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Genitourinary TraumaGenitourinary Trauma
TIM EVANSTIM EVANS VIRGINIA VIRGINIA
COMMONWEALTH COMMONWEALTH UNIVERSITYUNIVERSITY
January 28, 2015January 28, 2015
BackgroundBackground If injury to GU system identified, multi-If injury to GU system identified, multi-
organ injury is the rule.organ injury is the rule. Examples:Examples:
– If renal injury found following penetrating If renal injury found following penetrating trauma, 80-95% chance of other significant trauma, 80-95% chance of other significant injuryinjury
– If renal injury found following blunt trauma, 75% If renal injury found following blunt trauma, 75% chance of other significant injury foundchance of other significant injury found
Other injuries may be more immediately life Other injuries may be more immediately life threatening and thereforethreatening and therefore
GU injury diagnosis may be overlooked or GU injury diagnosis may be overlooked or delayeddelayed
CaseCase Patient #1 is a 25 year old male is struck in the Patient #1 is a 25 year old male is struck in the
flank with a baseball bat. His systolic blood flank with a baseball bat. His systolic blood pressure is always above 100 mm Hg and his pressure is always above 100 mm Hg and his exam is only remarkable for a flank hematoma exam is only remarkable for a flank hematoma without abdominal tenderness. His urinalysis without abdominal tenderness. His urinalysis shows no RBCs. shows no RBCs.
Patient #1 got pissed off at the guy who hit him so Patient #1 got pissed off at the guy who hit him so he shot Patient #2 in the flank. Patient #2 is he shot Patient #2 in the flank. Patient #2 is hemodynamically stable and does not have any hemodynamically stable and does not have any RBCs in his urineRBCs in his urine
Two Questions:Two Questions:– Do either of these reprobates need imaging?Do either of these reprobates need imaging?– Do we need more bat control legislation?Do we need more bat control legislation?
Renal TraumaRenal Trauma
Most common GU injury—65% of GU Most common GU injury—65% of GU injuriesinjuries
10% of abdominal injuries involve the 10% of abdominal injuries involve the kidneyskidneys
MechanismMechanism– 80-95% due to blunt force—MVC, falls, 80-95% due to blunt force—MVC, falls,
assaults, sporting eventsassaults, sporting events
Renal AnatomyRenal Anatomy
RetroperitonealRetroperitonealAdjacent to lower two Adjacent to lower two
thoracic and first four thoracic and first four lumbar vertebraelumbar vertebrae
Upper poles protected by Upper poles protected by ribs so lower poles ribs so lower poles more commonly more commonly injuredinjured
Right kidney inferior to Right kidney inferior to left and more left and more commonly injuredcommonly injured
Kidney mobile, hilum Kidney mobile, hilum more fixed—concern more fixed—concern with shearing injury with shearing injury with decelerationwith deceleration
When are you concerned about When are you concerned about renal injuries?renal injuries?
Mechanism of InjuryMechanism of Injury– Penetrating injuries of abdomen, back or Penetrating injuries of abdomen, back or
flankflank– Deceleration injuriesDeceleration injuries
Physical examPhysical exam– Tenderness of abdomen or flankTenderness of abdomen or flank– Ecchymosis of abdomen or flankEcchymosis of abdomen or flank
XrayXray– Fractures of lower ribs, thoraco-lumbar spineFractures of lower ribs, thoraco-lumbar spine
When are you concerned about When are you concerned about renal injuries?renal injuries?
