GENITOURINARY TRAUMA

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GENITOURINARY TRAUMA

• Mark Boyko EM

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Objectives

• Key aspects of GU trauma in an anatomical
  approach
• External Genitalia
• Urethral Injury
• Bladder Injury
• Ureteral Injury
• Renal Injury

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GU Trauma

• 80 of GU trauma is BLUNT trauma
• Very rarely is life threatening, so take a step
  back and move through your systems anatomically
• Assessing for concomitant pelvic fracture is one
  of the most important points

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Eur J Emerg Med. 2004 Aug11(4)223-4.A human
bite to the scrotum a case report and review of
the literature.Kerins M, Greene S, O'Connor
N.Emergency Department, St Thomas' Hospital,
Lambeth Palace Road, London, SE1 7EH, UK.
mkerins_fahey_at_hotmail.comHuman bites to the
scrotum are rare and can be associated with a
high morbidity rate if poorly managed. We report
a case of a human bite to the scrotum that was
successfully treated with a 5-day course of
antibiotics, surgical debridement and healing by
secondary intention.
Anything can happen
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External Genitalia

• Trauma here is rare in females
• In males, injury is often obvious
• Look for swelling, ecchymoses, deformity
• Testicular torsion can occur with trauma
• Testicular rupture occurs in 50 of patients with
  a direct blow to a testicle, have a low threshold
  to ultrasound

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Male External Genitalia

• Penile Fracture
• Usually a sexual accident
• Immediate pain, often hear a popping sound,
  early swelling
• Is a rupture of the tunica albuginea surrounding
  the corpora cavernosa
• 20 association with urethral injury
• Requires operative repair

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Question

• A penile fracture is classically described using
  what vegetable?

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Penile Fracture

• Eggplant Deformity

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Urethral Injuries

• Again, rare in females
• In males, divided into anterior and posterior
  urethra, divided by urogenital diaphragm

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Urethral Injury

• In males, 25 of all pelvic fractures have
  urethral injury (vs only 5 in females), more
  commonly the posterior division
• Gross hematuria and pelvic fracture posterior
  urethral injury until proven otherwise
• The big 4 clues to urethral injury
• Blood at meatus
• Gross hematuria
• Inability to void
• Ecchymoses, swelling of penis

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Question

• What 4 things are necessary before you can
  attempt to pass a foley catheter?

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The Great Foley Debate

• Textbook answer
• 4 things allowing you to pass a foley safely
• 1. No pelvic and suprapubic tenderness /
• 2. No penile, scrotal, or perineal hematoma
• 3. No blood at the urethral meatus
• 4. No abnormal findings on DRE

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The Great DRE Debate

• Textbook answer
• high riding prostate or boggy prostate is
  concerning for a posterior urethral injury
• blood causes the prostate to lift superiorly

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Is any of this true?? EM Rap 2008

• The Great Foley Debate
• Initial concept came from 1977 paper by a British
  urologist entitled A Personal View of Immediate
  Management of Pelvic Fracture and Ureteral
  Injury - no references
• UCLA retrospective review of 7 years trauma
  patients, 46 urethral injuries, 50 of blind
  passes were successful
• The classic signs of urethral injury were
  extremely non-sensitive
• One small retrospective review of 13 cases of
  urethral injury demonstrated no evidence that a
  blind attempt to insert a urinary catheter
  worsened the initial injury.
• No case reports that passing a foley
  caused/worsened urethral injury
• The Great DRE Debate
• -same UCLA retrospective review, 0 had high
  riding prostates
• -UCLA 1400 trauma patients, more false DREs
  than true (for tone, for sensation, for blood)

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Urethral Injury - Imaging

• If any concern for a urethral injury, do a
  retrograde urethrogram
• Will either be
• Normal
• Partial urethral injury (some dye in bladder,
  some extravascation)
• Complete urethral injury (no dye in bladder)

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Urethral Injury - Management

• If no concern for injury, or retrograde
  urethrogram normal, put a foley in.
• If a partial urethral tear, textbooks say one
  careful attempt to pass a 12- or 14-Fr Foley can
  be undertaken. Most urologists disagree with
  this, and wish to be consulted.
• If a complete tear suprapubic catheter, urology
  consult for operative repair.

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Bladder Injury

• Question Which part of the bladder is the
  weakest and most likely to rupture?
• A) Trigone
• B) Lateral walls
• C) Dome (superior wall)
• D) Posterior wall

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Bladder Injury

• 80 of bladder injuries associated with pelvic
• Injuries classified as
• Contusions
• Intra-peritoneal ruptures (through the dome)
• Extra-peritoneal ruptures (seen exclusively with
  pelvic fractures)

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Bladder Injury

• Signs
• GROSS hematuria (95 of cases)
• Microscopic hematuria with a pelvic fracture
• No pelvic fracture No gross hematuria excludes
  injury to bladder
• What about pelvic and microscopic hematuria?
  --gt Do a retrograde CT cystography

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Bladder Injury - Imaging

• Retrograde cystography (either CR or CT) is
  imaging modality of choice
• Very sensitive

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Bladder Injury
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Bladder Injury - Management

• Contusions conservative
• Intra-peritoneal operative repair
• Extra-peritoneal many are now managed
  non-operatively with an indwelling foley
  catheter, will usually heal spontaneously.

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Ureteral Injury

• Extremely rare, gunshot is most common
• No reliable Phx findings! Usually a retrograde
  diagnosis
• Urinalysis is normal 25 of the time, do not rely
  on it
• Being suspicious for it is the only way you will
  catch it
• Imaging Delayed CT with IV contrast
• Management Requires OR

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Renal Injury

• 90 blunt trauma, 10 penetrating
• Again, relax. Something else will kill them
  (less than 0.1 of trauma death)

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Classification of Renal Injury
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Hematuria and Renal Injury

• Poor correlation with degree of injury
• Microscopic hematuria on its own is not a
  concern. Repeat urinalysis in 3 weeks
• You should image if the following
• Microscopic hematuria with shock
• GROSS hematuria
• Rapid deceleration without hematuria or shock
  (rare, but important)
• Penetrating trauma in the region

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Renal Imaging

• CT with IV contrast is 90-100 SENS
• Remember, FAST ultrasound is not good for solid
  organ injury, do not use it in this setting
• Formal ultrasound not as sensitive as CT

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Renal Injury - Management

• If no rapid deceleration mechanism (how rapid?)
  and no gross hematuria, can d/c home with f/u
  urinalysis
• Grade I and II injuries ? non-operative. Bed
  rest until gross hematuria clears.
• Grade III and up ? decision point for urology

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Ask Me For References

• Questions?