitalization times and recovery

Gunshot Wounds.

77% to 80% of victims have significant associated injuries

Urethral injuries have been reported in 15% to 50%

Treatment principles include immediate exploration, copious irrigation, excision of foreign matter, antibiotic prophylaxis, and surgical closure.

Gunshot

Animal and Human Bites

Initial management of dog bites includes copious irrigation, débridement, and immediate primary closure along with prophylactic broad-spectrum antibiotics(penicillin V-chloramphenicol)

Human bites produce potentially contaminated wounds that often should not be closed primarily

Tetanus and rabies immunizations

Amputation rare, usually the result of genital self-mutilation. 65 to 87% of patients performing genital self-

mutilation are psychotic microsurgical repair achieve good results. Successful reimplantation is possible after 16 hours

of cold ischemia time or 6 hours of warm ischemia Adequate erectile function(more than 50%) is

possible with both technique, complications such as urethral strictures, skin loss,

and sensory abnormalities are all much higher without microvascular repair. Normal penile sensation returns in 0% to 10% of patients after macroscopic replantation whereas sensation is present in more than 80% of microscopic replantations

Penile amputation in the initial stage of replantation.

Partial penile amputation.

Partial penile amputation.

Repair of partial penile amputation

Testis trauma

blunt trauma (about 75% of cases) Penetrating injuries(25%) 1.5% of blunt testis injury and 30%

of penetrating scrotal trauma involves both gonads

Most penetrating scrotal trauma (72% to 83%) is associated with nongenitourinary injuries

Etiology The most common cause of blunt

testicular trauma is sports injuries The second most common cause of

testicular trauma is a kick to the groin. Less common etiologies include motor vehicle accidents, falls, and straddle injuries.

The most common cause of penetrating testicular injuries is a gunshot wound to the genital area. Other causes include stab wounds, self-mutilation, animal bites (usually dog), and emasculation

Sign -Symptom

exquisite scrotal pain and nausea. Swelling and ecchymosis Scrotal hemorrhage and hematocele tenderness to palpation degree of hematoma does not

correlate with the severity of testis injury

Imaging

Ultrasonography CT MRI

disrupted tunica albuginea intratesticular hematoma

Differential diagnosis of testis rapture

Hematocele without rupture, Torsion of the testis or an appendage

(5% of torsions are precipitated by trauma)

Reactive hydrocele, Hematoma of the epididymis or

spermatic cord Intratesticular hematoma. Dislocation after trauma.

Management MAJOR scrotal injuries: Early

exploration and repair of testis injury is associated with increased testis salvage, reduced convalescence and disability, faster return to normal activities, and preservation of fertility and hormonal function

Minor scrotal injuries: managed with ice, elevation, analgesics, and irrigation and closure in some circumstances

Indication of surgical exploration

tunica albuginea rupture Significant intratesticular

hematomas Significant hematoceles (up to 80%

are due to testis rupture ) Penetrating scrotal injuries

Surgical repair

Complications

Testicular infarction Testicular torsion Testicular or epididymal abscess Infertility Testicular necrosis Testicular atrophy

Outcome Testis salvage rates exceed 90% with

exploration and repair within 3 days of injury versus orchiectomy rates threefold to eightfold higher with conservative management and delayed surgery

Testis salvage rates with conservative management are as low as 33%, with delayed orchiectomy rates between 21% and 55%

Penetrating testis trauma is associated with gonad salvage in only 32% to 65% of cases