Genito-Urinary Trauma

Supervised bye Dr. Rami Al-Azab

Prepared by :Ahmad Kreeshan

&Al-Bara’a Zboon

Introduction

• GU Trauma is overlooked

• 10-20% of all injured patients• Life-threatening injuries first but DON’T

neglect GU trauma .• Long term morbidity

– Impotence– Incontinence

classification

• Upper tract– Kydney– Ureters

• Lower tract– Bladder– Urethra

• External genitalia

Urethral Trauma

• Almost exclusively in male

• 60 % due to Blunt trauma.

• 40 % due to penetrating and iatrogenic.

anatomy

anatomy

ProstaticMembranous

Bulbous

Pendulous

anatomy

• In males, the urethra is divided into the proximal (posterior) segment and the distal (anterior) segment by the urogenital diaphragm.

• The posterior urethra is further divided into membranous (sphincteric) and prostatic segments. About 3 cm long.

Classification

• Posterior urethral injuries >> most commonly related to major blunt trauma and major falls, and most of such cases are accompanied by pelvic fractures.

• anterior urethral injuries >> most commonly related to blunt trauma to the perineum (straddle injuries)

Etiology

• Blunt trauma• Penetrating trauma• Iatrogenic trauma (difficult catheterization )

Posterior urethral injuries

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.

Diagnosis:Retrograde Urethrogram

Retrograde Urethrogram

• MUST be performed prior to foley catheter placement .

• Pretest KUB film• Supine position 30 degree• Injection of 25ml of contrast medium• X-ray when 10ml left and after 25ml• Post-voiding x-ray .

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 : surgery

• Complete tear:– suprapubic cath. + surgery .

• surgery = primary endoscopic realignment and delayed repair (10-14 d) or late primary closure (>3 mo).

• Early urethral repair is not recommended because of risk of hemorrhage, and infection.

Complications

• Stricture• Incontinence• Impotence

Outcome and Prognosis

• Men with urethral injuries have an excellent prognosis when managed correctly.

• Problems arise if a urethral injury is unrecognized and the urethra is further damaged by attempts at blind catheterization.

• In those cases, future reconstruction may be compromised and recurrent stricture rates rise.

Foley Catheter

• NO if you suspect a urethral injury• When to suspect urethral injuries :

Pelvic # or Gross hematuria• Danger to convert partial into complete• NEVER REMOVE A FOLEY WHEN YOU SUSPECT A

PARTIAL TEAR AFTERWARDS.• ANY colored urine other that yellow >>> it’s BLOOD

until proven otherwise .

Anterior Urethra• More common than posterior• bulbous injury is the most common urethral

injury .• Direct trauma (straddle-type)• Usually NO pelvic #• Blood at meatus• Unable to micturate• Penile/Scrotal/Perineal

– Contusion– Hematoma– Fluid collection

Anterior Urethral Rupture

Urine filling penis and scrotum and extending into abdomen beneath Scarpa’s fascia. No extension into thigh.

Sleeve Hematoma

Blood Restricted to Buck's fascia. 

Butterfly Hematoma

Anterior urethral rupture through Buck’s fascia confined by Colles’ fascia

Management

• NO Foley if injury suspected

• Retrograde Urethrogram

• Surgical Treatment

Bladder Trauma

• Adult : Extraperitoneal organ• Peds: Intraperitoneal until 6 y.o

• Bladder dome = weakest point• 60-85 % due to blunt trauma• Most Common Cause is MVA

Anatomy

Etiology

• Blunt trauma .• Penetrating trauma .• Iatrogenic trauma .

Clinical Presentation

• low abdo pain• inability to void• ecchymosis over suprapubic and pelvic region• Gross hematuria• Pelvic #

examination

• Abdominal distention, guarding, or rebound tenderness.

• Absent bowel sounds and signs of peritoneal irritation indicate a possible intraperitoneal bladder rupture.

• A rectal examination should be performed to exclude rectal injury and, in males, to evaluate prostate position.

Investigation…

• Plan x-ray• Cystography : Gold standard

(MUST R/O urethral injury before doing it)• CT scan

Cystography• Obtain KUB.• Place a urethral catheter in the bladder.• Using a diluted contrast medium, slowly fill the bladder by

gravity (approximately 75 cm above the pelvis) to a volume of 300-400 mL.

• Obtain a single AP film of the pelvis and lower abdomen after the first 100 mL of contrast is instilled.

• If gross extravasation is noted, discontinue the procedure. If extravasation is absent, give the patient the remainder of the contrast.

• Obtain a KUB, followed by a postdrainage film of the pelvis.

Cystography ..• Obtain the postdrainage film after a complete drainage of the

contrast. This is the most critical part of the study because it checks for extravasation that may be hidden by the distended bladder.

• If possible, obtain lateral and oblique films of the bladder. In children, obtain the estimated filling for the cystogram based on the following formula:

Bladder capacity = 60 mL + (30 mL X age in years)

• accuracy of a well-performed static cystogram ranges from 85%-100%

Types of injury

1. Bladder contusion :• incomplete or partial-thickness tear of the

bladder mucosa >> resulting in localized injury and hematoma

• Patients presenting with gross hematuria after blunt trauma and normal imaging findings

• relatively benign , diagnosis of exclusion, self-limiting and require conservative therapy .

2. Rupture :• Extraperitoneal

– Most common– ~ 90% have a pelvic fracture– Bladder rupture in 5-10% of all pelvic #

• Intraperitoneal– Extravasation of urine in abdomen– Sudden force to full bladder

CT scan of extraperitoneal bladder rupture. The contrast extravasates from the bladder into the prevesical space

Cystogram of intraperitoneal bladder rupture. The contrast enters the intraperitoneal cavity and outlines loops of bowel.

