1. Pediatric Genitourinary Trauma
M. Penque, MD
Dec 2014

2. PEM Boards Genitourinary System Trauma
a. Etiology
b. Pathophysiology
Understand the importance of the mechanism of injury and pelvic trauma in evaluating genitourinary tract damage
c. Recognition
Recognize the signs and symptoms of urethral trauma
Recognize the signs and symptoms of genitourinary trauma
Recognize the signs and symptoms of bladder trauma
Recognize common patterns and mechanisms of pelvic injury
d. Management
Plan the management of a child with post-traumatic hematuria
Plan the diagnostic evaluation and the management of a patient with genitourinary trauma
Plan the management of a patient with bladder trauma
e. Ancillary Studies
Recognize the importance of and limitations of urinalysis, intra- venous pyelography, ultrasonography, and computed tomography in assessing genitourinary injuries

3. GU trauma
Kidney
Ureter
Bladder
Urethra
Study
Imaging
Nasty Zippers
Conclusion

4. In a patient with multisystem injuries, GU trauma is ____________ in frequency??
First
Second
Fifth
Sixth

5. 10% of trauma pts will have a UG injury
SECOND
Only to CNS trauma (shocking, I know!)
10% of trauma pts will have a UG injury

6. 90% are from BLUNT injury (vs . penetrating and Iatrogenic)
crush
acceleration/deceleration
MVC/peds
falls
sports related

7. The most common urinary tract injury is to the….
Kidney
Ureter
Bladder
Urethra
Boy parts

8. 11_Genitourinary Injuries
Kidney Trauma!
Occurs in 8-10% of patients with abdominal trauma
Most common organ damaged by blunt trauma in the pediatric population
Accounts for 50% of all GU trauma
Blunt mechanism is the cause of 70-80% of all traumatic injuries to the kidney
Co-existing injury will occur in 14-34% of cases
Direct blow to back, flank, upper abdomen
Suspect in Fx of 10th - 12th ribs or T12, L1, L2
Acceleration/Deceleration
Shearing of renal artery/vein
STN E-Library 2012

9. Who is more likely to sustain a kidney injury
Who is more likely to sustain a kidney injury??the big guy or the little guy??

10. Poor Elf….WHY??

11. In KIDS the kidney:
-is larger in proportion to the size of the abdomen
-retains fetal lobations
-easier paranchymal disruption
-has less protection
-weaker ab muscles
-less ossified thoracic cage
-less perirenal fat and fascia

12. Most Common Renal Injuries
Parenchymal contusions and hematomas (60-90%)
Lacerations are less common (10%)

13. Renal trauma - Presentation
Localized signs: flank tenderness, flank hematoma, or palpable flank mass.
Non specific: Abdominal tenderness, rigidity, paralytic ileus or hypovolemic shock
Gross hematuria is the hallmark of severe injury: BUT absent in 50% of patients with vascular pedicle injuries and 30% penetrating injuries talk about this later

14. 11_Genitourinary Injuries
Assessment
Inspection
Palpation
Percussion
What Sign is This???
Your examination of the patient will include inspecting for the following:
Bruising, ecchymosis, bleeding on abdomen, flank, pelvic and perineal areas
Abdomen: Flat or distended
Any signs of external injury including complex, open pelvis fractures; number of GSW or stabbing; impaled objects, Seat belt injury (from blunt trauma), Gunshot or stab wounds (from penetrating trauma)
Grey Turner’s sign – ecchymosis over the posterior aspect of the eleventh or twelfth rib or the flank may indicate renal trauma or retroperitoneal bleeding
Percussion of abdomen and flank area for hyerpressonance and dullness.
Hyperresonance indicates air
Dullness indicates fluid accumulation
Percussion tenderness constitutes a peritoneal sign and mandates further evaluation.
STN E-Library 2012

15. A. Cullen’s Sign
B. Grey Turner’s Sign
C. Stop Sign

16. Grey Turner’s Sign
ecchymosis over the posterior aspect of the 11th-12th rib or the flank
Described as sign in acute pancreatitis but
may indicate renal trauma or retroperitoneal bleeding

17. Classification of renal trauma
Grade l: Contusion or subcapsular nonexpanding hematoma
Grade II: Nonexpanding hematoma confined to the retroperitoneum or lac <1 cm
Grade III: Lac >1 cm into the renal cortex without collecting system rupture or urinary extravasation

18. Grade 1,2 and 3 renal injuries

19. Classification of renal trauma (con’t)
Grade IV : Lac extending into the collecting system or renal vascular injuries with contained hemorrhage
Grade V : Shattered kidneys or avulsions of renal hilum with devascularized kidneys
These are the ones we really worry about but make up only 3% of all renal injuries…phew!

