Genitourinary Trauma Dr. Andrew McDonald Sept. 19, 2006 Group B rounds presentation

Goals Interactive discussion of GU trauma cases Review relevant anatomy and epidemiology as needed Review current diagnostic and management approaches

Learning objectives When to suspect GU injury? Significance of hematuria or pelvic #? When to withhold a Foley catheter? When to do a cystogram/CT cystogram? Is CT grading of renal injuries helpful? What are the management strategies and when to call Urology? How do we approach penetrating GU trauma?

Case 1 21 year old man ejected from a car at high speed Hypotension at scene improves with fluids Has mild abdominal tenderness with left flank abrasions Does he likely have a GU injury?

Case 1 Epidemiology ~4% of trauma centre pts have GU injury 80% renal, 10% bladder, 10% other 72% minor, 17%moderate, 11% major 90+% conservative management

Case 1 Index of Suspicion Hx – deceleration injuries, abd blunt trauma, “straddle” injury Px – flank tenderness/bruising/abrasion, lower rib injury, abd tenderness, perineal hematoma, meatal blood, abn rectal exam

Case 1 Basic Investigations Pelvic xray ~90% bladder rupture have a pelvic fracture 10% of pelvic fracture have bladder injury Anterior pelvic fracture think of post urethral injury

Case 1 Basic Investigations Urinalysis Mee, S. J. Urology 141:1095 1989 All significant renal injuries had gross hematuria OR microhematuria and hypotension Degree of hematuria not correlated to injury Blunt trauma with shock usually get CT abd We have stopped dipping urines

Case 1 Pelvis xray Catheter urine Further investigate? Stable pelvic fracture Catheter urine Gross hematuria Further investigate?

Case 1 Renal Grading on CT I -contusion/subcapsular hematoma II -small cortical laceration/non- expanding retroperitoneal hematoma III -laceration >1cm or extravasation IV -laceration down to collecting system or vascular injury V -shattered kidney/avulsed hilum

Renal laceration

Case 1 Management Surgery for Ongoing hemorrhage Major laceration/shattered kidney Vascular pedicle injury Avoid contrast if going for CT if possible

Case 2 44 year old man pedestrian struck and thrown 10m Brief LOC, arm fractures, pain in pelvic area Prostate exam normal, pubic rami fractures Does he likely have a GU injury?

Case 2 Index of Suspicion Hx Straddle or direct penile trauma Pelvic pain or fracture Px Perineal hematoma Blood at meatus Abnormal rectal exam

Case 2 Urethrogram Technique Problems – relate to dye Options if abnormal One attempt if “channel” exists Insert suprapubic catheter Call Urology for suprapubic catheter

Urethrogram techniques

Case 2 Urethral injuries Posterior (75%) with pelvic fractures Anterior (25%) with straddle injury Penetrating Women (rare)

Urethrogram

Urethrogram

Urethrogram

Urethrogram

Case 2 Bladder injuries Intraperitoneal (20%) Extraperitoneal (80%) 95-100% have gross hematuria Presence of pelvic fracture not helpful in deciding whom to investigate

Case 2 Cystogram Plain cystogram CT cystogram Sequencing of tests Technique Advantages and Problems CT cystogram Advantages Sequencing of tests

Cystogram

Cystogram

CT cystogram

CT cystogram

CT cystogram

Case 2 Management Surgical repair Intraperitoneal bladder rupture Some Urethral repairs

Case 3 30 year old woman stabbed to flank and lower abdomen Hemodynamically stable Catheterized for clear urine Does she likely have a GU injury?

Case 3 Need to also consider ureter injury Hematuria correlates poorly in penetrating GU injury Higher proportion go to operative repair Decision to work up based on anatomy and index of suspicion

Case 3 Needs renal/ureter test e.g. CT/IVP Needs cystogram Low threshold for Urology referral

Other injuries Penis Scrotum/testes 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

Pediatric trauma Low threshold for CT in blunt abd trauma due to difficult exam Don’t work up microscopic hematuria alone if reliable

Mgt Summary Urology consultation for Ongoing renal hemorrhage Major renal laceration/vascular inj on CT Penetrating renal/ureteral trauma Intraperitoneal bladder rupture Urethral injury Penile reconstruction/fracture Testicular rupture

Learning objectives When to suspect GU injury? Significance of hematuria or pelvic #? When to withhold a Foley catheter? When to do a cystogram/CT cystogram? Is CT grading of renal injuries helpful? What are the management strategies and when to call Urology? How do we approach penetrating GU trauma?