Urogenital Trauma

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Urogenital Trauma

• Amit Sarnaik MD
• Scottish Rite Pediatric Emergency Department

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Genitourinary trauma

• In multiple trauma patients, GU trauma is second
  in frequency (1 CNS)- 10
• MOI Blunt (90) vs. Penetrating
• MVC most common
• Falls, Sport related and direct blow
• Most common Injury is to the kidney 47
• Associated intra-peritoneal injuries
• Penetrating 80 vs. Blunt

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Pediatric considerations

• Renal injury more likely in children
• Larger proportion of kidney to abdominal size
• Retained fetal lobulations Easier parenchymal
  disruption
• Weaker abdominal muscles
• Less ossified thoracic cage
• Less developed perirenal fat and fascia

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Renal trauma - Presentation

• Localized signs flank tenderness, flank
  hematoma, or palpable flank mass.
• Non specific Abdominal tenderness, rigidity,
  paralytic ileus or hypovolemic shock
• Gross hematuria is the hallmark of severe injury
  absent in 50 of patients with vascular pedicle
  injuries and 30 penetrating injuries
• Most common injuries
• Parenchymal contusions and hematomas (60-90)
• Lacerations are less common (10)

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Classification of renal trauma

• Grade I Contusion or subcapsular nonexpanding
  hematoma
• Grade II Nonexpanding hematoma confined to the
  retroperitoneum or lac lt1 cm
• Grade III Lac gt1 cm into the renal cortex
  without collecting system rupture or urinary
  extravasation
• Grade IV Lac extending into the collecting
  system or renal vascular injuries with contained
  hemorrhage
• Grade V Shattered kidneys or avulsions of renal
  hilum with devascularized kidneys

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Grade 1,2 and 3 renal injuries
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Grade 4 and 5 injuries
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Renal Trauma Management

• Evaluate GU system only after life threatening
  conditions have been indentified
• A urinalysis should be obtained in all patients
  with multisystem trauma or suspected isolated
  renal injury
• Pediatric renal trauma patient order a CXR,
  Abdominal and Pelvis X-rays

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Renal trauma Hematuria and Kidney injury

• Gross hematuria
• Microscopic hematuria with major mechanisms or
  signs of renal injury
• Hematuria of gt 20 RBC per hpf
• Microscopic hematuria with shock ( relied upon in
  adult EM)

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Imaging of renal trauma

• CT with contrast is preferred study at most
  trauma centers - 98 sensitivity
• Detection of associated injuries
• 3-D views and no dependence on renal vascularity 
• Ultrasound 70 sensitivity
• Not accepted for the staging of renal trauma
• Has been used for long term follow up
• Alternative modality for the evaluation of the
  pregnant trauma patient

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Imaging in renal trauma

• IVP used only if CT is not readily available
• Provides rapid information about the overall
  functional and anatomic integrity of both kidneys
• It can be obtained in the ED in an unstable
  patient or in the OR prior to surgery
• IVP will only diagnose 5 contusions, 50 lacs,
  29 pedicle injuries

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Blunt Uro-genital trauma Diagnostic evaluation

• Blunt and Unstable
• Limited IVP
• Blunt Stable, major renal injury, none lower
• CT scan
• Blunt and Stable, Findings of lower tract injury
• Cystourethrogram /- upper tract evaluation
• Blunt and Stable, Minor renal injury (Microscopic
  hematuria)
• No CT, serial UA, delayed imaging

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Management of blunt renal trauma

• Grades 1,2 and 3
• Strict bed rest, analgesia, prophylactic
  antibiotics.
• Limited activity on resolution of gross hematuria
• Grades 4,5 Management is controversial.
• Depends upon hemodynamic status, degree of
  urinary extravasation, renal bleeding, associated
  injuries.
• Many patients are being managed with serial
  hematocrit, vital signs and broad spectrum
  antibiotics

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Complications from non operative management of
Grade 4 and 5 renal trauma

• Patients managed nonoperatively have a 50
  complication rate
• Persistent/recurrent hemorrhage
• Extravasation and urinoma formation
• Infection
• Infarction
• Segmental hydronephrosis

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Penetrating Uro-genital trauma Diagnostic
evaluation

• Penetrating and Unstable
• Limited IVP
• Penetrating Stable, upper tract injury
  suspected
• CT scan
• Penetrating Stable, findings of lower tract
  injury
• Cystourethrogram /- upper tract evaluation

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Management of Penetrating renal trauma

