Genitourinary Trauma
François Dufresne
McGill Emergency Medicine
February 13th 2002
The Case of Jeremy
• 23 y.o male• Driver, Seatbelted• Frontal Impact, High Speed ( 100Km/h)• Airbag +• Other driver dead• Car completely destroyed• Empty EtOH bottles in the OTHER car• Patient was conscious at the scene.• On scene: BP=85/50 HR:120 RR:22 Sat:98%
Jeremy…
• A: Clear. C-spine protection. Backboard+
• B: A/E symetric. O2 Sat N. No crepitus. Trachea central.
• C: BP:100/60 HR:100 Mentating well.
• D: GCS=15 PERL.
• Pt is exposed.
• O2 - iv – monitor
• Temperature N Capillary Glucose N
Jeremy• AMPLE
– C/O abdo. Pain + “hip” pain
– C/O right lower leg pain
• Secondary Survey– Spleen normal. Mild suprapubic tenderness.
– Pelvic instability
– Probable right tibial #
– No gross blood at meatus. Rectal Normal.
• “Doctor, can I put a Foley?”
Jeremy• What are your concerns?• Foley?• What will be the usefulness of dipstick?• Dipstick good enough? U/A?• What if he has microscopic hematuria?• What if he has a pelvic fracture?• Any different if you had blood at meatus?• Urethrogram? Cystogram? Abdominal CT?• Worried about the kidneys? Bladder?• Does the low BP changes your suspicion for a
GU injury?
Introduction
• GU Trauma overlooked
• 10-20% of all injured patients
• Long term morbidity– Impotence– Incontinence
• Life-threatening injuries first
Plan
• Urethral Injury
• Bladder Injury
• Hematuria in Trauma
• Kidney Injury
Definitions
• Upper tract– Kydney– Ureters
• Lower tract– Bladder– Urethra
• External genitalia
Urethral Trauma• Almost exclusively in male
• Significant morbidity– Stricture– Incontinence– Impotence
• If unrecognized:– Converting partial to complete tear– Inaccurate assessment of U/O
• Foley catheter implication
Andrich DE et al. The nature of urethral injury in cases of pelvic fracture urethral trauma. Journal of Urology. 165(5):1492-5, 2001 May.
Anatomy
Bladder
Symphysis
Prostatic
Membranous
Bulbous
Pendulous
Posterior Urethra
• Violent external force
• Pelvic # in 90%
• Pelvic # : 5-25% of Posterior urethral injury
Clinical Features
• Gross hematuria in 98%
• Inability to void
• Blood at urethral meatus
• Pelvic / suprapubic tenderness
• Penile / scrotal / perineal hematoma
• Boggy / high-riding prostate/ ill-defined mass on rectal examination.
Digital Rectal Exam in Trauma
• Porter et al. Am Surg, 2001.– Prospective– Level II Trauma Center.– 423 patients.– DRE on all.– 7 (1.7%) pelvic fracture. NO Urethral injury– Prostate exam didn’t change management
Porter, J.M. et al. Digital rectal examination for trauma: does every patient need one? Am Surg 67(5):438, May 2001.
Posterior Urethral rupture
From McAnich JW. In Tanagho EA, McAninch JW, editors: Smith’s general urology, ed 14, Norwalk, Conn, 1995, Appleton & Lange.
Diagnosis:Retrograde Urethrogram
• Pretest KUB film
• Supine position
• Injection of 25ml of water-soluble contrast
• Different techniques
• X-ray when 10ml left and after 25ml
• Post-voiding x-ray.
Retrograde Urethrogram
Retrograde Urethrogram:Interpretation
• Contrast extravasation + Contrast in bladder
• Contrast extravasation only
PARTIAL Tear
COMPLETE Tear
Partial Tear
Complete Tear
Management• Partial tear
– careful passage of 12-14 Fr. Foley.– If any resistance: Urology
• Complete tear:– Urology + suprapubic cath.