Hematuria—over 95% of patients with Hematuria—over 95% of patients with renal trauma will have some degree of renal trauma will have some degree of hematuria (>5 rbc/hpf) hematuria (>5 rbc/hpf)
THE PRESENCE OR DEGREE OF THE PRESENCE OR DEGREE OF HEMATURIA DOES NOT CORRELATE WITH HEMATURIA DOES NOT CORRELATE WITH THE SEVERITY OF THE INJURYTHE SEVERITY OF THE INJURY– 25% of patients with gross hematuria have 25% of patients with gross hematuria have
minor injuriesminor injuries– 40% of the most serious renal injuries do not 40% of the most serious renal injuries do not
have any hematuriahave any hematuria
Indications for imaging for Indications for imaging for renal traumarenal trauma
Penetrating trauma in proximity to kidneys—the Penetrating trauma in proximity to kidneys—the presence or absence of hematuria in penetrating presence or absence of hematuria in penetrating trauma not predictive of injury, location of wound trauma not predictive of injury, location of wound is most important factoris most important factor
Gross hematuriaGross hematuria Microscopic hematuria (>3-5 RBC/HPF) with Microscopic hematuria (>3-5 RBC/HPF) with
hemodynamic instability—systolic BP<90 at any hemodynamic instability—systolic BP<90 at any timetime
Persistent microscopic hematuriaPersistent microscopic hematuria ?Significant deceleration mechanisms?Significant deceleration mechanisms ?Proximal injuries with blunt mechanisms?Proximal injuries with blunt mechanisms
Mee SL, et al: Radiographic Assessment of Renal Trauma: A ten-year prospective study of patient Mee SL, et al: Radiographic Assessment of Renal Trauma: A ten-year prospective study of patient selection. J Urol 141:1095, 1989selection. J Urol 141:1095, 1989
When When notnot to image in to image in patients with concern for patients with concern for
renal traumarenal trauma Patients with microscopic hematuria Patients with microscopic hematuria
who have always been who have always been hemodynamically stablehemodynamically stable
Patients who are not Patients who are not hemodynamically stablehemodynamically stable
No significant renal injuries missed
Miller KS, McAninch JW: Radiographic assessment of renal trauma. Our 15-year experience. J Urol 1995;154:352-355
1 renal repair
Without
Imaging
1004
Imaged-
Significant injury 3
Imaged-
Contusion
581
Microhematuria and no shock
Gross hematuria or
Microhematuria and shock (SBP<90
mmHg) all imaged-422
Significant renal injuries
78
Renal repair
34
Imaging techniquesImaging techniques Contrast enhanced CT—the best test, up to Contrast enhanced CT—the best test, up to
98% accurate, not great for renal vein injuries98% accurate, not great for renal vein injuries IVP—perhaps useful in the OR to determine function IVP—perhaps useful in the OR to determine function
of contralateral kidney before contemplated of contralateral kidney before contemplated nephrectomynephrectomy
Angiography—better than CT for defining injuries to Angiography—better than CT for defining injuries to renal artery and vein, also used therapeutically to renal artery and vein, also used therapeutically to embolize or stent artery injuryembolize or stent artery injury
Ultrasound—30% false negative rate for injury, used Ultrasound—30% false negative rate for injury, used to look for two kidneys, free fluidto look for two kidneys, free fluid
Contrast Enhanced Ultrasound—perhapsContrast Enhanced Ultrasound—perhaps MRI—not first line due to time, sensitivity similar to MRI—not first line due to time, sensitivity similar to
CT, can be used for follow up studiesCT, can be used for follow up studies
AAST Kidney Injury Severity AAST Kidney Injury Severity ScaleScale
AAST Kidney Injury Severity AAST Kidney Injury Severity Scale—Revision 2011Scale—Revision 2011
Grade IV Grade IV - originally encompassed contained - originally encompassed contained injuries to the main renal artery and vein, and injuries to the main renal artery and vein, and collecting system injuries. Revision: adds collecting system injuries. Revision: adds segmental arterial and venous injury, and segmental arterial and venous injury, and laceration to the renal pelvis or ureteropelvic laceration to the renal pelvis or ureteropelvic junction. Multiple lacerations into the collecting junction. Multiple lacerations into the collecting system used to be considered a shattered kidney system used to be considered a shattered kidney (Grade V), but now remains Grade IV. (Grade V), but now remains Grade IV.
Grade VGrade V - originally included main renal artery or - originally included main renal artery or vein laceration or avulsion, and multiple collecting vein laceration or avulsion, and multiple collecting system lacerations (shattered kidney). The revised system lacerations (shattered kidney). The revised classification includes only vascular injury (arterial classification includes only vascular injury (arterial or venous) and includes laceration, avulsion or or venous) and includes laceration, avulsion or thrombosis. thrombosis.