• Surgical
• Vascular injury
• Hemodynamic instability
• Urinary extravasation
• Non surgical
• Hemodynamically stable Isolated Low grade
• Delayed bleeding may occur in 24 with grade 3-4

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Complications of renal trauma

• Short Term
• Delayed hemorrhage
• Urinary extravasation
• Abscess formation
• Obstruction secondary to clot formation
• Long Term
• HTN (lt5)
• Hydronephrosis
• Arteriovenous fistulas
• Renal intestinal fistula
• Stone formation

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Ureteral Trauma

• Ureteral injuries are uncommon, lt1 of all
  urologic trauma
• Blunt trauma usually involves the UPJ
• Suspect ureter trauma if fracture of the
  transverse process of lumbar vertebra
• Penetrating injuries along the ureter 90
  association with other intra-abdominal injuries
• Stab wounds rarely cause ureteral injury, but 50
  of GSW to abdomen have injury to the ureter

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Ureteral trauma Diagnosis

• Diagnosis is difficult, gt50 not diagnosed in 1st
  24h
• PE may be unremarkable, urinalysis is unreliable
• Delayed diagnosis may manifest as fever, chills,
  lethargy, leukocytosis, pyuria, bacteriuria,
  flank mass/pain, fistulas, strictures

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Ureteral Trauma

• CT and IVP has low sensitivity (33)
• Retrograde pyelogram may be more reliable

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Bladder Trauma

• Blunt trauma secondary to MVC is most common
  cause
• 80 of injuries associated with pelvic fracture
• Mortality rate 40 with bladder rupture (from
  assoc head injury)

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Classification of bladder trauma

• Extraperitoneal associated with pelvic
  fractures.
• Intraperitoneal caused by blunt trauma to
  distended bladder.
• Combined GSW.

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Bladder trauma Diagnosis

• Hematuria and dysuria typically seen at
  presentation
• gt90 with bladder rupture have gross hematuria
• Diagnostic evaluation is indicated
• in patients who sustain pelvic or lower
  abdominal trauma with gross hematuria
• inability to void
• abnormal GU exam
• multiple associated injuries

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Evaluation of bladder trauma

• Pelvic X-rays
• Retrograde cystogram
• High suspicion and normal X-rays
• No catheterization if blood at the urethral
  meatus or high-riding prostate
• CT cystography is recommended over plain
  cystogram for patients undergoing CT for
  associated injuries

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Management of bladder injuries

• Extra peritoneal
• Contusion conservative management, /- catheter
  
• Manage with urethral cath or suprapubic drainage
  for 7-10 days.
• Large tear OR
• Intraperitoneal - Go to OR.
• Combined Go to OR

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Urethral trauma

• Mechanisms
• MVC
• straddle injuries
• Instrumentation
• More common in males
• Urethral injuries
• Anterior Pendulous and Bulbar
• Posterior Membranous and Prostatic

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Blunt Anterior Urethral trauma

• Due to direct trauma, usually isolated, low
  mortality
• Bulbar injuries common in straddle injury
• Blood at the urethral meatus is present in 90 of
  anterior injuries
• Perineal ecchymosis (butterfly),
  inability/difficulty voiding also possible
• Retrograde urethrogram is diagnostic
• Manage with 7-10 days of catheterization plus
  antibiotics

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Blunt Posterior urethral Trauma

• Occur with severe trauma and are associated with
  other injuries (pelvic fx)
• Signs are blood at the meatus, hematuria,
  perineal ecchymosis (butterfly),
  inability/difficulty voiding
• Retrograde urethrogram is diagnostic
• Urology consultation
• Higher rate of complications

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Female urethral trauma

• Urethral injuries in girls
• Rare, due to mobile short urethra
• Associated with pelvic fractures or
  instrumentation
• Managed with suprapubic drainage and elective
  repair

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Penile Trauma

• Blunt trauma from toilet seat is common
• Managed with warm soaks.
• Tourniquet injuries
• Exposure and removal of hair
• Urethrocutaneous fistula and penile loss
• Zipper entrapment.

