1. Genitourinary Trauma

2. Case 23 y.o male Driver, Seatbelted Frontal Impact, High Speed (  100Km/h) Airbag + Other driver dead Car completely destroyed Patient was conscious at the scene. On scene: BP=85/50 HR:120 RR:22 Sat:98%

3. cont. A: Clear. C-spine protection. Backboard+ B: A/E symetric. O 2 Sat N. No crepitus. Trachea central. C: BP:100/60 HR:100 Mentating well. D: GCS=15 Pt is exposed. O 2 - iv – monitor Temperature N Capillary Glucose N

4. cont. AMPLE –C/O abdo. Pain + “hip” pain –C/O right lower leg pain Secondary Survey –Spleen normal. Mild suprapubic tenderness. –Pelvic instability –Probable right tibial # –No gross blood at meatus. Rectal Normal. “Doctor, can I put a Foley?”

5. cont. What are your concerns? Foley? What will be the usefulness of dipstick? Dipstick good enough? U/A? What if he has microscopic hematuria? What if he has a pelvic fracture? Any different if you had blood at meatus? Urethrogram? Cystogram? Abdominal CT? Worried about the kidneys? Bladder? Does the low BP changes your suspicion for a GU injury?

6. Introduction GU Trauma overlooked 10-20% of all injured patients Long term morbidity –Impotence –Incontinence Life-threatening injuries first

7. Plan Urethral Injury Bladder Injury Hematuria in Trauma Kidney Injury

8. Definitions Upper tract –Kydney –Ureters Lower tract –Bladder –Urethra External genitalia

9. Urethral Trauma Almost exclusively in male Significant morbidity –Stricture –Incontinence –Impotence If unrecognized: –Converting partial to complete tear –Inaccurate assessment of U/O Foley catheter implication Andrich DE et al. The nature of urethral injury in cases of pelvic fracture urethral trauma. Journal of Urology. 165(5):1492-5, 2001 May.

10. Anatomy Bladder Symphysis

11. Prostatic Membranous Bulbous Pendulous

12. Clinical Features 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.

13. Posterior Urethral rupture From McAnich JW. In Tanagho EA, McAninch JW, editors: Smith’s general urology, ed 14, Norwalk, Conn, 1995, Appleton & Lange.

14. Diagnosis: Retrograde Urethrogram Pretest KUB film Supine position Injection of 60ml of water-soluble contrast Different techniques X-ray when 10ml left and after 60ml Post-voiding x-ray.

15. Retrograde Urethrogram

16. Retrograde Urethrogram: Interpretation Contrast extravasation + Contrast in bladder Contrast extravasation only PARTIAL Tear COMPLETE Tear

17. Partial Tear

18. Complete Tear

19. Management 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 –Small feeding tube alongside the foley

20. Foley Catheter NO if you suspect a urethral injury Most of urethral injuries: Pelvic # or Gross hematuria Initial bladder effluent MUST be looked at. Danger to convert partial into complete Successful passage  complete tear NEVER REMOVE A FOLEY WHEN YOU SUSPECT A PARTIAL TEAR AFTERWARDS. ANY colored urine other that yellow = BLOOD until proven otherwise

21. Bladder Trauma Adult: Extraperitoneal organ Bladder dome = weakest point Blunt: 60-85% MVA: #1 cause Important to recognize –Pelvic/abdominal wall abscess/necrosis –Peritonitis –Intra-abdominal abscess –Sepsis / Death

22. Types of rupture Extraperitoneal –Most common –Pelvic # in 89-100% –Bladder rupture in 5-10% of all pelvic # Intraperitoneal –Extravasation of urine in abdomen –Sudden force to full bladder –Associated injuries +++ Mortality (20%)

23. Investigation Cystography: Gold standard CT Cystography : New trend

24. Treatment Penetrating injuries: OR Blunt –Intraperitoneal: Almost all OR –Extraperitoneal: Urethral cath. drainage

25. Kidney Injury Retroperitoneal organ Cushoned by perinephric fat Gerota’s fascia Along T10 - L4 Ribs 10-12 Fixed only through pedicle. 1.2L of blood / min

26. Kidney Injury… Blunt trauma: 80-90% Rapid deceleration / Direct blow MUST be suspected if –Trauma to back / flank / lower thorax / upper abdomen –Flank pain / low rib # –Hematuria / Ecchymosis over the flanks –Sudden decelaration / Fall from height. –Lumbar transverse process #

27. Grade I Contusion –Hematuria –Urologic studies N Hematoma –Subcapsular –Non expanding –Parenchyma N

28. Grade II Hematoma –Perirenal –Nonexpanding Laceration –< 1.0 cm –Renal cortex only –No urinary extravasation

29. Grade III Laceration –> 1.0 cm –Renal cortex only –No urinary extravasation –Intact collecting system

30. Grade IV Laceration –Renal cortex –Renal medulla –Collecting system Vascular –Main renal artery/vein injury with contained hemorrage.

31. Grade V Completely shattered kidney. Avulsion of renal hilum (pedicule) which devascularizes kidney. Kennon et al. Radiographic assessment of renal trauma: our 15-year experience. The Journal of Trauma, 154: 353-355; August 1995.

32. Investigation IVP –Used to be intial exam of choice. –Very poor sensitivity for penetrating injury –Limitation in staging renal injuries –Not 1 st choice anymore. Only if pt unstable. Contrast CT –Study of choice if stable –More sensitive and specific for staging –Detects other abdominal injuries

33. Management Penetrating trauma: –Imaging for ALL (9%: NO hematuria) Blunt trauma Imaging: –Gross hematuria –Microscopic hematuria (  5 RBC/hpf) + shock (BPs  90) –Any child with > 50 RBC / hpf –Acceleration decceleration –Pelvic FX

34. Management… Absolute indication for Surgery: –Uncontrollable renal hemorrage –Multiply lacerated, shattered kidney –Main renal vessels avulsed –Penetrating injuries usually Grade I-II –conservative Grade III-IV –Conservative if stable hemodynamically vs. surgery Grade V –Surgery Grade V

35. Back to case First urine: Dipstick +++ (15 RBC/hpf) Pelvic x-ray: Straddle #

36. Kozin, Berlet. Handbook of Common Orthopaedic Fractures, 4 th ed., 2000.

37. case First urine: Dipstick +++ (15 RBC/hpf) Pelvic x-ray: Straddle # Keypoints… –BP: 85/50 on scene –Microhematuria –Pelvic # NO FOLEY

38. case Urology consulted Retrograde urethrogram: N CT cystogram: N Contrast CT to look for renal injury: Grade II renal injury.

39. Conclusion No Foley if you suspect urethral trauma Gross hematuria OR microhematuria + Shock = GU Trauma. Pelvic # + Microhematuria GU investigation Don’t remove Foley if you suspect a partial tear of urethra afterwards. Microhematuria alone : No imaging …but F/U. In peds: Imaging for ALL hematuria.

40. The End