Genitourinary trauma

Background

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

Renal anatomy.

Perinephric space with exaggerated pararenal space to show retroperitoneal structures. Perinephric bridging septa are seen between the left kidney and the adjacent renal fascia.

• Typically divided into:
  • Upper tract injuries (kidney + ureter)
    • Majority of blunt trauma injuries present with hematuria
    • Renal pedicle injuries and penetrating injuries to ureter may not cause hematuria
    • Renal injuries are associated with flank hematoma, lower rib fracture, penetrating wounds to flanks
  • Lower tract Injuries (bladder + urethra + genitalia)
    • Often accompany pelvic fracture

Differential Diagnosis

Genitourinary Trauma

• Urinary system
  • Renal trauma
  • Ureter trauma
  • Bladder trauma
  • Urethral trauma
    • Traumatic foley catheter removal
• Genital
  • Penile trauma
    • Traumatic foley catheter removal
  • Testicular trauma
  • Vaginal trauma
• Other
  • Child abuse
  • Pelvic fracture (often accompanies)
  • Sexual assault

Abdominal Trauma

• Abdominal compartment syndrome
• Diaphragmatic trauma
• Duodenal hematoma
• Genitourinary trauma
• Liver trauma
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Retroperitoneal hemorrhage
• Renal trauma
• Splenic trauma
• Trauma in pregnancy
• Ureter trauma

Evaluation

Workup

• Who to image?
  • Penetrating Trauma
    • Any degree of hematuria
  • Blunt Trauma
    • Gross hematuria
    • Hypotension and any degree of hematuria
    • Child with >50rbc/HPF
    • High index of suspicion for renal trauma
      • Deceleration injuries even with no hematuria
      • Multiple trauma patient

Diagnosis

• CT with IV contrast is the gold standard in assessing renal and GU trauma
  • More sensitive and specific than IVP, ultrasound, or angiography
  • However, can miss significant injuries to the renal pelvis, collecting system and ureter given CT generally obtained before contrast is excreted in the urine.
  • If initial CT shows high grade renal injury (grade IV of V), UPJ injury, or concern for ureteral injury, should obtain additional 10 minute delayed CT
  • Exception to using IVP over CT is perioperatively in unstable patients requiring immediate operation for other injuries
  • Note, CT A/P with IV contrast NOT sensitive enough for bladder rupture, requires CT cystography

See Also

• Traumatic Foley Catheter Removal
• Abdominal trauma
• Trauma (main)