20. Grade 4 and 5 injuries

21. Renal Trauma Management
11_Genitourinary Injuries
Renal Trauma Management
Grade III: usually resolve spontaneously; at greater risk for delayed hemorrhage so monitor more closely
Grade I/II: conservative management
Monitor H/H, renal fxt and hemodynamic stablity, bed rest, pain control similar to liver/spleen lac treatment plans
Grade I-II injuries usually are managed non-operatively; monitoring of renal function and hemodynamic stability is essential. Non-operative management for renal trauma is similar to that of splenic and liver management. It includes but is not limited to:
Frequent monitoring of vital signs and hematocrit
Reassessment of abdomen a(pt should be alert and cooperative during abdominal and flank examinations)
Bed rest with a gradual increase in activity and diet
Pain control
STN E-Library 2012

22. 11_Genitourinary Injuries
Renal Trauma
Grade IV & V:
Shattered kidneys may be removed to control hemorrhage
Kidneys with pedicle injuries may be removed but non-removal does not routinely result in late sequelae (i.e. pain, HTN)
Grades III, IV, and V injuries are considered major renal injuries. Kidney function is threatened by nephron damage or accumulation of free urine and blood in collecting ducts and around the kidney. Grade III injuries may be treated with non-operative management depending on how the patient is clinically . They are at risk for delayed hemorrhage and need to be close monitoring, bed rest and a slow return to physical activity until healed.
Grade III: The shattered kidney that is able to demonstrate perfusion and requires minimal transfusion may be repaired. Embolization is being utilized more and more with this injuries with mixed results.
Image is of shattered kidney
STN E-Library 2012

23. 11_Genitourinary Injuries
Grade IV and V Injuries
Renal damage
Partial nephrectomy
Renorrhaphy
Nephrectomy
Renovascular Injury
Shattered kidney, renal pedicle damage
Intimal tears-thrombosis in renal pedicle
Grade IV and V injury usually requires surgical intervention due to hemorrhage. Every effort should be made to preserve the kidney if possible.
Partial nephrectomy - performed when there is damage to upper and lower pole.
Renorrhaphy – performed when there is damage to midportion.
Nephrectomy – before one considers performing a nephrectomy one must evaluate the function of uninjured kidney first.
Renal trauma results in a 20-43% incidence of the patient requiring a nephrectomy.
If a nephrectomy needs to be done, a one-shot IVP should be done to ensure that there is a second kidney present and that it is functioning. If the contra lateral kidney does not function properly, efforts should be made to preserve renal function.
Renovascular injury – repair is essential to prevent ischemia, necrosis, loss of function.
Grade IV injuries involve the pedicle or vascular injury and require surgical repair.
In the higher graded injuries, devitalized renal tissue is a common result despite appropriate interventions. When devitalized (necrotic) tissue develops, the patient has a 85% chance of serious complications such as an urinoma, or an abscess developing in the pancreas or small bowel. Any devitalized tissue needs to be removed surgically to improve the outcome.
Image is of bullet in kidney.
STN E-Library 2012

24. Renal Trauma Complications
11_Genitourinary Injuries
Renal Trauma Complications
Minor Trauma
Sepsis
Decreased H/H
Expanding perirenal mass
Hemodynamic instability
Major Trauma
Abscess/urinomas
Sepsis
Fistula
Renal atrophy
Rhabdomyolysis/myoglobinuria
Renal HTN
Renal Failure
Blunt trauma cases usually have more issues than penetrating cases because the penetrating cases have had a surgical intervention and structures have been visualized
Examples of common complications seen with minor renal trauma are the following.
5% require surgical exploration due to an expanding perirenal mass or hemodynamic instability
There are rare incidences of sepsis, loss of renal function, and hemorrhage.
Examples of some common complications seen with major renal trauma are:
Abscesses to pancreas and small bowel.
Sepsis from infections, abscesses, UTI, polynephritis
Fistulas to almost any part of the abdomen or pelvis
Urinomas: Grade III and IV renal injuries are associated with urinomas (a cyst filled with urine). They are caused by the extravasation of urine during the injury. Percutaneous drainage is essential to prevent further injury to the renal collecting ducts. Usually during surgery for Grade IV and V injuries, drainage of any urinomas is done. Persistent extravasation of urine is a problems that can result in sepsis.
Renal atrophy, Urethral stricture and obstructive hydronephrosis and loss of renal function are all complications that can occur. They are rare but they can occur up to 4 weeks after injury.
Rhabdomyolysis/myoglobinuria is a complication that can occur with burns, orthopedic/soft tissue damage, crush injuries, patients who were immobile for long periods of time. It will be discussed more in detail in the burn lecture. It is discussed briefly here since it can contribute to renal failure.
STN E-Library 2012