• If Foley already there and suspect tear:– LEAVE FOLEY IN PLACE– Small tube alongside the foley– Angiocath 16-gauge– Modified urethrogram
Management…by Urology
• Controversial
• Complete VS Partial
• Posterior VS Anterior
• Foley X 3-14 days
• Suprapubic catheters
• Surgical approach / Endoscopy
• Delayed repair usually
Foley Catheter• NO if you suspect a urethral injury• Most of urethral injuries:
Pelvic # or Gross hematuria• Initial bladder effluent MUST be looked at.• Danger to convert partial into complete• Successful passage complete tear• NEVER REMOVE A FOLEY WHEN YOU
SUSPECT A PARTIAL TEAR AFTERWARDS.• ANY colored urine other that yellow
= BLOOD until proven otherwise
Prostatic
Membranous
Bulbous
Pendulous
Anterior Urethra• More common than posterior• Direct trauma• Usually NO pelvic #• Blood at meatus• Unable to micturate• Penile/Scrotal/Perineal
– Contusion– Hematoma– Fluid collection
Sleeve Hematoma
Butterfly Hematoma
Anterior Urethral Rupture
Anterior Urethra:Management
• NO Foley if injury suspected
• Retrograde Urethrogram
• Urology:– Surgical Treatment
Bladder Trauma
• Adult: Extraperitoneal organ• Bladder dome = weakest point• Blunt: 60-85%• MVA: #1 cause• Important to recognize
– Pelvic/abdominal wall abscess/necrosis
– Peritonitis
– Intra-abdominal abscess
– Sepsis / Death
Types of rupture
• Extraperitoneal– Most common– Pelvic # in 89-100%– Bladder rupture in 5-10% of all pelvic #
• Intraperitoneal– Extravasation of urine in abdomen– Sudden force to full bladder– Associated injuries +++ Mortality (20%)
Clinical Presentation
• 98% : Gross hematuria• 2%: Microscopic hematuria + Pelvic #
• 100%: Gross hematuria• 85% Pelvic #
•McConnel et al. Rupture of the bladder. Urol Clin North Am. 1982.
•Carroll et al. Major bladder trauma: Mechanisms of injury and a unified method of diagnosis and repair. Journal of Urology. 1984.
•Morey AF et al. Bladder rupture after blunt trauma : guidelines for diagnostic imaging. Journal of Trauma-Injury Infections & Critical Care. 51(4): 683-6, 2001 Oct.
Investigation
• Cystography: Gold standard• CT Cystography : New trend• Peng et al. AJR 1999.
– Prospective study– 55 patients. 5 bladder rupture– Cystography VS. CT cystography– Ruptures confirmed by Surgery– 100% sensitive and specific
Peng et al. CT cystography versus conventional cystography in evaluation of bladder injury. AJR 1999; 173:1269-1272.
Investigation…
Deck et al. Journal of Urology, 2000.– Retrospective study– 316 patients with CT Cystography– Sensitivity/Specificity = 95% and 100%– But 78% and 99% for intraperitoneal
rupture– Comparable to Cystography alone– Identifies other injuries
Deck AJ et al. CT Cystography for the diagnosis of traumatic bladder rupture. J Urol, Jul. 2000; 164(1); 43-6.
Standard Helical CT
• Pao et al. Acad Radiol 2000.– With IV contrast– Misses bladder rupture– 100% sensitive if “free fluid” criteria used.– Can R/O bladder injury if NO free fluid.– Not specific.– Not accepted as diagnostic tool.
Pao et al. Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 2000; 7:317-324.
Treatment
• Penetrating injuries: OR
• Blunt– Intraperitoneal: Almost all OR– Extraperitoneal: Urethral cath. drainage
x 7-10 days.
Hematuria• Hardeman and al. Journal Urol, 1987.
– Prospective study– 506 patients– IVP in all. CT/arteriography/O.R. PRN– Shock: BPs<90 at any time– 25 Injuries– ALL had either
• Gross hematuria• Shock + microhematuria
Hardeman et al. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. The Journal of Urology. 38:99-101, 1987.
Hardeman et al. …
• 365 (52 %) had microhematuria only– 174 D/C’ed , F/U and no problem– 191 admitted
• 1 renal contusion (Grade I)
• 2 minor lacerations (Grade II)
• No complication
Hardeman et al. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. The Journal of Urology. 38:99-101, 1987.
Mee et al. Journal Urol, 1989
• Prospective
• 1146 patients
• IVP = Gold standard
• ALL significant renal injuries had either:– Gross hematuria– Microscopic hematuria + shock
• Intensity of hematuria Severity of injury
Mee et al. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. Journal of Urology. 141(5):1095-8, 1989 May.
Gross « Hematuria »: False +
• Alphamethyldopa• Ibuprofen• Levodopa• Metronidazole• Nitrofurantoin• Phenazopyridine• Phenolphtalein-containing laxatives• Rifampin• Beets/berries
Microscopic hematuria…
• 8 major studies
• 3406 adult blunt trauma with microscopic hematuria and NO shock.
• 0.23% major renal injuries (gradeII)
• No imaging necessary for that group
• F/U 3-4 weeks to R/O underlying pathology.
• BUT…
Microscopic hematuria…
• Patients with pelvic # often excluded from studies.
• Penetrating trauma excluded.
• Pediatric population excluded
• « Rapid Deceleration injuries »
• Urinalysis on FIRST urine.
Dipstick vs. U/A
• Daum et al. AM J Clin Pathol, 1988.– Prospective– 178 patients– Abdominal Trauma– Dipstick AND Microscopic
examination
Daum et al. Dipstick evaluation of hematuria in abdominal trauma. Am J Clin Pathol, 1988; 89:538-542.
Daum et al.