Grade I-Renal contusionGrade I-Renal contusion
Grade I-Subcapsular Grade I-Subcapsular HematomaHematoma
Grade II-Small Cortical Grade II-Small Cortical LacerationLaceration
Grade III-Major Renal Grade III-Major Renal LacerationLaceration
Grade IV-Major Laceration Grade IV-Major Laceration involving Collecting Systeminvolving Collecting System
Grade IV- Multiple Renal Grade IV- Multiple Renal LacerationsLacerations
Grade IV-“Shattered” Grade IV-“Shattered” KidneyKidney
Grade V- Avascular Left Grade V- Avascular Left KidneyKidney
Trauma
Blunt
Hematuria
Microscopic (>5 RBC/HPF)
No shock
Image with concern for
other organs
Clinical
follow-up
Hematuria (Gross or microscopic)
Associated with shock
(SBP <90)
Unstable
Abdominal exploration
Single-shot
IVP on table
Abnormal or inconclusive
Renal exploration
Penetrating
Injury in proximity to kidney
Stable
CT scan with IV contrast
Grades III-V
Selective renal
exploration
Management of Renal Management of Renal InjuriesInjuries
Grade I—homeGrade I—home Grade II-IV—admit, observeGrade II-IV—admit, observe Grade V—observe, vascular repair/stent, Grade V—observe, vascular repair/stent,
or nephrectomyor nephrectomy
Only absolute indications for surgery are Only absolute indications for surgery are persistent renal bleeding with persistent renal bleeding with hemodynamic instability, active hemodynamic instability, active extravasation of IV contrast, expanding or extravasation of IV contrast, expanding or pulsatile perirenal hematoma suggesting pulsatile perirenal hematoma suggesting Grade V vascular injuryGrade V vascular injury
Complications of Renal Complications of Renal InjuriesInjuries
Mortality 3%Mortality 3% ComplicationsComplications
– First six weeksFirst six weeks Hemorrhage/shockHemorrhage/shock Sepsis/abscessSepsis/abscess ATNATN
– LateLate Renovascular HTN 1-4%Renovascular HTN 1-4%
CASECASE
30 year old s/p cystoscopic removal 30 year old s/p cystoscopic removal of distal ureteral stone. Now with of distal ureteral stone. Now with flank pain and nausea. T 39 C, flank pain and nausea. T 39 C, diffuse abdominal and flank diffuse abdominal and flank tenderness noted.tenderness noted.
U/A--negativeU/A--negative
Diagnosis? Studies?Diagnosis? Studies?
Ureteral TraumaUreteral Trauma
Accounts for 1% of urologic traumaAccounts for 1% of urologic trauma Most commonly iatrogenic following Most commonly iatrogenic following
GU, gynecologic, vascular or GU, gynecologic, vascular or colorectal surgerycolorectal surgery
If following external trauma, 80-95% If following external trauma, 80-95% due to penetrating mechanism, due to penetrating mechanism, usually GSWusually GSW
Ureteral AnatomyUreteral Anatomy
Thin, mobile tubes Thin, mobile tubes running between running between renal pelvis and renal pelvis and posterior superior posterior superior angle of bladderangle of bladder
Retroperitoneal in Retroperitoneal in abdomenabdomen
Protected from Protected from injury by size and injury by size and mobilitymobility
When are you concerned about When are you concerned about ureteral injuries?ureteral injuries?
Recent GU, gynecologic, vascular or Recent GU, gynecologic, vascular or colorectal procedure colorectal procedure
Penetrating (usually GSW) trauma to Penetrating (usually GSW) trauma to abd, back, flank abd, back, flank
Deceleration mechanismsDeceleration mechanisms Suspicion raised with injuries to iliac Suspicion raised with injuries to iliac
vessels, urinary bladder, sigmoid vessels, urinary bladder, sigmoid colon, thoracolumbar dislocations, colon, thoracolumbar dislocations, lumbar spine (including process) lumbar spine (including process) fracturesfractures
Hematuria following ureteral Hematuria following ureteral injuriesinjuries
Ureteral injury following iatrogenic cause—10-Ureteral injury following iatrogenic cause—10-15% of patients with hematuria15% of patients with hematuria
Hematuria absent in 30-60% of identified ureteral Hematuria absent in 30-60% of identified ureteral injuries from external violenceinjuries from external violence
Hematuria following penetrating trauma—a study Hematuria following penetrating trauma—a study of 71 ureteral injuries of 71 ureteral injuries – 32% without hematuria32% without hematuria– 40% with gross hematuria40% with gross hematuria– 28% with microscopic hematuria28% with microscopic hematuria
Brandes SB, et al: Ureteral injuries from penetrating trauma, J Trauma Brandes SB, et al: Ureteral injuries from penetrating trauma, J Trauma 36:766, 1994.36:766, 1994.
