GENITOURINARY TRAUMA

Mark Boyko EM

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. mkerins_fahey@hotmail.com

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

Question

• A penile fracture is classically described using what vegetable?

Penile Fracture

• ‘Eggplant Deformity’

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

Question

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

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

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)

Classification of Renal Injury

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

Ask Me For References

• Questions?