genitourinary trauma
DESCRIPTION
GENITOURINARY TRAUMA. Mark Boyko EM. Objectives. Key aspects of GU trauma in an anatomical approach: External Genitalia Urethral Injury Bladder Injury Ureteral Injury Renal Injury. GU Trauma. 80% of GU trauma is BLUNT trauma - PowerPoint PPT PresentationTRANSCRIPT
Objectives
1. Key aspects of GU trauma in an anatomical approach:
• External Genitalia
• Urethral Injury
• Bladder Injury
• Ureteral Injury
• Renal Injury
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
Eur J Emerg Med. 2004 Aug;11(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. [email protected]
Human 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…
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
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
Urethral Injuries• Again, rare in females
• In males, divided into ‘anterior’ and ‘posterior’ urethra, divided by urogenital diaphragm
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
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
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
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 + DRE’s than true + (for tone, for sensation, for blood)
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)
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.
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
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)
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? --> Do a retrograde CT cystography
Bladder Injury - Imaging
• Retrograde cystography (either CR or CT) is imaging modality of choice
• Very sensitive
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.
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
Renal Injury
• 90% blunt trauma, 10% penetrating
• Again, relax. ‘Something else will kill them’ (less than 0.1% of trauma death)
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
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
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