GU TraumaGU TraumaJulian Gordon, MD Julian Gordon, MD

FACSFACS

May 23, 2006May 23, 2006

PerspectivePerspectivePerspectivePerspective

Commonly covert entity, occurs in Commonly covert entity, occurs in 10% of injured patients10% of injured patients

Diagnosis usually done in Diagnosis usually done in retrograde fashion,retrograde fashion,– i.e. urethra evaluated before bladder, i.e. urethra evaluated before bladder,

etc.etc. GU trauma divided into lower tract GU trauma divided into lower tract

(bladder, urethra), upper tract (bladder, urethra), upper tract (renal, ureter) or external genitalia(renal, ureter) or external genitalia

Commonly covert entity, occurs in Commonly covert entity, occurs in 10% of injured patients10% of injured patients

Diagnosis usually done in Diagnosis usually done in retrograde fashion,retrograde fashion,– i.e. urethra evaluated before bladder, i.e. urethra evaluated before bladder,

etc.etc. GU trauma divided into lower tract GU trauma divided into lower tract

(bladder, urethra), upper tract (bladder, urethra), upper tract (renal, ureter) or external genitalia(renal, ureter) or external genitalia

Physical ExamPhysical ExamPhysical ExamPhysical Exam

Careful exam of abdomen/torso and Careful exam of abdomen/torso and compression of pelvic girdle/pubic compression of pelvic girdle/pubic symphysissymphysis

Examine genitalia, looking for Examine genitalia, looking for hematoma or blood at urethral hematoma or blood at urethral meatusmeatus

Do not insert foley if blood at Do not insert foley if blood at meatus until retrograde meatus until retrograde urethrogram doneurethrogram done

Careful exam of abdomen/torso and Careful exam of abdomen/torso and compression of pelvic girdle/pubic compression of pelvic girdle/pubic symphysissymphysis

Examine genitalia, looking for Examine genitalia, looking for hematoma or blood at urethral hematoma or blood at urethral meatusmeatus

Do not insert foley if blood at Do not insert foley if blood at meatus until retrograde meatus until retrograde urethrogram doneurethrogram done

Lower Tract InjuriesLower Tract Injuries

Women with pelvic fractures need Women with pelvic fractures need to have a vaginal exam as bone to have a vaginal exam as bone fragments may lacerate the fragments may lacerate the vaginal vaultvaginal vault

OK to pass a Foley in females with OK to pass a Foley in females with pelvic fracturespelvic fractures

Rectal exam to check for “high Rectal exam to check for “high riding” prostateriding” prostate

Women with pelvic fractures need Women with pelvic fractures need to have a vaginal exam as bone to have a vaginal exam as bone fragments may lacerate the fragments may lacerate the vaginal vaultvaginal vault

OK to pass a Foley in females with OK to pass a Foley in females with pelvic fracturespelvic fractures

Rectal exam to check for “high Rectal exam to check for “high riding” prostateriding” prostate

Physical ExamPhysical Exam

Foley should be placed in all major Foley should be placed in all major trauma patientstrauma patients

Any urine that is not clear or yellow is Any urine that is not clear or yellow is considered gross hematuriaconsidered gross hematuria

Most lower tract injuries accompanied Most lower tract injuries accompanied by pelvic fracture will have blood at by pelvic fracture will have blood at meatus or gross hematuria meatus or gross hematuria

Blunt trauma to renovascular pedicle or Blunt trauma to renovascular pedicle or penetrating uretral injury may not penetrating uretral injury may not produce hematuriaproduce hematuria

Foley should be placed in all major Foley should be placed in all major trauma patientstrauma patients

Any urine that is not clear or yellow is Any urine that is not clear or yellow is considered gross hematuriaconsidered gross hematuria

Most lower tract injuries accompanied Most lower tract injuries accompanied by pelvic fracture will have blood at by pelvic fracture will have blood at meatus or gross hematuria meatus or gross hematuria

Blunt trauma to renovascular pedicle or Blunt trauma to renovascular pedicle or penetrating uretral injury may not penetrating uretral injury may not produce hematuriaproduce hematuria

