Genitourinary trauma

Upper Tract Injuries (kidney + ureter)

• Majority of blunt trauma injuries present w/ hematuria
• 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

Diagnosis

Who to image?

1. Penetrating trauma
2. Blunt trauma with gross hematuria
3. Blunt trauma with microscopic hematuria (>5 rbc/HPF) and hemodynamic instability
4. High-energy deceleration mechanism or suspected associated intra-abdominal injuries

Disposition

Majority of blunt renal injuries and all penetrating renal injuries require admission

Lower Tract Injuries (bladder + urethra + genitalia)

• 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

Source

Harwood-Nuss