Cystogram of extraperitoneal bladder rupture. Note the fractured pelvis and contrast extravasation into the space of Retzius.

Indications for immediate repair• Intraperitoneal injury from external trauma • Penetrating or iatrogenic non-urologic injury • Inadequate bladder drainage or clots in urine • Bladder neck injury • Rectal or vaginal injury • Open pelvic fracture • Pelvic fracture requiring ORIF• Patients undergoing laparotomy for other reasons • Bone fragments projecting into bladder

Pelvic wall anatomy

Treatment• Most extraperitoneal ruptures can be managed safely with simple

catheter drainage (ie, urethral or suprapubic). Leave the catheter in for 7-10 days and then obtain a cystogram. Approximately 85% of the time, the laceration is sealed and the catheter is removed for a voiding trial.

• extraperitoneal bladder injuries heal within 3 weeks.• extensive extraperitoneal extravasation are often repaired

surgically• Most, if not all, intraperitoneal bladder ruptures require surgical

exploration. These injuries do not heal with prolonged catheterization alone. Urine takes the path of least resistance and continues to leak into the abdominal cavity. This results in urinary ascites, abdominal distention, and electrolyte disturbances.

complications

• Potential complications of bladder surgery – Urinary extravasation– Wound dehiscence– Hemorrhage– Pelvic infection– Small-capacity bladder– urge incontinence

Hematuria and trauma

Ureteral Trauma• Ureteral injuries due to external trauma are rare. The ureter

is well-protected in the retroperitoneum by the bony pelvis, psoas muscle, and vertebrae.

• Iatrogenic trauma is the most common cause .• Most iatrogenic injuries (70%-80%) are diagnosed

postoperatively. The presenting signs and symptoms may include flank pain (36%-90%), fever and sepsis (10%), fistula (ureterovaginal and/or ureterocutaneous), or renal failure secondary to bilateral obstruction (10%).

• abdominal or flank mass, costovertebral angle tenderness

invistigation

• CT scan >> primary imaging modality to evaluate for ureteral integrity in the stable patient.

• Retrograde pyelography (RPG) is the most sensitive radiographic study for the diagnosis of ureteral injury in the stable patient and allows for ureteral stent placement in the same session, as indicated.

• Surgical exploration of the retroperitoneum with direct visualization of the ureter is the best method of diagnosing ureteral injury.

treatment

Transureteroureterostomy

Vesicopsoas hitch

Complication

• The most common acute complication is prolonged urinary leakage from the anastomosis. >>> This can manifest as urinoma, abscess, or peritonitis >>> can be prevented by intraoperative placement of a drain in the retroperitoneum.

• Other complications common to all repairs may include stricture, hydronephrosis, abscess, fistula formation, and infection.

Kidney trauma

• Retroperitoneal organ• Cushoned by perinephric fat• Along T10 - L4• Ribs 10-12

Kidney trauma• 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 #

• 5-10% will NOT have hematuria

Classification of kidney Injury

• American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney …

• 5 Classes of Renal Injury :

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.

Organ Injury Severity Scale

• 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%

Invistigations

• 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• 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

Testicular trauma• Penetrating testicular trauma usually requires scrotal exploration to

determine the severity of testicular injury, to assess the structural integrity of the testis, and to control intrascrotal hemorrhage.

• If the tunica albuginea is violated, early surgical exploration, debridement, and closure of the tunica albuginea are necessary.

• Blunt injuries are encountered more often than penetrating injuries and are usually unilateral, whereas penetrating injuries involve both testes in a third of cases.

• Most cases of blunt trauma to the testicles are minor and usually require only conservative therapy, However, in one study, Buckley and McAninch (2006) reported that 46% of patients presenting with blunt scrotal trauma underwent surgical exploration and were found to have rupture of the tunica albuginea.

This scrotal sonogram shows a healthy testis

This scrotal sonogram shows a fractured testis with a disrupted tunica albuginea and testicular contents surrounded by tunica vaginalis .

Etiology• The most common cause of blunt testicular trauma is

sports injuries .• The second most common cause of testicular trauma is a

kick to the groin. • Less common etiologies include motor vehicle accidents,

falls, and straddle injuries.• The most common cause of penetrating testicular

injuries is a gunshot wound to the genital area .

presentation

• scrotal pain, frequently associated with nausea and vomiting .

• Physical examination often reveals a swollen, severely tender testicle with a visible hematoma.

• Scrotal or perineal ecchymosis may be present. • Bilateral testicular examination and perineal

examination should always be performed to rule out associated pathologies.

management

• Institute conservative treatment for patients with minor trauma in which the testes are unequivocally spared and the scrotum has not been violated.

• The usual treatment consists of scrotal support, nonsteroidal anti-inflammatory medications, ice packs, and bed rest for 24-48 hours

management Indications for scrotal exploration include the

following: • Uncertainty in diagnosis after appropriate clinical

and radiographic evaluations• Clinical findings consistent with testicular injury• Disruption of the tunica albuginea• Absence of blood flow on sonograms with Doppler

studies

Penile fracture• Penile fracture is the traumatic rupture of the corpus

cavernosum. • Traumatic rupture of the penis is relatively uncommon and

is considered a urologic emergency.• Sudden blunt trauma or abrupt lateral bending of the penis

in an erect state can break the markedly thinned and stiff tunica albuginea, resulting in a fractured penis .

• Penile fracture is treated by early exploration and repair of the tunica albugenia of the penis.

penile fracture involving the right corpus cavernosum.

Classification of bladder injury

• Type 1 Bladder contusion• Type 2 Intraperitoneal rupture• Type 3 Interstitial bladder injury• Type 4 Extraperitoneal rupture:• A. Simple• B. Complex• Type 5 Combined injury