Foley CatheterFoley Catheter

Urethral TraumaUrethral TraumaUrethral TraumaUrethral Trauma

Anatomy:Anatomy: Divided by UG diaphragm into Divided by UG diaphragm into

anterior and posterior urethraanterior and posterior urethra Pelvic fracture may result in a Pelvic fracture may result in a

laceration of the prostatic or laceration of the prostatic or membranous urethramembranous urethra

Anatomy:Anatomy: Divided by UG diaphragm into Divided by UG diaphragm into

anterior and posterior urethraanterior and posterior urethra Pelvic fracture may result in a Pelvic fracture may result in a

laceration of the prostatic or laceration of the prostatic or membranous urethramembranous urethra

PathophysiologyPathophysiology Most posterior urethral injuries due Most posterior urethral injuries due

to pelvic fracturesto pelvic fractures Most anterior injuries due to Most anterior injuries due to

straddle injuries, GSW, self-straddle injuries, GSW, self-instrumentationinstrumentation

PathophysiologyPathophysiology Most posterior urethral injuries due Most posterior urethral injuries due

to pelvic fracturesto pelvic fractures Most anterior injuries due to Most anterior injuries due to

straddle injuries, GSW, self-straddle injuries, GSW, self-instrumentationinstrumentation

Urethral TraumaUrethral Trauma

Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

Lack of pelvic tenderness, no Lack of pelvic tenderness, no hematomas, normal rectal exam hematomas, normal rectal exam all support an intact urethraall support an intact urethra

Pelvic crush injuryPelvic crush injury Blood at meatusBlood at meatus Distended BladderDistended Bladder Catheter-no urine outputCatheter-no urine output

Lack of pelvic tenderness, no Lack of pelvic tenderness, no hematomas, normal rectal exam hematomas, normal rectal exam all support an intact urethraall support an intact urethra

Pelvic crush injuryPelvic crush injury Blood at meatusBlood at meatus Distended BladderDistended Bladder Catheter-no urine outputCatheter-no urine output

DiagnosisDiagnosisDiagnosisDiagnosis

Ability to pass a Foley precludes Ability to pass a Foley precludes complete urethral disruption, complete urethral disruption, partial tear may existpartial tear may exist

If partial tear exists/attempt of If partial tear exists/attempt of passage of a Foley may be done, passage of a Foley may be done, consult urology if difficulty consult urology if difficulty

Consider urethral tear in any Consider urethral tear in any patient following unsuccessful cath patient following unsuccessful cath followed by bleedingfollowed by bleeding

Ability to pass a Foley precludes Ability to pass a Foley precludes complete urethral disruption, complete urethral disruption, partial tear may existpartial tear may exist

If partial tear exists/attempt of If partial tear exists/attempt of passage of a Foley may be done, passage of a Foley may be done, consult urology if difficulty consult urology if difficulty

Consider urethral tear in any Consider urethral tear in any patient following unsuccessful cath patient following unsuccessful cath followed by bleedingfollowed by bleeding

RadiologyRadiologyRadiologyRadiology

Retrograde urethrogram is procedure of Retrograde urethrogram is procedure of choice is all suspected urethral injurieschoice is all suspected urethral injuries

Perform urethrogram with patient in Perform urethrogram with patient in supine position with penis stretched supine position with penis stretched obliquely over the thigh, or in oblique obliquely over the thigh, or in oblique positionposition

First obtain KUB, and try to do with flouroFirst obtain KUB, and try to do with flouro Using a Toomey syringe, inject 60 ml of Using a Toomey syringe, inject 60 ml of

contrast into the penis over 30-60 secondscontrast into the penis over 30-60 seconds

Retrograde urethrogram is procedure of Retrograde urethrogram is procedure of choice is all suspected urethral injurieschoice is all suspected urethral injuries

Perform urethrogram with patient in Perform urethrogram with patient in supine position with penis stretched supine position with penis stretched obliquely over the thigh, or in oblique obliquely over the thigh, or in oblique positionposition