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Penile Trauma

• Penis fracture.
• Traumatic rupture of corpus cavernosum.
• Erect penis vs. hard surface.
• Patient may hear a cracking sound with pain and
  edema.
• Most required surgical evacuation of hematoma,
  ice packs, pressure dressing
• Lacerations
• Involving the corporal bodies or the urethra
  require urologic consult
• Superficial simple repair
•  

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Perineal trauma

• Most common is straddle injury
• Vulvar hematomas ice packs and rest
• Superficial lacerations treat with sitz baths
• Deep lacerations Extension into rectum or
  urethra

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Straddle injury

• Injury is caused by the compression of soft
  tissues against the bony margins of the pelvic
  outlet
• Mechanisms
• Bicycle riding
• Falls
• Monkey bars

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Straddle injury Appearance

• Straddle injuries typically are unilateral and
  superficial
• Anterior portion of genitalia involved
• Girls
• Mons, clitoral hood and labia minora anterior and
  lateral to hymen
• Straddle injury to hymen and posterior fourchette
  is rare
• Boys Injury to penis or scrotum

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Straddle injury vs Abuse

• Infant younger than nine months
• Perianal, rectal, vaginal, or hymenal injury
  without history of penetrating trauma
• Extensive or severe trauma
• Presence of non-urogenital trauma
• Lack of correlation between history and physical
  findings
• Abnormal genital secretions

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Straddle injury Treatment principles

• Visibility of injury
• Physician must be assured that the injury is
  properly inspected
• Ability to void
• Inability to void
• Pain
• Large hematoma
• Urethral disruption

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Treatment Girls

• Vulvar hematoma size dependant
• Ice packs, analgesia, sitz baths
• Increasing size Surgical drainage
• Vulvar lacerations
• Heal by secondary intention ( lateral wall of
  vestibule)
• Repair of perineal lacerations under sedation
• Vaginal injury suspect if hymenal tear
• Lacerations superficial or deep - Repair
• Hematomas Observation

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Treatment Boys

• Urethral injury Anterior vs. posterior
• Testicular injury
• Depends on severity
• Assessment with US and Urology
• Scrotal injury
• Hematoma, ecchymosis Ice packs
• Superficial lacerations Repair in ED
• Hematocele and scrotal swelling
• Deep ( extension through Dartos) Urology
• Penile injuries

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Penile Trauma Direct Injury

• Causes and management
• Falling toilet seat
• Significant penile edema
• Injury to corporal bodies or urethra is rare
• Treatment warm soaks, void in bath tub,
  Observation
• Blunt trauma Blood at urethral meatus
• Urethral injury
• Diagnosis Retrograde urethrogram
• Laceration to penile shaft
• R/O urethral injury and injury to corporal bodies
• Consult urology, urethrogram, exploration in ??
  Cases
• Simple laceration Repair with chromic catgut

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Penile Trauma Zipper Injury

• Most common genital injuries in prepubertal boys.
  
• Typically involve the foreskin or redundant
  penile skin and may occur during the zipping or
  unzipping process
• Localized edema and pain are the most common
  complications
• Significant injury, including skin loss or
  necrosis, is unusual.

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Zipper Injury Treatment

• Mineral oil Allows tissue to slide freely
• Entrapment release  The procedure for entrapment
  release depends upon the site of entrapment
  within the zipper.
• Entrapment of penile skin between the zipper
  teeth (and not the zipper mechanism)
• Release by cutting the cloth of the zipper -
  results in separation of the zipper teeth
• Local anesthesia or sedation usually is not
  necessary for this procedure.

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Zipper Injury Treatment

• Entrapment of penile skin in the zipper mechanism
  (which consists of two faceplates connected with
  a median bar)- More difficult to release.
• Sedation may be necessary to complete procedures
• Local anesthesia usually is adequate for older
  children.

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Zipper injury Treatment

• Recommended technique
• The median bar may be cut with wire cutters, bone
  cutters, or a mini hacksaw
• Allows the mechanism to fall apart and leads to
  release of the entrapped skin
• Alternate technique
• Thin blade of a small flathead screwdriver
• Placed between the faceplates on the side of the
  mechanism in which the penile skin is not
  entrapped.
• The blade is then rotated toward the median bar
• This widens the gap between the faceplates,
  releasing the skin

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Penile Injury Strangulation

• Constriction ring Hair, fiber, thread
• Pitfall Local edema may hide the ring of hair
• Treatment
• Division of hair release of constriction
• May require GA and urologic consultation
• Complication
• Urethrocutaneous fistula
• Penile loss case report
• Occasional report as form of sexual abuse

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Scrotal Trauma

• Mechanisms of trauma
• Direct blow
• Straddle injury Impingement of testis against
  the pubic bone
• Penetrating injuries Rare
• Spectrum of scrotal trauma
• Minimal scrotal swelling to testicular rupture
  with blood filled scrotum
• Suspicion of testicular rupture surgical
  exploration
• Best salvage of ruptured testis
• Rare presentation of testicular torsion

