Liping Xie

Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University

Urogenital Trauma

Urogenital Trauma

Renal & Ureteral InjuryBladder InjuryUrethral InjuryInjuries of the external genitalia

Three to 10% of trauma patients have GU involvement; 10-15% of trauma patients with abdominal injuries have GU involvement.

Renal Injury

Renal Injury

Renal injuries constitute 45% of all GU injuries;

Most renal injuries (80%) are minor and do not require surgical intervention;

Renal trauma can happen in both blunt or penetrating trauma;

Renal injuries are most commonly from motor vehicle accidents (MVAs);

Renal Injury Scale

Renal InjuryPhysical examination: Flank ecchymosis or mass indicates a

retroperitoneal process but is not specific to renal injuries and rarely occurs acutely.– The most important indicator of renal trauma

is gross or microscopic hematuria.– The absence of hematuria, although rare,

does not exclude renal injury because it is absent in 5% of patients.

Radiographic Staging IVP - double dose CT Scan - best method of staging - radiog

raphic study of choice Ultrasound Angiography - used for suspected renovas

cular injury

Renal Injury

CT Staging for Renal Injury

Right renal stab wound (Grade IV)

Left renal laceration

Management of Renal Injury

Surgical Management for Renal Injury

Ureteral Injury

Ureteral Injury

Ureteral injuries after external violence are rare, occurring in less than 4% of cases of penetrating trauma and less than 1% cases of blunt trauma.

Ureteral injuries after external violence, unlike renal injuries, are difficult to detect with the usual array of diagnostic tools.

Ureteral Injury

Excretory urography demonstrating extravasation in the upper right ureter consequent to stab wound (Arr

ow)

Surgical Management for Ureteral Injury

Bladder InjuryBladder injuries classified into contusions, extraperitoneal and intraperitoneal ruptures ;

Intraperitoneal (20%)

Extraperitoneal (80%)

Rupture

A full bladder is more likely to become injured than an empty one.

Bladder Injury

mostly occur in blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures;

15% occur with penetrating trauma and blunt mechanism without a pelvic fracture (ie, full bladder blowout).

gross hematuria in the trauma setting requires imaging of both upper and lower urinary tract

Bladder Injury

Diagnosis

Cystogram and CT are helpful diagnostic tools. Cystogram (left) shows extraperitoneal bladder rupture with extravasation into scrotum. CT(right) reveals intraperitoneal bladder rupture with contrast material surroundin

g bowel loops

Surgical Mangement of Bladder Rupture

Urethra Injury

Urethra Injury

Almost exclusively in maleMost common in straddle injureSignificant morbidity

– Stricture– Incontinence– Impotence

Foley catheter implication

Urethra Injury

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.

More common than posterior

Direct trauma Usually NO pelvic injury Blood at meatus Unable to micturate Penile/Scrotal/Perineal

– Contusion– Hematoma– Fluid collection

Posterior Urethra- Anterior Urethra-

Urethra Injury

EXTRAVASATION OF URINEHigh Riding Prostate on DRE

Diagnosis

Urethrogram is the best diagnostic tool-

Urethrogram

Contrast extravasation + Contrast in bladder

Contrast extravasation only

Urethrogram

PARTIAL Tear

COMPLETE Tear

retrograde urethrography via meatus

Extravasation of contrast medium with the “missing” bladder indicates a complete tear of

the urethra

Urethrogram

Management of Urethral Injury

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

IInitial urethral repair is not recommended nitial urethral repair is not recommended because of risk of hemorrhage, impotence, and because of risk of hemorrhage, impotence, and

infection of pelvic hematoma. infection of pelvic hematoma.

Management of Urethral Injury

Surgical Repair Bank’s Method

Penis– Penetrating, skin avulsion and amputation

repaired surgically– “fracture” repaired and drained surgically

Scrotum/testes– Hematocele and contusion (mild) or rupture

(severe, needs exploration)– Penetrating injuries need exploration

Injuries of the external genitalia

Injuries of the external genitalia

Penile fracturescrotal hematoma af

ter straddle injure