First obtain KUB, and try to do with flouroFirst obtain KUB, and try to do with flouro Using a Toomey syringe, inject 60 ml of Using a Toomey syringe, inject 60 ml of

contrast into the penis over 30-60 secondscontrast into the penis over 30-60 seconds

Complete vs. partial tear Complete vs. partial tear distinguished by the presence of distinguished by the presence of contrast in the bladdercontrast in the bladder

Complete vs. partial tear Complete vs. partial tear distinguished by the presence of distinguished by the presence of contrast in the bladdercontrast in the bladder

RadiologyRadiology

TreatmentTreatmentTreatmentTreatment

If normal urethrogram, place a If normal urethrogram, place a Foley Foley

For a partial tear, 1 attempt at For a partial tear, 1 attempt at Foley placement may be doneFoley placement may be done

For complete tear consult urology, For complete tear consult urology, may need to place suprapubic may need to place suprapubic catheter, or attempt endoscopic catheter, or attempt endoscopic assisted cathassisted cath

If normal urethrogram, place a If normal urethrogram, place a Foley Foley

For a partial tear, 1 attempt at For a partial tear, 1 attempt at Foley placement may be doneFoley placement may be done

For complete tear consult urology, For complete tear consult urology, may need to place suprapubic may need to place suprapubic catheter, or attempt endoscopic catheter, or attempt endoscopic assisted cathassisted cath

Bladder TraumaBladder Trauma

Bladder AnatomyBladder AnatomyBladder AnatomyBladder Anatomy

Lies within pelvis when empty, can Lies within pelvis when empty, can reach umbilicus when fullreach umbilicus when full

Consists of 3 muscle layersConsists of 3 muscle layers Blood supplied from int. iliac artery, Blood supplied from int. iliac artery,

nerve supply from lumbar and sacral nerve supply from lumbar and sacral plexusplexus

Bladder trauma usually associated Bladder trauma usually associated with severe injuries, mortality 22-with severe injuries, mortality 22-44%44%

Lies within pelvis when empty, can Lies within pelvis when empty, can reach umbilicus when fullreach umbilicus when full

Consists of 3 muscle layersConsists of 3 muscle layers Blood supplied from int. iliac artery, Blood supplied from int. iliac artery,

nerve supply from lumbar and sacral nerve supply from lumbar and sacral plexusplexus

Bladder trauma usually associated Bladder trauma usually associated with severe injuries, mortality 22-with severe injuries, mortality 22-44%44%

PathophysiologyPathophysiologyPathophysiologyPathophysiology

Can rupture in or outside of Can rupture in or outside of peritoneum, or bothperitoneum, or both

Extraperitoneal rupture usually Extraperitoneal rupture usually from pelvic fracture with laceration from pelvic fracture with laceration of bladder, but may occur with of bladder, but may occur with blunt traumablunt trauma

Can rupture in or outside of Can rupture in or outside of peritoneum, or bothperitoneum, or both

Extraperitoneal rupture usually Extraperitoneal rupture usually from pelvic fracture with laceration from pelvic fracture with laceration of bladder, but may occur with of bladder, but may occur with blunt traumablunt trauma

Intraperitoneal rupture usually Intraperitoneal rupture usually from blunt trauma in patients with from blunt trauma in patients with a full bladdera full bladder

Clinically will see lower abdominal Clinically will see lower abdominal pain, inability to urinate, blood at pain, inability to urinate, blood at meatusmeatus

Intraperitoneal rupture usually Intraperitoneal rupture usually from blunt trauma in patients with from blunt trauma in patients with a full bladdera full bladder

Clinically will see lower abdominal Clinically will see lower abdominal pain, inability to urinate, blood at pain, inability to urinate, blood at meatusmeatus

PathophysiologyPathophysiology

LabLabLabLab

Gross hematuria indicative of Gross hematuria indicative of urologic injuryurologic injury

Clear urine and no pelvic fracture Clear urine and no pelvic fracture virtually eliminates possibility of virtually eliminates possibility of bladder rupturebladder rupture