IMAGING FOR URETERAL IMAGING FOR URETERAL INJURIESINJURIES
Most injuries diagnosed during laparotomy Most injuries diagnosed during laparotomy and no imaging ever doneand no imaging ever done
Contrast CT with delayed imaging—most Contrast CT with delayed imaging—most common findings are extravasation of common findings are extravasation of contrast into medial perirenal space and contrast into medial perirenal space and absence of contrast in distal ureter if absence of contrast in distal ureter if transected transected
Retrograde pyelogramRetrograde pyelogram IVP—one shot IVP done in OR for IVP—one shot IVP done in OR for
penetrating traumapenetrating trauma
Delayed CT images showing Delayed CT images showing extravasation of urine from ureteral extravasation of urine from ureteral
injuryinjury
Blunt trauma
Gross hematuria, or microhematuria with deceleration or hypotension or associated injuries
Unstable, to OR
Intraoperative one-shot IVP
Normal
Consider other sources for
hematuria (bladder, urethra, kidney)
Penetrating trauma
Stable, to CT + contrast + delayed films
Potential ureteral injury (ureteral nonopacification or extravasation)
Unstable, to OR
Gross or micro-hematuria
Yes No
Intraoperative
One-shot IVP
Normal
Bullet/knife wound in vicinity of ureter
Explore ureter and repair
Stent removal
6 weeksAfter stent removal consider periodic renogram or surveillance ultrasound (defect hydronephrosis to rule out recurrence
Abnormal
American Association for the Surgery of American Association for the Surgery of Trauma (AAST)Trauma (AAST)
Ureter Injury Severity Scale Ureter Injury Severity Scale
GradeGrade DescriptionDescription
II HematomaHematoma Contusion or hematoma without Contusion or hematoma without devascularization devascularization
IIII LacerationLaceration <50% transection<50% transectionIIIIII LacerationLaceration >50% transection>50% transectionIVIV LacerationLaceration Complete transection with <2 cm Complete transection with <2 cm
devascularizationdevascularization
VV LacerationLaceration Avulsion with >2 cm devascularizationAvulsion with >2 cm devascularization
MANAGEMENT OF MANAGEMENT OF URETERAL INJURIESURETERAL INJURIES
TreatmentTreatment– Stents—Grade 1Stents—Grade 1– Surgery—Grade 2 and aboveSurgery—Grade 2 and above
ComplicationsComplications– Ureteral strictureUreteral stricture– FistulaFistula– Retroperitoneal fibrosisRetroperitoneal fibrosis– Abscess/SepsisAbscess/Sepsis
Intraoperative recognition
Minor ureteral injury Major ureteral injury
Stent Primary stented ureterourostony, psoas hitch, or flap with or without kidney mobilization
Ureteral stent 6 weeks
Follow-up retrograde pyelography and stent removal or replacement as needed
Consider placement of percutaneous nephrostomy in rare case of extremely long injury
After stent removal consider periodic renogram or surveillance ultrasound to rule our recurrence
Consider endoscopic methods (laser, balloon)
Primary stented ureteroureterostomy
Postoperative recognition
CT with contrast (+ delayed films) + retrograde pyelography
Minor ureteral injury
Ureteral stent 6 weeks
Follow-up retrograde pyelography and stent removal or replacement as needed
Success
Fail
After stent removal consider renogram or surveillance ultrasound to rule out recurrence
Consider endoscopic methods (laser, balloon)
Primary stented ureteroureterostomy, psoas hitch or flap
Consider autotransplant or ileal loop in rare case of extremely long injury
Major ureteral injury
Attempted retrograde stent placement
Success
Percutaneous nephrostomy and anterograde stent placement, if possible
Fail, wait
6 weeks
CaseCase
Urinary Bladder TraumaUrinary Bladder Trauma
Mechanisms of InjuryMechanisms of Injury– Blunt—up to 85% of casesBlunt—up to 85% of cases
70-95% of patients with bladder injuries will 70-95% of patients with bladder injuries will have pelvic fractureshave pelvic fractures
6-10% of patients with pelvic fractures will 6-10% of patients with pelvic fractures will have bladder injurieshave bladder injuries
– Penetrating—up to 15% of casesPenetrating—up to 15% of cases– Surgical/CystoscopySurgical/Cystoscopy
Urinary Bladder AnatomyUrinary Bladder Anatomy
Empty bladder is a Empty bladder is a pelvic organ and pelvic organ and protected by pelvic protected by pelvic bonesbones
With distention, With distention, becomes an becomes an abdominal organ and abdominal organ and more prone to injury more prone to injury due to direct traumadue to direct trauma
Peritoneum covers Peritoneum covers superior surface of superior surface of bladderbladder
When are you concerned about When are you concerned about a bladder injury?a bladder injury?
