Genitourinary Trauma

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Genitourinary Trauma

• François Dufresne
• McGill Emergency Medicine
• February 13th 2002

2
The Case of Jeremy

• 23 y.o male
• Driver, Seatbelted
• Frontal Impact, High Speed (? 100Km/h)
• Airbag
• Other driver dead
• Car completely destroyed
• Empty EtOH bottles in the OTHER car
• Patient was conscious at the scene.
• On scene BP85/50 HR120 RR22 Sat98

3
Jeremy

• A Clear. C-spine protection. Backboard
• B A/E symetric. O2 Sat N. No crepitus. Trachea
  central.
• C BP100/60 HR100 Mentating well.
• D GCS15 PERL.
• Pt is exposed.
• O2 - iv monitor
• Temperature N Capillary Glucose N

4
Jeremy

• AMPLE
• C/O abdo. Pain hip pain
• C/O right lower leg pain
• Secondary Survey
• Spleen normal. Mild suprapubic tenderness.
• Pelvic instability
• Probable right tibial
• No gross blood at meatus. Rectal Normal.
• Doctor, can I put a Foley?

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Jeremy

• What are your concerns?
• Foley?
• What will be the usefulness of dipstick?
• Dipstick good enough? U/A?
• What if he has microscopic hematuria?
• What if he has a pelvic fracture?
• Any different if you had blood at meatus?
• Urethrogram? Cystogram? Abdominal CT?
• Worried about the kidneys? Bladder?
• Does the low BP changes your suspicion for a GU
  injury?

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Introduction

• GU Trauma overlooked
• 10-20 of all injured patients
• Long term morbidity
• Impotence
• Incontinence
• Life-threatening injuries first

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Plan

• Urethral Injury
• Bladder Injury
• Hematuria in Trauma
• Kidney Injury

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Definitions

• Upper tract
• Kydney
• Ureters
• Lower tract
• Bladder
• Urethra
• External genitalia

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Urethral Trauma

• Almost exclusively in male
• Significant morbidity
• Stricture
• Incontinence
• Impotence
• If unrecognized
• Converting partial to complete tear
• Inaccurate assessment of U/O
• Foley catheter implication

Andrich DE et al. The nature of urethral injury
in cases of pelvic fracture urethral trauma.
Journal of Urology. 165(5)1492-5, 2001 May.
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Anatomy
Bladder
Symphysis
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Prostatic
Membranous
Bulbous
Pendulous
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Posterior Urethra

• Violent external force
• Pelvic in ? 90
• Pelvic 5-25 of Posterior urethral injury

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Clinical Features

• Gross hematuria in 98
• Inability to void
• Blood at urethral meatus
• Pelvic / suprapubic tenderness
• Penile / scrotal / perineal hematoma
• Boggy / high-riding prostate/ ill-defined mass on
  rectal examination.

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Digital Rectal Exam in Trauma

• Porter et al. Am Surg, 2001.
• Prospective
• Level II Trauma Center.
• 423 patients.
• DRE on all.
• 7 (1.7) pelvic fracture. NO Urethral injury
• Prostate exam didnt change management

Porter, J.M. et al. Digital rectal examination
for trauma does every patient need one? Am Surg
67(5)438, May 2001.
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Posterior Urethral rupture
From McAnich JW. In Tanagho EA, McAninch JW,
editors Smiths general urology, ed 14, Norwalk,
Conn, 1995, Appleton Lange.
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DiagnosisRetrograde Urethrogram

• Pretest KUB film
• Supine position
• Injection of 25ml of water-soluble contrast
• Different techniques
• X-ray when 10ml left and after 25ml
• Post-voiding x-ray.

