Injuries to the genitourinary tract

*10% of all injuries seen in the emergency room involve the genitourinary system to some extent. *Many of them are subtle & difficult to define & require great diagnostic expertise. *early diagnoses is essential to prevent serious complications.

The mnemonic “ABCDE” defines these priorities in order of importance: A, airway with cervical spine protection B, breathing C, circulation and control of external bleeding D, disability or neurologic status E, exposure (undress) and environment (temperature control)

management of injured pt. should start by. *history include description of the accident, in gunshot wounds, the type & caliber of the weapon should be determined, since high velocity projectile cause much more extensive damage. *physical examination initial assessment should include control of hemorrhage & shock along with resuscitation as required.

after general examination. examination of abdomen &genitalia for evidence of contusions or subcutaneous hematomas -Fractures of the lower ribs are often associated with renal injuries -pelvic fractures often accompany bladder & urethral injuries. -Diffuse abdominal tenderness is consist with perforated bowel, free intraperitoneal blood or urine, or retroperitoneal hematoma.

1-catheterization. Blood at the urethral meatus in men indicates urethral injury. So catheterization is contraindicated if blood is present (may convert partial injury to complete one). Retrograde urethrography should be done immediately. If no blood is present at the meatus, urethral catheter can be carefully passed to the bladder, microscopic or gross hematuria indicate urinary system injury

2-excretory urography. Immediately after IV line have been established &resuscitation process has began 150ml (2ml/kg) of contrast material can be injected IV. Plain abdominal films permit adequate visualization of the kidneys. It Can be used to detect renal & ureteral injury.

3-retrograde cystography. Filling of the bladder with contrast material is essential to establish whether bladder perforation exist. At least 300ml should be instilled for full vesical distention. A film should be obtained with the bladder filled & second after the bladder has emptied itself.

4-urethrography. A small (12 F) catheter can be inserted into the urethral meatus & 3ml of water placed in the balloon to hold the catheter in position. After retrograde injection of 20 ml of contrast material. The urethra will be clearly outlined on film, & extravasation will be visualized if there is injury. 5-Arteiography. may help define renal parenchymal or renal vascular injury.

Injuries to the kidney -Renal injuries are most common injuries of the urinary system. -The kidney is well protected by heavy lumbar muscles, vertebral bodies, ribs, & the viscera anteriorly. -Fractured rib & transverse vertebral processes may penetrate the renal parenchyma or vasculature. *Kidneys with existing pathologic conditions such as hydronephrosis or malignant tumors are more readily rupture from mild trauma.

Etiology. 1-Blunt trauma directly to the abdomen, flank, or back is the most common mechanism, (80-85%) of all renal injuries. 2-Gunshot & knife wounds cause penetrating injuries & usually (80%) associated with abdominal visceral injuries. Pathology & classification. Pathologic classification of renal injuries is as follow: A-Early pathologic finding Staging of renal injuries.

Grade1 (the most common)—renal contusion or bruising of the renal parenchyma. Subcapsular hematoma without parenchymal laceration. Microscopic hematuria is common, rarely gross hematuria. Grade2—laceration extend (<1cm) in the renal cortex. Perirenal hematoma is usually small. Grade3—the laceration extend through the cortex into the medulla (>1cm)without urinary extravasation. Bleeding can be significant in the presence of large retroperitoneal hematoma. Grade4—the laceration extend into the collecting system. Laceration or thrombosis at a segmental vessel may also present. Grade5—a. multiple major lacerations (shattered kidney). b. avulsion of the renal pedicle or thrombosis of the main renal artery.

B-Late pathologic finding: 1-Urinoma. Deep laceration that are not repaired may result in persistent urinary extravasation & late complications of large perinephric renal mass & eventually, hydronephrosis & abscess formation. 2-Hydronephrosis. Large hematoma in the retroperitoneum & associated urinary extravasation may result in perinephric fibrosis engulfing the puj causing hydronephrosis.

3-Arteiovenous fistula. May occur after penetrating injury, but are not common. 4-Renal vascular hypertension. Which either due to compromised blood flow to the injured area (non viable) or due to fibrosis from surrounding hematoma cause constricted renal artery.