25. Ureter Trauma RARE <1% of all urologic trauma
Blunt trauma usually involves the UPJ trunk hyperextention
Suspect if fracture of the transverse process of lumbar vertebra
Stab wounds rarely cause ureteral injury, but 50% of GSW to abdomen have injury to the ureter

26. Ureter trauma: Diagnosis
difficult >50% not diagnosed in 1st 24h
PE may be unremarkable, urinalysis normal in 30%
Delayed diagnosis may manifest as fever, chills, lethargy, leukocytosis, pyuria, bacteriuria, flank mass/pain, fistulas, strictures

27. Ureter trauma imaging CT and IVP can show extravasation but have
low sensitivity (33%)
Retrograde pyelogram may be more reliable

28. Ureter Trauma Management
11_Genitourinary Injuries
Ureter Trauma Management OR
Ureterostomy
Irrigation and Drainage
Antibiotics
Stenting
Stab wound and iatrogenic traumatic injuries are taken to the Operating Room due to need for minor debridement and suture approximation
GSW and blast injuries can cause microvascular deficits and produce delayed necrosis and extravasation
Ureter transection requires surgical repair and ureterostomy to divert urine flow, wound irrigation, competent drainage and prophylactic antibiotic
Internal stenting is usually done for those injuries that have the potential to be complicated by contamination, ischemia or associated vascular injury
STN E-Library 2012

29. Bladder Trauma Fun Facts
Blunt trauma secondary to MVC is most common cause
Full bladder will increase risk of injury (pee 1st!!)
80% of injuries associated with pelvic fracture
(penetrated by bony fragment) 10% of pelvic fx with bladder injury
Kids more susceptible because of higher abd location

30. Bladder trauma: Diagnosis
>90% with bladder rupture have gross hematuria
Diagnostic evaluation is indicated
in patients who sustain pelvic or lower abdominal trauma with gross hematuria
inability to void
abnormal GU exam
multiple associated injuries

31. Evaluation of bladder trauma
Pelvic X-rays
Retrograde cystogram
High suspicion and normal X-rays
**No cath if blood at the urethral meatus or high-riding prostate
CT cystography is recommended over plain cystogram…new trend and eval other injuries
Why not just a contrast CT since you’re probably getting one anyway??

32. Standard Helical CT in bladder rupture
Pao et al. Acad Radiol 2000.
With IV contrast
Misses bladder rupture
100% sensitive if “free fluid” criteria used.
Can R/O bladder injury if NO free fluid.
Not specific.
Not accepted as diagnostic tool.
- Some people thought: « Well, if we’re gonna do a CT for abdominal injury, maybe it will pick up bladder injuries as well ».
Pao et al. Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 2000; 7:

33. Management of bladder injuries
Extra peritoneal (assoc w/ pelvic fx)
Contusion = conservative management, +/- catheter
Manage with urethral cath or suprapubic drainage for 7-10 days.
Large tear = OR
Intraperitoneal - Go to OR.
Combined(GSW) – Go to OR

34. Urethral trauma Mechanisms More common in males Urethral injuries MVC
straddle injuries
Instrumentation
More common in males
Urethral injuries
Anterior: Pendulous and Bulbar
Posterior: Membranous and Prostatic

36. Blunt Anterior Urethral trauma
Pendulous (penile) urethrea: direct trauma
Bulbar urethra : straddle injury vs pubic symphasis
Blood at the urethral meatus is present in 90% of anterior injuries = DO NOT CATH!!
inability/difficulty voiding possible
Retrograde urethrogram is diagnostic
Tx: 7-10 days of cath + plus antibiotics…if severe they need diversion
Severe injuries need urinary diversion

37. Posterior Urethral Trauma
Occur with severe trauma and are associated with other injuries (pelvic fx)
Signs are blood at the meatus, hematuria, perineal ecchymosis (butterfly hematoma), inability/difficulty voiding
Retrograde urethrogram
Higher rate of complications
Ct scan not useful for urethral injuries Initial management is controversial…they vary from immediate exploration to placement of tube with delayed urethroplasty

38. Butterfly Hematoma
Anterior urethral rupture through Buck’s fascia confined by Colles’ fascia.

39. J Pediatr Surg. 1996 Jan;31(1):86-9
Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma.
Abou-Jaoude WA1, Sugarman JM, Fallat ME, Casale AJ.
1Department of Surgery, University of Louisville School of Medicine, KY, USA.