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Retrograde Urethrogram
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Retrograde UrethrogramInterpretation

• Contrast extravasation Contrast in bladder
• Contrast extravasation only

PARTIAL Tear
COMPLETE Tear
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Partial Tear
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Complete Tear
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Management

• Partial tear
• careful passage of 12-14 Fr. Foley.
• If any resistance Urology
• Complete tear
• Urology suprapubic cath.
• If Foley already there and suspect tear
• LEAVE FOLEY IN PLACE
• Small tube alongside the foley
• Angiocath 16-gauge
• Modified urethrogram

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Managementby Urology

• Controversial
• Complete VS Partial
• Posterior VS Anterior
• Foley X 3-14 days
• Suprapubic catheters
• Surgical approach / Endoscopy
• Delayed repair usually

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Foley Catheter

• NO if you suspect a urethral injury
• Most of urethral injuries
• Pelvic or Gross hematuria
• Initial bladder effluent MUST be looked at.
• Danger to convert partial into complete
• Successful passage ? complete tear
• NEVER REMOVE A FOLEY WHEN YOU SUSPECT A PARTIAL
  TEAR AFTERWARDS.
• ANY colored urine other that yellow

BLOOD until proven otherwise
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Prostatic
Membranous
Bulbous
Pendulous
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Anterior Urethra

• More common than posterior
• Direct trauma
• Usually NO pelvic
• Blood at meatus
• Unable to micturate
• Penile/Scrotal/Perineal
• Contusion
• Hematoma
• Fluid collection

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Sleeve Hematoma
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Butterfly Hematoma
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Anterior Urethral Rupture
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Anterior UrethraManagement

• NO Foley if injury suspected
• Retrograde Urethrogram
• Urology
• Surgical Treatment

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Bladder Trauma

• Adult Extraperitoneal organ
• Bladder dome weakest point
• Blunt 60-85
• MVA 1 cause
• Important to recognize
• Pelvic/abdominal wall abscess/necrosis
• Peritonitis
• Intra-abdominal abscess
• Sepsis / Death

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Types of rupture

• Extraperitoneal
• Most common
• Pelvic in 89-100
• Bladder rupture in 5-10 of all pelvic
• Intraperitoneal
• Extravasation of urine in abdomen
• Sudden force to full bladder
• Associated injuries Mortality (20)

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Clinical Presentation

• McConnel et al. Rupture of the bladder. Urol Clin
  North Am. 1982.
• Carroll et al. Major bladder trauma Mechanisms
  of injury and a unified method of diagnosis and
  repair. Journal of Urology. 1984.

• 98 Gross hematuria
• 2 Microscopic hematuria Pelvic
• 100 Gross hematuria
• 85 Pelvic

• Morey AF et al. Bladder rupture after blunt
  trauma guidelines for diagnostic imaging.
  Journal of Trauma-Injury Infections Critical
  Care. 51(4) 683-6, 2001 Oct.

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Investigation

• Cystography Gold standard
• CT Cystography New trend
• Peng et al. AJR 1999.
• Prospective study
• 55 patients. 5 bladder rupture
• Cystography VS. CT cystography
• Ruptures confirmed by Surgery
• 100 sensitive and specific

Peng et al. CT cystography versus conventional
cystography in evaluation of bladder injury. AJR
1999 1731269-1272.
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Investigation

• Deck et al. Journal of Urology, 2000.
• Retrospective study
• 316 patients with CT Cystography
• Sensitivity/Specificity 95 and 100
• But 78 and 99 for intraperitoneal rupture
• Comparable to Cystography alone
• Identifies other injuries

Deck AJ et al. CT Cystography for the diagnosis
of traumatic bladder rupture. J Urol, Jul. 2000
164(1) 43-6.
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Standard Helical CT

• Pao et al. Acad Radiol 2000.
• With IV contrast
• Misses bladder rupture
• 100 sensitive if free fluid criteria used.
• Can R/O bladder injury if NO free fluid.
• Not specific.
• Not accepted as diagnostic tool.

Pao et al. Utility of routine trauma CT in the
detection of bladder rupture. Acad Radiol 2000
7317-324.
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Treatment

• Penetrating injuries OR
• Blunt
• Intraperitoneal Almost all OR
• Extraperitoneal Urethral cath. drainage x 7-10
  days.