98% of patients with bladder 98% of patients with bladder rupture have gross hematuriarupture have gross hematuria

Gross hematuria indicative of Gross hematuria indicative of urologic injuryurologic injury

Clear urine and no pelvic fracture Clear urine and no pelvic fracture virtually eliminates possibility of virtually eliminates possibility of bladder rupturebladder rupture

98% of patients with bladder 98% of patients with bladder rupture have gross hematuriarupture have gross hematuria

RadiologyRadiologyRadiologyRadiology

Retrograde cystogram is Retrograde cystogram is diagnostic procedure of choicediagnostic procedure of choice

Retrograde cystogram is Retrograde cystogram is diagnostic procedure of choicediagnostic procedure of choice

Retrograde CystogramRetrograde CystogramRetrograde CystogramRetrograde Cystogram

Exclude urethral injury and place a FoleyExclude urethral injury and place a Foley Contrast is instilled under gravity thru a Contrast is instilled under gravity thru a

Toomey syringe without its central pistonToomey syringe without its central piston Obtain KUB firstObtain KUB first Instill contrast until 100cc with x-ray Instill contrast until 100cc with x-ray

evidence of extravasation, 300-400 cc in evidence of extravasation, 300-400 cc in patient older than 11patient older than 11

Use flouroscopic monitoringUse flouroscopic monitoring Children (age+2)x30ccChildren (age+2)x30cc

Exclude urethral injury and place a FoleyExclude urethral injury and place a Foley Contrast is instilled under gravity thru a Contrast is instilled under gravity thru a

Toomey syringe without its central pistonToomey syringe without its central piston Obtain KUB firstObtain KUB first Instill contrast until 100cc with x-ray Instill contrast until 100cc with x-ray

evidence of extravasation, 300-400 cc in evidence of extravasation, 300-400 cc in patient older than 11patient older than 11

Use flouroscopic monitoringUse flouroscopic monitoring Children (age+2)x30ccChildren (age+2)x30cc

Foley is clamped and AP film takenFoley is clamped and AP film taken Then empty bladder and take post-Then empty bladder and take post-

evacuation filmevacuation film If extraperitoneal perforation, will see If extraperitoneal perforation, will see

contrast in area of pubic contrast in area of pubic symphysis,intraperitoneal perforation symphysis,intraperitoneal perforation will outline abdominal contentswill outline abdominal contents

May see false negatives if less than 300-May see false negatives if less than 300-400cc of contrast used400cc of contrast used

Foley is clamped and AP film takenFoley is clamped and AP film taken Then empty bladder and take post-Then empty bladder and take post-

evacuation filmevacuation film If extraperitoneal perforation, will see If extraperitoneal perforation, will see

contrast in area of pubic contrast in area of pubic symphysis,intraperitoneal perforation symphysis,intraperitoneal perforation will outline abdominal contentswill outline abdominal contents

May see false negatives if less than 300-May see false negatives if less than 300-400cc of contrast used400cc of contrast used

Retrograde CystogramRetrograde Cystogram

CT SCANCT SCANCT SCANCT SCAN

Obtain same anatomic info, Obtain same anatomic info, contrast instilled in retrograde contrast instilled in retrograde fashionfashion

Obtain same anatomic info, Obtain same anatomic info, contrast instilled in retrograde contrast instilled in retrograde fashionfashion

TreatmentTreatmentTreatmentTreatment

If no extravasation treat with or If no extravasation treat with or without Foley drainagewithout Foley drainage

Extraperitoneal ruptures treated Extraperitoneal ruptures treated with Foley drainage for 7 to 15 with Foley drainage for 7 to 15 days with 20Fr. or greater sized days with 20Fr. or greater sized cathetercatheter

If no extravasation treat with or If no extravasation treat with or without Foley drainagewithout Foley drainage

Extraperitoneal ruptures treated Extraperitoneal ruptures treated with Foley drainage for 7 to 15 with Foley drainage for 7 to 15 days with 20Fr. or greater sized days with 20Fr. or greater sized cathetercatheter