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Scrotal trauma hematocele

• Hematocele Blood within tunica vaginalis
• May represent severe testicular injury
• Ecchymosis of scrotal wall in setting of trauma
• Sonography
• Identifies fluid collection in the tunica
• Blood more echogenic than hydrocele fluid
• Treatment Surgical exploration to drain large
  hematoceles as well as testicular repair if
  ruptured

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Scrotal trauma spectrum

• Intratesticular hematoma or laceration of tunica
• Ultrasound Assists to determine location of
  blood
• Intact Tunica Surgery not necessary
• ? Testicular laceration surgical exploration
• Traumatic epididymitis
• Results from blunt trauma
• Initial pain, then pain free, then pain returns
• Scrotal erythema, edema, epididymal tenderness
• Ultrasound rules out severe injury
• Treatment Supportive
• Scrotal laceration
• Evaluate testis and spermatic cord for injury
• Simple laceration Hemostasis and chromic sutures

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Scrotal injuries Urology intervention

• Large testicular hematoma may need drainage
• Delay in surgery may lead to ischemic necrosis,
  secondary infections, disruption of testicular
  function
• Testicular rupture with tear of the tunica
  albuginea requires surgical exploration.
• Salvage more likely if repaired within 24h
• Laceration to scrotum through the dartos
• All penetrating testicular injuries

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Testicular torsion

• Scrotal pain and swelling common presenting
  symptom in ED
• Acute scrotum
• Acute testicular torsion rapid pickup is vital
  for salvage
• Salvage rate drops when repair delayed beyond 6-8
  hours after acute event
• Acute scrotum Testicular torsion is the working
  diagnosis until proven otherwise

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Testicular torsion Stats

• 1 out of every 4000 males before age of 25
• Peak incidence 13 years of age
• Another peak
• Perinatal period.
• Newborn born with hard, necrotic testis.
• Hard or discolored scrotum
• Salvage not possible
• Rare after age of 30 yrs

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Testicular torsion Cause

• Basic mechanism Movement of testis that is
  abnormally fixed in tunica vaginalis
• Infants Lack of fixation of tunics in the
  scrotum. Extravaginal torsion
• Bell Clapper deformity Tunica vaginalis has
  abnormally high attachment to spermatic cord
• Testis not fixed. Prone to torsion
• Allows testis to lie transversely and rotate
• Found in most cases. Commonly bilateral

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Bell Clapper deformity

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Testicular torsion Clinical features

• PAT
• Appearance Crying, irritable, uncomfortable
• WOB Normal
• Circulation Normal systemic
• Other findings
• History of pain in past
• Acute onset pain in groin or scrotum
• Nausea and vomiting
• High riding testis, Transverse lie of testis
• Diffuse testicular pain, absent cremasteric reflex

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Testicular torsion Complications

• Delay in re-establishing blood flow loss of
  testicular function
• Delay
• Patient presentation
• Physician taking his or her time to establish
  diagnosis
• Testicular salvage
• 80-90 within 8 hours of acute pain
• lt20 for delay up to 12 hrs

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Diagnostic studies

• Lab studies not sufficient to make definitive
  diagnosis
• Ultrasound with Doppler
• Readily available, non invasive and highly
  accurate
• Any uncertainty Indicates surgical exploration
• Testicular scintigraphy
• PPV of 95
• Access may not be easy at all times
• High index of suspicion Do not delay surgical
  procedure to confirm suspicion with a diagnostic
  study.

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Testicular torsion Differential

• Torsion of appendix testis or appendix epididymis
• Epididymitis
• Orchitis
• Incarcerated Inguinal Hernia
• Scrotal trauma
• Hydrocele
• Varicocele
• HSP/ Kawasaki disease
• Scrotal cellulitis
• Testicular tumors

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Management

• Analgesia IV narcotic
• Manual detorsion Can preserve testicular
  viability and provide time
• Twist affected testis outwardly
• Successful detorsion Relief of pain and visible
  lengthening of cord structures
• More than 360o detorsion may be required
• Surgery
• Non viable testis Orchiectomy
• Viable testis Orchiopexy
• Exploration of unaffected testis

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Torsion of testicular appendageAppendix testis
or Appendix epididymis

• Average age 10 years
• Clinical features
• Sudden onset pain limited to scrotum
• No abdominal or urinary symptoms
• Point tenderness at superior aspect of testis in
  early stages
• Blue dot visible tender nodule in 20 cases

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Diagnosis and Management

• Testicular scan and Ultrasound
• Increased blood flow
• Inflammation at superior aspect of testis
• Treatment
• Expectant
• Analgesics
• Any doubt about diagnosis
• Urology consultation for exploration