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Hematuria

• Hardeman and al. Journal Urol, 1987.
• Prospective study
• 506 patients
• IVP in all. CT/arteriography/O.R. PRN
• Shock BPslt90 at any time
• 25 Injuries
• ALL had either
• Gross hematuria
• Shock microhematuria

Hardeman et al. Blunt urinary tract trauma
identifying those patients who require
radiological diagnostic studies. The Journal of
Urology. 3899-101, 1987.
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Hardeman et al.

• 365 (52 ) had microhematuria only
• 174 D/Ced , F/U and no problem
• 191 admitted
• 1 renal contusion (Grade I)
• 2 minor lacerations (Grade II)
• No complication

Hardeman et al. Blunt urinary tract trauma
identifying those patients who require
radiological diagnostic studies. The Journal of
Urology. 3899-101, 1987.
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Mee et al. Journal Urol, 1989

• Prospective
• 1146 patients
• IVP Gold standard
• ALL significant renal injuries had either
• Gross hematuria
• Microscopic hematuria shock
• Intensity of hematuria ? Severity of injury

Mee et al. Radiographic assessment of renal
trauma a 10-year prospective study of patient
selection. Journal of Urology. 141(5)1095-8,
1989 May.
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Gross  Hematuria  False

• Alphamethyldopa
• Ibuprofen
• Levodopa
• Metronidazole
• Nitrofurantoin
• Phenazopyridine
• Phenolphtalein-containing laxatives
• Rifampin
• Beets/berries

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Microscopic hematuria

• 8 major studies
• 3406 adult blunt trauma with microscopic
  hematuria and NO shock.
• 0.23 major renal injuries (?gradeII)
• No imaging necessary for that group
• F/U 3-4 weeks to R/O underlying pathology.
• BUT

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Microscopic hematuria

• Patients with pelvic often excluded from
  studies.
• Penetrating trauma excluded.
• Pediatric population excluded
•  Rapid Deceleration injuries 
• Urinalysis on FIRST urine.

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Dipstick vs. U/A

• Daum et al. AM J Clin Pathol, 1988.
• Prospective
• 178 patients
• Abdominal Trauma
• Dipstick AND Microscopic examination

Daum et al. Dipstick evaluation of hematuria in
abdominal trauma. Am J Clin Pathol, 1988
89538-542.
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Daum et al.
Dipstick (Sensitivity) Dipstick (Sensitivity) Dipstick (Sensitivity) Dipstick (Sensitivity)
Microscopy Trace 1 2 3
? 5 RBC/hpf 100 92 84 62
? 10 RBC/hpf 100 96 92 81
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Dipstick vs. U/A

• Chandhoke et al. J Urol, 1988.
• Prospective study
• 339 patients
• Suspected blunt renal trauma
• Dipstick AND microscopic examination

Chandhoke et al. Detection and significance of
microscopic hematuria in patients with blunt
renal trauma. J.Urol. 140 16-18, 1988.
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Chandhoke et al.
Dipstick (Sensitivity) Dipstick (Sensitivity) Dipstick (Sensitivity) Dipstick (Sensitivity)
Microscopy Trace 1 2 3
? 5 RBC/hpf 98 89 76 51
? 10 RBC/hpf 98 92 82 59
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Kidney Injury

• Retroperitoneal organ
• Cushoned by perinephric fat
• Gerotas fascia
• Along T10 - L4
• Ribs 10-12
• Fixed only through pedicle.
• 1.2L of blood / min

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Kidney Injury

• Blunt trauma 80-90
• Rapid deceleration / Direct blow
• MUST be suspected if
• Trauma to back / flank / lower thorax / upper
  abdomen
• Flank pain / low rib
• Hematuria / Ecchymosis over the flanks
• Sudden decelaration / Fall from height.
• Lumbar transverse process