Clinical PresentationClinical Presentation– Suprapubic painSuprapubic pain– Difficulty voidingDifficulty voiding
Gross Hematuria—incidence approaches 100%Gross Hematuria—incidence approaches 100% Microscopic Hematuria possible with Microscopic Hematuria possible with
penetrating trauma, spontaneous bladder penetrating trauma, spontaneous bladder rupturerupture
X-rayX-ray– Widened symphysis pubis is stongest predictorWidened symphysis pubis is stongest predictor– Pelvic, sacrum, iliac, ramus fracturesPelvic, sacrum, iliac, ramus fractures– Widening of SI jointWidening of SI joint
Diagnostic StudiesDiagnostic Studies
Retrograde cystogramRetrograde cystogram Retrograde CT cystogramRetrograde CT cystogram
Either one follows urethogram if Either one follows urethogram if concern for urethral injury existsconcern for urethral injury exists
Indications for CystographyIndications for Cystography
Blunt Trauma in close proximity to Blunt Trauma in close proximity to bladder with gross hematuriabladder with gross hematuria
Pelvic fractures from blunt mechanism Pelvic fractures from blunt mechanism with any degree of hematuriawith any degree of hematuria
Penetrating Trauma in proximity to the Penetrating Trauma in proximity to the bladder bladder
Penetrating trauma with any degree of Penetrating trauma with any degree of hematuriahematuria
Technique for CystogramTechnique for Cystogram Retrograde Retrograde
urethrogram if urethrogram if indicatedindicated
Urinary catheterUrinary catheter 100 cc contrast100 cc contrast Plain filmPlain film 200-250 cc contrast 200-250 cc contrast
(5cc/kg)(5cc/kg) Plain filmPlain film Empty bladderEmpty bladder Plain filmPlain film Sensitivity for bladder Sensitivity for bladder
rupture near 100% if rupture near 100% if each step performedeach step performed
Retrograde Cystogram--Retrograde Cystogram--NormalNormal
Retrograde Cystogram—Retrograde Cystogram—Post-Void, NormalPost-Void, Normal
CT CystogramCT Cystogram
Same technique as Same technique as for plain for plain cystogram, no cystogram, no need to do post need to do post void studyvoid study
Sensitivity also Sensitivity also approaches 100%approaches 100%
Extraperitoneal Bladder Extraperitoneal Bladder RuptureRupture
50-90% of bladder 50-90% of bladder rupturesruptures
Usually associated Usually associated with pelvic fracturewith pelvic fracture
Usually treated Usually treated with with urethral/suprapubiurethral/suprapubic catheterc catheter
Retrograde Cystogram—Retrograde Cystogram—Extraperitoneal RuptureExtraperitoneal Rupture
Retrograde Cystogram—Retrograde Cystogram—Extraperitoneal RuptureExtraperitoneal Rupture
CT Cystogram—Extraperitoneal CT Cystogram—Extraperitoneal RuptureRupture
CT Cystogram with CT Cystogram with Extraperitoneal RuptureExtraperitoneal Rupture
CT Cystogram with CT Cystogram with Extraperitoneal Rupture with Extraperitoneal Rupture with
Sagittal ViewSagittal View
Intraperitoneal Bladder Intraperitoneal Bladder RuptureRupture
15-35% of bladder 15-35% of bladder rupturesruptures
Bladder usually Bladder usually distended at time distended at time of traumaof trauma
Historically treated Historically treated surgicallysurgically
Conservative Conservative management management possiblepossible
Retrograde Cystogram—Retrograde Cystogram—Intraperitoneal RuptureIntraperitoneal Rupture
Retrograde Cystogram—Retrograde Cystogram—Intraperitoneal RuptureIntraperitoneal Rupture
Retrograde Cystogram—Retrograde Cystogram—Intraperitoneal RuptureIntraperitoneal Rupture
Retrograde Cystogram—Retrograde Cystogram—Intraperitoneal RuptureIntraperitoneal Rupture
CT Cystogram-Intraperitoneal CT Cystogram-Intraperitoneal RuptureRupture