Clinical findings -Microscopic or gross hematuria following trauma to the abdomen indicate injury to the urinary tract. -Some cases of renal vascular injury are not associated with hematuria. (These cases are almost always due to rapid deceleration accident & are an indication for imaging studies.) the degree of renal injury does not correspond to the degree of hematuria. *patient with gross hematuria or microscopic hematuria+history of shock should undergo radiographic assessment.

A-Symptoms &signs pain may localized to one flank area or over the abdomen. *There is usually visible evidence of abdominal trauma (ecchymosis or lower rib fracture). *diffuse abdominal tenderness (acute abdomen) -free blood in the peritoneum, -rupture abdominal viscera or -multiple pelvic fractures also cause abdominal pain may obscure the presence of renal injury.

*shock or signs of large loss of blood from heavy retroperitoneal bleeding may be noted. *palpable mass (retroperitoneal hematoma or urinoma) may be present. B-Laboratory finding. *microscopic or gross hematuria. *normal hematocrit ratio initially later may drop if bleeding persist.

C-Staging & x-ray finding. *allows systemic approach by define the extent of the injury & dictate appropriate management. *Abdominal CT is the most direct & effective means of staging renal injuries, it clearly define -the parenchymal laceration -urinary extravasation -retroperitoneal hematoma -identifies the nonviable tissue -outline injuries to the surrounding organs.

*If CT not available IVU can be obtained. *Arteriography defines major arterial & parenchymal injuries when previous studies not done so. *the major causes of nonvisualized kidney on IVU -total pedicle avulsion, -arterial thrombosis, -severe contusion causing vascular spasm, -absence of kidney (either congenital or from surgery).

Complications. A-early complications. *Hemorrhage is the most important immediate complication. Pt must be observed closely (monitoring of BP & hematocrit). Bleeding ceases spontaneously in 80-85% of cases. Persistent retroperitoneal bleeding or heavy gross hematuria may require early operation. .

*Urinary extravasation from renal fracture may show an expanding mass (urinoma). These collections are prone to abscess formation & sepsis B-late complications -Hypertension, -hydronephrosis, -arteriovenous fistula, -calculus formation, & -pyelonephritis.

Treatment A .emergency measure prompt treatment of shock & hemorrhage, complete resuscitation, & evaluation of associated injuries. B. surgical measures 1-blunt injuries. 85% of blunt injuries are minor (grade 1&2) & don’t require operation. Bleeding stop spontaneously with bed rest & hydration.

Aggressive preoperative staging allow complete definition of injury before operation. Indication of surgery absolute -persistent renal bleeding, -expanding perirenal hematoma -Pulsatile perirenal hematoma -renal pedicle injuries (<5%) of all renal injuries. relative -urinary extravasation -evidence of nonviable renal parenchyma -segmental arterial injury, and -incomplete staging.

2-penetrating injuries should be surgically explored, except when staging show minor parenchymal injury & no urinary extravasation. *80% of cases penetrating injuries associated with other organ injuries, & renal exploration is only extension of this procedure.

Ureteral injuries Ureteral injures after external violence are rare, occurring in less than 4% of penetrating and 1% of blunt traumas. Ureteropelvic junction disruption after blunt trauma is rare and can be missed because -patients often do not exhibit hematuria -the injury is difficult to palpate during intraoperative manual examination

hysterectomy was responsible for the majority (54%), followed by colorectal surgery (14%), pelvic surgery such as ovarian tumor removal (8%), and abdominal vascular surgery (6%). but now a day endoscopic procedures regarded the most common cause of ureteral injury.

bladder injuries Either blunt or penetrating trauma they are rare, constituting less than 2% of abdominal injuries requiring surgery -6% to 10% of all cases of pelvic fractures after blunt trauma are associated with bladder injuries Conversely, most patients with bladder injuries (83% to 100%) have an associated pelvic fracture

*Extraperitoneal rupture can most commonly be managed with catheter drainage only *Intraperitoneal rupture 1-often much larger than suggested on cystography and are unlikely to heal spontaneously. 2-often associated with persistent urinary leakage if conservative management is attempted. 3-They cause urinary leakage into the abdominal cavity with resultant peritonitis, which can be fatal.

Urethral rupture Clinically, posterior urethral disruption is heralded by 1-blood at the urethral meatus 2- perineal pain & hematoma 3-inability to urinate (retention) 4-palpably full bladder. When blood at the urethral meatus is discovered, it is our policy to obtain an immediate retrograde urethrogram to rule out urethral injury.