Dipstick (Sensitivity)
Microscopy Trace 1+ 2+ 3+
5 RBC/hpf 100% 92% 84% 62%
10 RBC/hpf 100% 96% 92% 81%
Dipstick vs. U/A
• Chandhoke et al. J Urol, 1988.– Prospective study– 339 patients– Suspected blunt renal trauma– Dipstick AND microscopic examination
Chandhoke et al. Detection and significance of microscopic hematuria in patients with blunt renal trauma. J.Urol. 140: 16-18, 1988.
Chandhoke et al.
Dipstick (Sensitivity)
Microscopy Trace 1+ 2+ 3+
5 RBC/hpf 98% 89% 76% 51%
10 RBC/hpf 98% 92% 82% 59%
Kidney Injury
• Retroperitoneal organ
• Cushoned by perinephric fat
• Gerota’s fascia
• Along T10 - L4
• Ribs 10-12
• Fixed only through pedicle.
• 1.2L of blood / min
Kidney Injury…
• Blunt trauma: 80-90%• Rapid deceleration / Direct blow• MUST be suspected if
– Trauma to back / flank / lower thorax / upper abdomen
– Flank pain / low rib #– Hematuria / Ecchymosis over the flanks– Sudden decelaration / Fall from height.– Lumbar transverse process #
Lumbar Transverse Process Fractures
• Prospective study (1994-1999)
• Lumbar spine #
• 191 patients
• Transverse # in 29%
• Abdominal organ injuries 47% vs. 6%
• Kidney: 1/3
• Liver: 1/3
• Spleen: 1/4
Miller et al. Lumbar transverse process fractures: a sentinel marker of abdominal organ injuries. Injury. 31:773; 2000.
Abdominal organ injuries 47% vs. 6%
Kidney: 1/3
Classification of Injury
• 5 Classes of Renal Injury :
Organ Injury Scaling
CommitteeMoore et al. Organ Injury Scaling: Sleen, Liver and Kidney, The Journal of Trauma, 29: 1664; 1989.
Grade I
• Contusion– Hematuria
– Urologic studies N
• Hematoma– Subcapsular
– Non expanding
– Parenchyma N
Grade II
• Hematoma– Perirenal
– Nonexpanding
• Laceration– < 1.0 cm
– Renal cortex only
– No urinary extravasation
Grade III
• Laceration– > 1.0 cm
– Renal cortex only
– No urinary extravasation
– Intact collecting system
Grade IV
• Laceration– Renal cortex
– Renal medulla
– Collecting system
• Vascular– Main renal artery/vein
injury with contained hemorrage.
Grade V
• Completely shattered kidney.
• Avulsion of renal hilum (pedicule) which devascularizes kidney.
Kennon et al. Radiographic assessment of renal trauma: our 15-year experience. The Journal of Trauma, 154: 353-355; August 1995.
Pedicule Injury
Organ Injury Severity Scale
• Validated lately: Journal of Trauma, 2001
• Predicts the need for surgery
• Need for surgery ; nephrectomy rates:– Grade I: 0 ; 0%– Grade II: 15 ; 0%– Grade III: 76 ; 3%– Grade IV: 78 ; 9%– Grade V: 93 ; 86%
Santucci et al. Validation of the American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney. J Trauma; 50:195-200; 2001.
Investigation
• IVP– Used to be intial exam of choice.– Very poor sensitivity for penetrating injury– Limitation in staging renal injuries– Not 1st choice anymore. Only if pt unstable.
• Contrast CT– Study of choice if stable– More sensitive and specific for staging– Detects other abdominal injuries
Management
• Penetrating trauma:– Imaging for ALL (9%: NO hematuria)
• Blunt trauma Imaging:– Gross hematuria– Microscopic hematuria (5 RBC/hpf)
+ shock (BPs90)– Any child with > 50 RBC / hpf
Management…• Absolute indication for Surgery:
– Uncontrollable renal hemorrage– Multiply lacerated, shattered kidney– Main renal vessels avulsed– Penetrating injuries usually
• Grade I-II– conservative
• Grade III-IV– Conservative if stable hemodynamically vs. surgery
• Grade V– Surgery
Grade V
Back to Jeremy…
• First urine: Dipstick +++ (15 RBC/hpf)
• Pelvic x-ray: Straddle #
Kozin, Berlet. Handbook of Common Orthopaedic Fractures, 4th ed., 2000.
Jeremy…
• First urine: Dipstick +++ (15 RBC/hpf)
• Pelvic x-ray: Straddle #
• Keypoints…– BP: 85/50 on scene– Microhematuria– Pelvic #
• NO FOLEY
Jeremy…
• Urology consulted
• Retrograde urethrogram: N
• CT cystogram: N
• Contrast CT to look for renal injury: Grade II renal injury.
Conclusion
• No Foley if you suspect urethral trauma• Gross hematuria OR microhematuria + Shock =
GU Trauma.• Pelvic # + Microhematuria GU investigation• Don’t remove Foley if you suspect a partial tear
of urethra afterwards.• Microhematuria alone : No imaging …but F/U.• In peds: Imaging for ALL hematuria.
The EndThe End