Surgical repair if rupture involves Surgical repair if rupture involves bladder neck or proximal urethrabladder neck or proximal urethra

Intraperitoneal ruptures always Intraperitoneal ruptures always require surgical repairrequire surgical repair– Children 77%Children 77%– Increased Bun/CrIncreased Bun/Cr– Potentially lethalPotentially lethal

Surgical repair if rupture involves Surgical repair if rupture involves bladder neck or proximal urethrabladder neck or proximal urethra

Intraperitoneal ruptures always Intraperitoneal ruptures always require surgical repairrequire surgical repair– Children 77%Children 77%– Increased Bun/CrIncreased Bun/Cr– Potentially lethalPotentially lethal

TreatmentTreatment

Upper Tract TraumaUpper Tract Trauma

Renal InjuryRenal Injury

ComplicationsComplicationsComplicationsComplications

Renovascular HTN in 1% Renovascular HTN in 1% associated with pedicle injuries associated with pedicle injuries and failed arterial repairsand failed arterial repairs

Renovascular HTN in 1% Renovascular HTN in 1% associated with pedicle injuries associated with pedicle injuries and failed arterial repairsand failed arterial repairs

EpidemiologyEpidemiologyEpidemiologyEpidemiology

Blunt trauma accounts for 80-85% of all Blunt trauma accounts for 80-85% of all renal injuriesrenal injuries– MVAMVA– SportsSports– Domestic violenceDomestic violence

Intraperitoneal injury found in 20% of Intraperitoneal injury found in 20% of blunt trauma and 80% of penetrating blunt trauma and 80% of penetrating traumatrauma

Pedicle injuries due to Pedicle injuries due to acceleration/decelerationacceleration/decelerationor penetrating injuryor penetrating injury

Blunt trauma accounts for 80-85% of all Blunt trauma accounts for 80-85% of all renal injuriesrenal injuries– MVAMVA– SportsSports– Domestic violenceDomestic violence

Intraperitoneal injury found in 20% of Intraperitoneal injury found in 20% of blunt trauma and 80% of penetrating blunt trauma and 80% of penetrating traumatrauma

Pedicle injuries due to Pedicle injuries due to acceleration/decelerationacceleration/decelerationor penetrating injuryor penetrating injury

LabsLabsLabsLabs

Degree of hematuria not indicative Degree of hematuria not indicative of severity of severity

1998 guidelines state major renal 1998 guidelines state major renal lacerations may be repaired, adults lacerations may be repaired, adults at risk for major lacerations have at risk for major lacerations have gross or microscopic hematuria and gross or microscopic hematuria and shock shock

CT is procedure of choice for CT is procedure of choice for imagingimaging

Degree of hematuria not indicative Degree of hematuria not indicative of severity of severity

1998 guidelines state major renal 1998 guidelines state major renal lacerations may be repaired, adults lacerations may be repaired, adults at risk for major lacerations have at risk for major lacerations have gross or microscopic hematuria and gross or microscopic hematuria and shock shock

CT is procedure of choice for CT is procedure of choice for imagingimaging

PedsPedsPedsPeds

Kidney most frequently injured Kidney most frequently injured organ in blunt traumaorgan in blunt trauma

Major injuries may have Major injuries may have microscopic hematuria without microscopic hematuria without shockshock

If less than 50RBC/hpf, imaging If less than 50RBC/hpf, imaging can be deletedcan be deleted

Kidney most frequently injured Kidney most frequently injured organ in blunt traumaorgan in blunt trauma

Major injuries may have Major injuries may have microscopic hematuria without microscopic hematuria without shockshock

If less than 50RBC/hpf, imaging If less than 50RBC/hpf, imaging can be deletedcan be deleted

When is Imaging Indicated When is Imaging Indicated ??

When is Imaging Indicated When is Imaging Indicated ??