CT Cystogram—Intraperitoneal CT Cystogram—Intraperitoneal RuptureRupture
American Association for the Surgery of Trauma (AAST)American Association for the Surgery of Trauma (AAST)
Bladder Injury Severity ScaleBladder Injury Severity Scale
Grade Grade DescriptionDescription
II HematomaHematoma Contusion, intramural hematomaContusion, intramural hematoma LacerationLacerationPartial thicknessPartial thickness
IIII LacerationLaceration Extraperitoneal bladder wall laceration <2 cmExtraperitoneal bladder wall laceration <2 cmIIIIII LacerationLaceration Extraperitoneal (>2 cm) or intraperitoneal (<2 cm)Extraperitoneal (>2 cm) or intraperitoneal (<2 cm)
bladder wall lacerationbladder wall laceration
IVIV LacerationLaceration Intraperitoneal bladder wall laceration >2 cmIntraperitoneal bladder wall laceration >2 cmVV LacerationLaceration Intraperitoneal or extraperitoneal bladder wallIntraperitoneal or extraperitoneal bladder wall
laceration extending into the bladder neck or ureteral laceration extending into the bladder neck or ureteral orifice (trigone)orifice (trigone)
Urinary Bladder RupturesUrinary Bladder Ruptures
Patients may have both intra- and Patients may have both intra- and extra-peritoneal bladder rupturesextra-peritoneal bladder ruptures
20-40% Mortality for 20-40% Mortality for – Associated InjuriesAssociated Injuries– HemorrhageHemorrhage– SepsisSepsis
CaseCase
22 year old male 22 year old male engaging in engaging in sexual activitysexual activity
Hears and feels Hears and feels snap, crack and snap, crack and poppop
No more sexNo more sex Diagnosis? Diagnosis?
Penile FracturePenile Fracture
Urethral InjuriesUrethral Injuries
10% of all injuries to GU system10% of all injuries to GU system Potentially most debilitating GU injury due Potentially most debilitating GU injury due
to complicationsto complications Rare in womenRare in women Mechanism of InjuryMechanism of Injury
– Blunt trauma such as mvc, bike accidents, Blunt trauma such as mvc, bike accidents, straddle mechanismsstraddle mechanisms
– Often associated with pelvic fracturesOften associated with pelvic fractures– Rarely penetrating traumaRarely penetrating trauma– Occasionally iatrogenicOccasionally iatrogenic
Urethral AnatomyUrethral Anatomy
Anatomy Anatomy based on based on relation to relation to urogenital urogenital diaphragmdiaphragm– PosteriorPosterior
ProstaticProstatic MembranousMembranous
– AnteriorAnterior BulbousBulbous PenilePenile
Posterior Urethral InjuriesPosterior Urethral Injuries
80-90% occur in 80-90% occur in combination with combination with pelvic fracturepelvic fracture
10-25% of pelvic ring 10-25% of pelvic ring fractures disrupt fractures disrupt posterior urethra as posterior urethra as puboprostatic puboprostatic ligaments are torn or ligaments are torn or stretchedstretched
Associated with Associated with bladder injuries and bladder injuries and vaginal lacerationsvaginal lacerations
Anterior Urethral DisruptionAnterior Urethral Disruption
Usually due to direct Usually due to direct blunt force trauma blunt force trauma such as saddle injurysuch as saddle injury
Does not cause high Does not cause high riding prostate as riding prostate as injury is below the injury is below the urogenital diaphragmurogenital diaphragm
Ureteral injury present in Ureteral injury present in 10-38% of penile 10-38% of penile fractures (rupture of fractures (rupture of one or both tunica one or both tunica albuginea, fibrous albuginea, fibrous covering of corpus covering of corpus cavernosa) cavernosa)
When do you worry about When do you worry about urethral injuries?urethral injuries?
