Genitourinary trauma: Difference between revisions

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Upper Tract Injuries (kidney + ureter)
==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


*Majority of blunt trauma injuries present w/ hematuria
===Evaluation===
*Renal pedicle injuries and penetrating injuries to ureter may not cause hematuria!
 
*AAST Grading System for renal injuries
*Non-operative management
**Grade I: Cortex contusion
**Grade II: Cortex laceration
*Possible operative management
**Grade III: Corticomedullary junction laceration
***Grade IV: Collecting system laceration
*Operative management
**Grade V: Shattered kidney, thrombosis of renal artery, avulsion of hilum
*Who to image?
*Who to image?
**Penetrating trauma
**Penetrating Trauma
**Blunt trauma with gross hematuria
***Any degree of hematuria
**Blunt trauma with microscopic hematuria (>5 rbc/HPF) and hemodynamic instability
**Blunt Trauma
**High-energy deceleration mechanism or suspected associated intra-abdominal injuries
***Gross hematuria
*Disposition
***[[Hypotension]] and any degree of hematuria
**Majority of blunt renal injuries and all penetrating renal injuries require admission
***Child with >50rbc/HPF
***High index of suspicion for renal trauma
****Deceleration injuries even with no hematuria
****Multiple trauma patient
*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<ref>Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335.</ref><ref>33.* Holevar M, DiGiacomo C, Ebert J, et al. Practice management guidelines for the evaluation of genitourinary trauma. </ref>
**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 trauma|bladder rupture]], requires CT cystography


<br/>Lower Tract Injuries (bladder + urethra + genitalia)
===Types===
*[[Renal Injuries]]
*[[Ureter Injuries]]


==Lower Tract Injuries (bladder + urethra + genitalia)==
*Often accompany pelvic fracture
*Often accompany pelvic fracture
*Urethral Injuries
**Anterior: Self-instrumentation, falls, straddle injuries
**Posterior: Accompany pelvic fx
*Perform pelvic exam in all women with pelvic fractures!
*Signs: Blood at meatus, high prostate, difficulty voiding
*Management
**Presence of urethral injury should be ruled out prior to foley insertion!
**Retrograde urethogram
**Suprapubic cystotomy to allow drainage of bladder
*Bladder Rupture
**Extraperitoneal
***Assoc w/ pelvic fx and laceration by bony fragments
***Leakage of urine into perivesicular space
**Intraperitoneal
***Assoc w/ compresive force in presence of full bladder
**Pelvic fracture + gross hematuria = bladder rupture!
*Fewer than 1% of all blunt bladder injuries present with urinalysis w/ <25 RBCs/HPF
*Signs: blood at meatus, inability to void, suprapubic pain
*Management
**Bladder drainage via foley cather
**Diagnosic w/u indicated for patients with:
***Gross hematuria
***Inability to void
***Pelvic ring fx in assoc w/ microscopic hematuria
*Retrograde cystography
**A "tear drop" shape suggests extraperitoneal bladder rupture
*A routine abd/pelvis CT is not sensitive for bladder rupture!
**Need retrograde contrast
*Extraperitoneal rupture - nonoperative management with simple urinary drainage
*Intraperitoneal rupture - primary surgical repair
*External Genitalia Injury
**If suspect testicular injury obtain ultrasound
**Any pt with external genitialia trauma w/ hematuria, urinary retention or dysuria requires a retrograde urethrogram


Reference: Harwood-Nuss
{{Lower GU trauma DDX}}
 
==Differential Diagnosis==
{{Abdominal trauma DDX}}
 
==See Also==
*[[Traumatic Foley Catheter Removal]]
*[[Abdominal trauma]]
*[[Trauma (main)]]


==References==
<references/>
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Urology]]

Revision as of 04:06, 9 January 2020

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

Evaluation

  • 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
  • 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[1][2]
    • 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

Types

Lower Tract Injuries (bladder + urethra + genitalia)

  • Often accompany pelvic fracture

Genitourinary Trauma

Differential Diagnosis

Abdominal Trauma

See Also

References

  1. Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335.
  2. 33.* Holevar M, DiGiacomo C, Ebert J, et al. Practice management guidelines for the evaluation of genitourinary trauma.