Penetrating traumaPenetrating trauma Pediatric traumaPediatric trauma

– Blunt > 50 rbc’sBlunt > 50 rbc’s Deceleration injuryDeceleration injury Adult blunt traumaAdult blunt trauma

– Gross hematuriaGross hematuria– Microhematuria & shock (sbp<90)Microhematuria & shock (sbp<90)

Penetrating traumaPenetrating trauma Pediatric traumaPediatric trauma

– Blunt > 50 rbc’sBlunt > 50 rbc’s Deceleration injuryDeceleration injury Adult blunt traumaAdult blunt trauma

– Gross hematuriaGross hematuria– Microhematuria & shock (sbp<90)Microhematuria & shock (sbp<90)

RadiologyRadiologyRadiologyRadiology

IVP: 1.5 – 2ml/kg bolus IVP IVP: 1.5 – 2ml/kg bolus IVP preferredpreferred– This study is adequate 60-85% of the This study is adequate 60-85% of the

timetime– Abnormal findings often require Abnormal findings often require

further imagingfurther imaging– ““single shot” IVP is discouragedsingle shot” IVP is discouraged

CT with IV contrast is procedure of CT with IV contrast is procedure of choicechoice

IVP: 1.5 – 2ml/kg bolus IVP IVP: 1.5 – 2ml/kg bolus IVP preferredpreferred– This study is adequate 60-85% of the This study is adequate 60-85% of the

timetime– Abnormal findings often require Abnormal findings often require

further imagingfurther imaging– ““single shot” IVP is discouragedsingle shot” IVP is discouraged

CT with IV contrast is procedure of CT with IV contrast is procedure of choicechoice

What is the Best Imaging What is the Best Imaging Study ?Study ?

What is the Best Imaging What is the Best Imaging Study ?Study ?

Computed TomographyComputed Tomography– Accurate stagingAccurate staging– Non-invasiveNon-invasive– Detects associated injuriesDetects associated injuries– RapidRapid– Need contrastNeed contrast

Computed TomographyComputed Tomography– Accurate stagingAccurate staging– Non-invasiveNon-invasive– Detects associated injuriesDetects associated injuries– RapidRapid– Need contrastNeed contrast

RENAL INJURY SCALERENAL INJURY SCALERENAL INJURY SCALERENAL INJURY SCALE

II Contusion Contusion hematuria with hematuria with normal studies normal studies

IIII Hematoma Hematoma subcapsular or subcapsular or perirenalperirenal

IIIIII Laceration Laceration <1cm renal cortex<1cm renal cortex IVIV Laceration Laceration >1cm w/o extrav or >1cm w/o extrav or

into collecting systeminto collecting system VV Vascular Vascular Renal artery or Renal artery or

vein, vein, or or shattered kidneyshattered kidney

II Contusion Contusion hematuria with hematuria with normal studies normal studies

IIII Hematoma Hematoma subcapsular or subcapsular or perirenalperirenal

IIIIII Laceration Laceration <1cm renal cortex<1cm renal cortex IVIV Laceration Laceration >1cm w/o extrav or >1cm w/o extrav or

into collecting systeminto collecting system VV Vascular Vascular Renal artery or Renal artery or

vein, vein, or or shattered kidneyshattered kidney

TreatmentTreatment

Blunt InjuryBlunt InjuryBlunt InjuryBlunt Injury

Adults with less than 3-5 RBC/hpf or Adults with less than 3-5 RBC/hpf or children with less than 50 RBC/hpf children with less than 50 RBC/hpf can be discharged from ED with can be discharged from ED with close follow upclose follow up

Only 1-2% of injuries involve the Only 1-2% of injuries involve the pedicle, but salvage rate is only 15-pedicle, but salvage rate is only 15-20%20%

Renal injuries are more common, Renal injuries are more common, result from deceleration tend to be result from deceleration tend to be partial tearspartial tears

Adults with less than 3-5 RBC/hpf or Adults with less than 3-5 RBC/hpf or children with less than 50 RBC/hpf children with less than 50 RBC/hpf can be discharged from ED with can be discharged from ED with close follow upclose follow up

Only 1-2% of injuries involve the Only 1-2% of injuries involve the pedicle, but salvage rate is only 15-pedicle, but salvage rate is only 15-20%20%