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Lumbar Transverse Process Fractures

• Prospective study (1994-1999)
• Lumbar spine
• 191 patients
• Transverse in 29
• Abdominal organ injuries 47 vs. 6
• Kidney 1/3
• Liver 1/3
• Spleen 1/4

Abdominal organ injuries 47 vs. 6
Kidney 1/3
Miller et al. Lumbar transverse process
fractures a sentinel marker of abdominal organ
injuries. Injury. 31773 2000.
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Classification of Injury

• 5 Classes of Renal Injury

Organ Injury Scaling Committee Moore et al. Organ
Injury Scaling Sleen, Liver and Kidney, The
Journal of Trauma, 29 1664 1989.
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Grade I

• Contusion
• Hematuria
• Urologic studies N
• Hematoma
• Subcapsular
• Non expanding
• Parenchyma N

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Grade II

• Hematoma
• Perirenal
• Nonexpanding
• Laceration
• lt 1.0 cm
• Renal cortex only
• No urinary extravasation

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Grade III

• Laceration
• gt 1.0 cm
• Renal cortex only
• No urinary extravasation
• Intact collecting system

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Grade IV

• Laceration
• Renal cortex
• Renal medulla
• Collecting system
• Vascular
• Main renal artery/vein injury with contained
  hemorrage.

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Grade V

• Completely shattered kidney.
• Avulsion of renal hilum (pedicule) which
  devascularizes kidney.

Kennon et al. Radiographic assessment of renal
trauma our 15-year experience. The Journal of
Trauma, 154 353-355 August 1995.
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Pedicule Injury
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Organ Injury Severity Scale

• Validated lately Journal of Trauma, 2001
• Predicts the need for surgery
• Need for surgery nephrectomy rates
• Grade I 0 0
• Grade II 15 0
• Grade III 76 3
• Grade IV 78 9
• Grade V 93 86

Santucci et al. Validation of the American
Association for the Surgery of Trauma Organ
Injury Severity Scale for the Kidney. J Trauma
50195-200 2001.
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Investigation

• IVP
• Used to be intial exam of choice.
• Very poor sensitivity for penetrating injury
• Limitation in staging renal injuries
• Not 1st choice anymore. Only if pt unstable.
• Contrast CT
• Study of choice if stable
• More sensitive and specific for staging
• Detects other abdominal injuries

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Management

• Penetrating trauma
• Imaging for ALL (9 NO hematuria)
• Blunt trauma Imaging
• Gross hematuria
• Microscopic hematuria (?5 RBC/hpf) shock
  (BPs?90)
• Any child with gt 50 RBC / hpf

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Management

• Absolute indication for Surgery
• Uncontrollable renal hemorrage
• Multiply lacerated, shattered kidney
• Main renal vessels avulsed
• Penetrating injuries usually
• Grade I-II
• conservative
• Grade III-IV
• Conservative if stable hemodynamically vs.
  surgery
• Grade V
• Surgery

Grade V
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Back to Jeremy

• First urine Dipstick (15 RBC/hpf)
• Pelvic x-ray Straddle

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Kozin, Berlet. Handbook of Common Orthopaedic
Fractures, 4th ed., 2000.
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Jeremy

• First urine Dipstick (15 RBC/hpf)
• Pelvic x-ray Straddle
• Keypoints
• BP 85/50 on scene
• Microhematuria
• Pelvic
• NO FOLEY

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Jeremy

• Urology consulted
• Retrograde urethrogram N
• CT cystogram N
• Contrast CT to look for renal injury Grade II
  renal injury.

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Conclusion

• No Foley if you suspect urethral trauma
• Gross hematuria OR microhematuria Shock GU
  Trauma.
• Pelvic Microhematuria GU investigation
• Dont remove Foley if you suspect a partial tear
  of urethra afterwards.
• Microhematuria alone No imaging but F/U.
• In peds Imaging for ALL hematuria.

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The End
The End