SymptomsSymptoms– Abdominal/Perineal PainAbdominal/Perineal Pain– Difficulty urinating—females can present with incontinenceDifficulty urinating—females can present with incontinence
Posterior—unable to urinatePosterior—unable to urinate Anterior—dysuria, small amountsAnterior—dysuria, small amounts
SignsSigns– Gross hematuriaGross hematuria– Blood at urethral meatusBlood at urethral meatus– Perineal swelling/ecchymosisPerineal swelling/ecchymosis– Vaginal lacerationsVaginal lacerations– Inability to pass urinary catheter (gentle attempt) Inability to pass urinary catheter (gentle attempt) – Abnormal prostate examAbnormal prostate exam
AbsentAbsent High ridingHigh riding BoggyBoggy
X raysX rays– Pelvic FracturesPelvic Fractures
Retrograde UrethrogramRetrograde Urethrogram
If urethral injury suspected, you may try If urethral injury suspected, you may try one gentle attempt at passing urinary one gentle attempt at passing urinary catheter—if it does not pass easily, don’t catheter—if it does not pass easily, don’t pushpush
Perform urethrogram—instill 10-30 cc of Perform urethrogram—instill 10-30 cc of contrast retrograde through urethracontrast retrograde through urethra
Complete disruption—contrast Complete disruption—contrast extravasates and none reaches bladderextravasates and none reaches bladder
Partial disruption—contrast extravasates Partial disruption—contrast extravasates and some reaches bladderand some reaches bladder
American Association for the Surgery of Trauma (AAST) American Association for the Surgery of Trauma (AAST) Urethra Injury Severity ScaleUrethra Injury Severity Scale
II ContusionContusion Blood at urethral meatus; urethrography Blood at urethral meatus; urethrography normalnormal
IIII Stretch InjuryStretch Injury Elongation of urethra without extravasation on Elongation of urethra without extravasation on urethrography urethrography
IIIIII Partial Partial Extravasation of urethrography contrast at injury Extravasation of urethrography contrast at injury site with site with DisruptionDisruption contrast visualized in the bladder contrast visualized in the bladder
IVIV CompleteComplete Extravasation of urethrography contrast at Extravasation of urethrography contrast at injury site injury site DisruptionDisruption without contrast visualization in without contrast visualization in the bladder; <2 cmthe bladder; <2 cm
of urethral separationof urethral separation
VV Complete Complete Complete transection with >2 cm urethral Complete transection with >2 cm urethral separation, orseparation, or DisruptionDisruption extension into the prostate or extension into the prostate or vaginavagina
Grade* Injury Type Description
Normal UrethrogramNormal Urethrogram
Grade III-Partial Urethral Grade III-Partial Urethral DisruptionDisruption
Grade III Partial Urethral Grade III Partial Urethral DisruptionDisruption
Grade IV or V Complete Grade IV or V Complete Urethral DisruptionUrethral Disruption
Grade V Complete Urethral Grade V Complete Urethral DisruptionDisruption
Urethral Trauma Urethral Trauma
DiagnosisDiagnosis– Retrograde UrethrogramRetrograde Urethrogram
TreatmentTreatment– Catheter, Stent, Primary anastomosisCatheter, Stent, Primary anastomosis
ComplicationsComplications– StrictureStricture– ImpotenceImpotence– IncontinenceIncontinence
CaseCase
Testicular TraumaTesticular Trauma
Mechanism—fall, Mechanism—fall, kick, sportskick, sports
Symptoms—pain, Symptoms—pain, N/V, lightheaded, N/V, lightheaded, remorseremorse
Diagnosis—Diagnosis—laceration, laceration, contusion, fracture, contusion, fracture, dislocationdislocation
Testicular TraumaTesticular Trauma
Diagnosis—Color flow Doppler ultrasoundDiagnosis—Color flow Doppler ultrasound ManagementManagement
– Contusion—rest, ice, analgesia, F/UContusion—rest, ice, analgesia, F/U– Laceration, dislocation, rupture--operativeLaceration, dislocation, rupture--operative
Penile AmputationPenile Amputation
Penile AmputationPenile Amputation
Penile Resurrection!Penile Resurrection!
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