Renal injuries are more common, Renal injuries are more common, result from deceleration tend to be result from deceleration tend to be partial tearspartial tears

Venous injuries tend to bleed moreVenous injuries tend to bleed more CT scan will diagnosis most arterial CT scan will diagnosis most arterial

injuries, venous injuries diagnosed injuries, venous injuries diagnosed indirectly due to large hematomaindirectly due to large hematoma

Renal lacerations account for 2-4% Renal lacerations account for 2-4% of all renal injuries, diagnosed by of all renal injuries, diagnosed by CTCT

Venous injuries tend to bleed moreVenous injuries tend to bleed more CT scan will diagnosis most arterial CT scan will diagnosis most arterial

injuries, venous injuries diagnosed injuries, venous injuries diagnosed indirectly due to large hematomaindirectly due to large hematoma

Renal lacerations account for 2-4% Renal lacerations account for 2-4% of all renal injuries, diagnosed by of all renal injuries, diagnosed by CTCT

Blunt InjuryBlunt Injury

Surgical repair controversialSurgical repair controversial Minor renal lacerations/contusions Minor renal lacerations/contusions

managed expectantlymanaged expectantly

Surgical repair controversialSurgical repair controversial Minor renal lacerations/contusions Minor renal lacerations/contusions

managed expectantlymanaged expectantly

Blunt InjuryBlunt Injury

Penetrating InjuriesPenetrating InjuriesPenetrating InjuriesPenetrating Injuries

Hematuria is of no consequence as Hematuria is of no consequence as all patients need CT, most will all patients need CT, most will need surgeryneed surgery

Hematuria is of no consequence as Hematuria is of no consequence as all patients need CT, most will all patients need CT, most will need surgeryneed surgery

Ureteral TraumaUreteral Trauma

PathophysiologyPathophysiologyPathophysiologyPathophysiology

Rare, most due to penetrating Rare, most due to penetrating injury or iatrogenicinjury or iatrogenic

Most in upper 1/3 of ureter, Most in upper 1/3 of ureter, consider in patient with recent consider in patient with recent penetrating injury and palpable penetrating injury and palpable flank massflank mass

Blunt injuries often associated with Blunt injuries often associated with other injuriesother injuries

Rare, most due to penetrating Rare, most due to penetrating injury or iatrogenicinjury or iatrogenic

Most in upper 1/3 of ureter, Most in upper 1/3 of ureter, consider in patient with recent consider in patient with recent penetrating injury and palpable penetrating injury and palpable flank massflank mass

Blunt injuries often associated with Blunt injuries often associated with other injuriesother injuries

Diagnosis/TreatmentDiagnosis/TreatmentDiagnosis/TreatmentDiagnosis/Treatment

Usually made by finding urine in Usually made by finding urine in surgical wounds/dressings or the surgical wounds/dressings or the development of a urinomadevelopment of a urinoma

Contrast CT or bolus IVP will Contrast CT or bolus IVP will delineate the injurydelineate the injury

Retrograde pyelography will aid in Retrograde pyelography will aid in diagnosisdiagnosis

All injuries need surgical repairAll injuries need surgical repair

Usually made by finding urine in Usually made by finding urine in surgical wounds/dressings or the surgical wounds/dressings or the development of a urinomadevelopment of a urinoma

Contrast CT or bolus IVP will Contrast CT or bolus IVP will delineate the injurydelineate the injury

Retrograde pyelography will aid in Retrograde pyelography will aid in diagnosisdiagnosis

All injuries need surgical repairAll injuries need surgical repair

External Genital TraumaExternal Genital TraumaPenile TraumaPenile Trauma

Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

Strangulation with string or hair Strangulation with string or hair seen in kidsseen in kids

Adolescents /adults may have Adolescents /adults may have incarceration injuries with metal incarceration injuries with metal rings, bottles, etcrings, bottles, etc

Consider abuse in childrenConsider abuse in children

Strangulation with string or hair Strangulation with string or hair seen in kidsseen in kids