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Phimosis Paraphimosis

• Phimosis Tightness of distal foreskin
• Cannot withdraw to expose the glans
• Not to be confused with penile adhesions
• Paraphimosis Foreskin is retracted behind glans
  and left there swollen, retracted foreskin
• Venous congestion edema reduction to normal
  position is difficult

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Paraphimosis Treatment

• Manual reduction Application of ice and steady
  local compression
• Local anesthesia Penile block
• Pressure on glans (turning a sock inside out)
• Surgical reduction Failure of manual reduction
  (2-3 attempts)
• Surgical division of foreskin
• Circumcision after a few weeks
• Prevention Education of uncircumcised male

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Improving success of manual reduction

• Wrap the penis in plastic and apply ice packs
• Use compressive elastic dressings
• Apply direct circumferential manual compression
• Granulated sugar
• Hyaluronidase therapy - directly into several
  sites of the edematous prepuce.
• Puncture of the edematous site

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An 8 yo boy is brought to the ED after getting
hit by a car while riding his bicycle. On exam,
he has stable vital signs, GCS of 15, and his
abdomen is soft without tenderness. Blood is
noted at the urethral meatus and he is unable to
void. Which of the following is the most
appropriate for management? a. Retrograde
urethrogram b. Foley catheter placement c.
Abdominal ultrasound d. Intravenous pyelogram
(IVP) e. Ice packs and ibuprofen
70
A 13 yo boy comes to the ED with back pain after
playing ice hockey. He was checked and hit his
back onto the boards. He noted gross hematuria a
few hours afterwards. On exam, he has normal
vital signs. His right flank shows a small
ecchymosis on inspection. His abdomen is soft
without tenderness. His urinalysis shows numerous
RBCs per high power field. Which of the following
tests is most appropriate in this patient? a.
Intravenous pyelogram (IVP) b. Ultrasonography c.
Cystourethrogram d. Abdominal CT e. Serial
urinalyses
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A 6 yo girl comes to the ED after sustaining an
injury to the perineum. The patient was climbing
on a tree when she fell approximately 4 feet
landing on a large rock. She complains of pain
and bleeding from vaginal area. She has been
refusing to urinate due to pain. A 1-cm
superficial vulvar laceration is noted at 3
oclock with small amount of oozing blood. The
hymen appears intact. The most appropriate
management is a. Surgical exploration under
general anesthesia b. Laceration repair under
local anesthesia c. Consultation with the child
protection team d. Supportive care and sitz
baths e. Placing a Foley catheter and
hospitalization
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A 13 yo boy comes to the ED after sustaining a
straddle injury to his scrotum while riding his
bicycle. He is able to urinate without difficulty
and has no gross hematuria. There is no trauma to
the abdomen. On exam, he has normal vital
signs. His right hemi-scrotum is swollen and
ecchymotic. There is marked tenderness on
palpation. There is no ecchymosis or swelling of
the penis, and no blood per meatus.
The management includes a. Pelvic x-ray b.
Needle aspiration c. Retrograde urethrogram d.
Scrotal ultrasound e. No intervention is needed
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An 8 yo boy presents to the ED after his penile
skin got caught in the zipper of his pants. On
exam, his foreskin is caught in the zipper
mechanism. Management includes a. Cutting the
median bar of the zipper b. Dissecting the skin
free c. Applying ice before unzipping over the
entrapped skin d. Moving the zipper back and
forth after local anesthesia e. Performing a
dorsal slit procedure
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A 16 yo boy comes to the ED with left-sided groin
pain and scrotal swelling that began 4 hours
prior to arrival. He also reports mild lower
abdominal pain and nausea. On exam, his
left scrotum is erythematous, moderately swollen
and diffusely tender on palpation. A cremasteric
reflex cannot be elicited. There is mild
tenderness on palpation of lower abdomen.
The most appropriate management of this patient
is a. Scrotal ultrasound b. Immediate surgical
exploration c. Ceftriaxone and doxycycline d.
Trimethoprim/sulfamethoxazole e. Incision and
drainage
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A 3 yo uncircumcised boy presents to the ED with
swelling and penis pain since the morning of
presentation. There is no history of trauma. He
is able to void without difficulty. On exam, his
foreskin is retracted and swollen, and the
glans appears swollen. Which of the following
would be the most appropriate initial
treatment? a.Oral antibiotics b. Manual
reduction c. Topical antibiotic d.
Circumcision e. Warm sitz baths