Adolescents /adults may have Adolescents /adults may have incarceration injuries with metal incarceration injuries with metal rings, bottles, etcrings, bottles, etc

Consider abuse in childrenConsider abuse in children

Penile FracturePenile FracturePenile FracturePenile Fracture

During an erectionDuring an erection Loud crack and detumescenceLoud crack and detumescence Penile hematomaPenile hematoma Urethral injury in 20%(blood at Urethral injury in 20%(blood at

meatus)meatus) R/O dorsal vein or artery lacerationR/O dorsal vein or artery laceration ? Cavernosogram, MRI, exploration? Cavernosogram, MRI, exploration

During an erectionDuring an erection Loud crack and detumescenceLoud crack and detumescence Penile hematomaPenile hematoma Urethral injury in 20%(blood at Urethral injury in 20%(blood at

meatus)meatus) R/O dorsal vein or artery lacerationR/O dorsal vein or artery laceration ? Cavernosogram, MRI, exploration? Cavernosogram, MRI, exploration

Penile Trauma TreatmentPenile Trauma TreatmentPenile Trauma TreatmentPenile Trauma Treatment

Superficial lacerations repaired with 4.0 Superficial lacerations repaired with 4.0 absorbable sutureabsorbable suture

Degloving injuries need to go to the ORDegloving injuries need to go to the OR Penile amputation may be reattached Penile amputation may be reattached

within 6 hours (preserve in saline & pack in within 6 hours (preserve in saline & pack in ice)ice)

Most penile fractures need operative repairMost penile fractures need operative repair Human bites to penis treated same as Human bites to penis treated same as

other body areasother body areas

Superficial lacerations repaired with 4.0 Superficial lacerations repaired with 4.0 absorbable sutureabsorbable suture

Degloving injuries need to go to the ORDegloving injuries need to go to the OR Penile amputation may be reattached Penile amputation may be reattached

within 6 hours (preserve in saline & pack in within 6 hours (preserve in saline & pack in ice)ice)

Most penile fractures need operative repairMost penile fractures need operative repair Human bites to penis treated same as Human bites to penis treated same as

other body areasother body areas

Testicular TraumaTesticular Trauma

Testicular TraumaTesticular TraumaTesticular TraumaTesticular Trauma

Usually caused by a fall or kickUsually caused by a fall or kick Will see pain, n/v, occasional Will see pain, n/v, occasional

urinary retentionurinary retention Testicle may be swollen, or small Testicle may be swollen, or small

hematoma felthematoma felt All patients need color doppler All patients need color doppler

ultrasoundultrasound

Usually caused by a fall or kickUsually caused by a fall or kick Will see pain, n/v, occasional Will see pain, n/v, occasional

urinary retentionurinary retention Testicle may be swollen, or small Testicle may be swollen, or small

hematoma felthematoma felt All patients need color doppler All patients need color doppler

ultrasoundultrasound

TreatmentTreatmentTreatmentTreatment

ContusionContusion– IceIce– RestRest– NSAIDsNSAIDs

Dislocations, lacerations, Dislocations, lacerations, disruptiondisruption– SurgerySurgery

ContusionContusion– IceIce– RestRest– NSAIDsNSAIDs

Dislocations, lacerations, Dislocations, lacerations, disruptiondisruption– SurgerySurgery

Necrotizing Skin InfectionsNecrotizing Skin InfectionsNecrotizing Skin InfectionsNecrotizing Skin Infections

Predisposing factorsPredisposing factors– ETOH abuseETOH abuse– Diabetes mellitusDiabetes mellitus– Prolonged bed restProlonged bed rest

– EtiologyEtiology: perirectal, periurethral, : perirectal, periurethral, cutaneous abcessescutaneous abcesses

Predisposing factorsPredisposing factors– ETOH abuseETOH abuse– Diabetes mellitusDiabetes mellitus– Prolonged bed restProlonged bed rest

– EtiologyEtiology: perirectal, periurethral, : perirectal, periurethral, cutaneous abcessescutaneous abcesses