40. PURPOSE:
What factors warrant evalutaion of the GU tract in trauma??
METHODS:
-Retrospective chart review
-100 patients <18 years with discharge diagnosis in the trauma registry included hematuria or GU tract injury
-Looked at age, sex, mechanism of injury, physical findings, associated injuries, urinalysis results, radiographic study results, disposition, and outcome

41. RESULTS:
-Majority=MVA
-27 with GU injuries (9 contusions, 5 lacerations, 1 vascular pedicle injury, 4 bladder injuries, 3 urethral/vaginal tears, 5 anomalies)
-about 25% of minor or major GU injuries had only MICROSCOPIC hematuria (<20 rbc/hpf)
Mechanism of injury and hypotenison were NOT associated with GU tract injury
1/3 with isolated chest or abdominal injuries, and 50% of those with combined chest/abdominal injuries had GU tract injuries or anomalies identified
Pelvic fracture was associated with GU tract injury or anomaly in 50% of cases (P < 0.02).

42. CONCLUSION:
Gross hematuria as an indication for radiograph evaluation would have missed 28% of cases with GU tract injuries or anomalies in peds pelvic fractures and abdominal/chest injuries help to identify patients who require evaluation of the GU tract

43. Imaging GU trauma CT w/ IV contrast (or MRI) vs IVP as initial test
Cystogram (CT cystography)
After initial eval
Retrograde urethrography
?U/S

44. Imaging GU trauma IVP vs CT
11_Genitourinary Injuries
Imaging GU trauma IVP vs CT
preferred imaging is CT w/contrast
Highly sensitive and specific (staging)
Extravasation of contrast-enhanced urine
See other injuries
IVP
Used to be intial exam of choice.
Very poor sensitivity for penetrating injury
Limitation in staging renal injuries
Not 1st choice anymore. Only if pt unstable
Computerized tomography scan provides the most precise delineation of GU injury as CT imaging is both sensitive and specific and can accurately delineate segmental and arterial injuries.
For stable patients, renal injury can be most accurately and completely imaged and staged using computed tomography (CT).
CT imaging has largely replaced the once standard IVU and arteriography and has completely replaced arteriography in the acute setting.
Renal artery occlusion and global renal infarct are noted on CT scans by lack of parenchymal enhancement or a persistent cortical rim sign but it is usually not seen until at least 8 hours after injury.
Helical CT scanners have improved imaging over the past few years. Turnaround times are about 10 minutes for an abdominal trauma scan
CT cystogram - One minute to 90 seconds before initiating helical CT scanning, intravenous contrast can be administered for evaluating the arterial and cortical phases which help delineate any renal artery injury, but the early cortical phase still misses parenchymal injuries and delayed images are needed to detect these injuries, venous injuries as well as urine and blood extravasation. One can distinguish the two in that urine extravasation accumulates whereas blood dilutes out after bolus stopped.
Advantages
Reveals functional and anatomic assessment of the kidneys and urinary tract
Establishes the presence or absence of 2 functional kidneys
Assists in the diagnosis of concurrent injuries.
Disadvantages
Requires intravenous contrast in order to maximize imaging
The patient must be stable enough to go to the scanner
Timing of contrast and scanning in order to view the bladder and ureters is important.
STN E-Library 2012

45. 11_Genitourinary Injuries
IVP
One shot to see if there’s a 2nd kidney before emergency surgery in an unstable patient
IVP
If emergency surgery or interventional radiology is to be done, a one-shot IVP can be done to ensure that there is a second kidney present and that it is functioning.
If the contralateral kidney does not function properly, efforts should be made to preserve renal function.
Intravenous pyelogram (IVP) – detects 80% of renal injuries. It should only be used as an alternative when CT is unavailable. It detects extravasation of the contrast media into surrounding tissues which indicates a disruption in the integrity of the kidney, ureters or bladder. A one-shot IVP may be valuable pre or during surgery to evaluate for pedicle injury and excretion of the contralateral kidney.
For a satisfactory study, a systolic blood pressure above 90 mm Hg is needed. In order to save time, the contrast can be injected at the time of the initial resuscitation. Unstable patients who are emergently taken to the operating room, should be stabilized first and undergo one-shot IVU in the operating room once they are stabilized.
Ultrasound has proven useful and reliable for evaluating blunt intra-abdominal injuries by detecting the presence of hemoperitoneum. It is used to direct patients to CT imaging when hemoperitoneum is noted and to observation in those with negative findings.
STN E-Library 2012

46. Cystogram
Normal
Bladder rupture

47. Retrograde Urethrogram
Use to evaluate for urethral injuries
if there is blood at the urinary meatus
or high riding prostate

48. Retrograde Urethrogram

49. RUG
normal
type III urethral tear at the urogenital diaphragm (solid arrow) and a type IV urethral disruption at the bladder neck (dashed arrow).

50. Ultrasound
U/S exam of the bladder may reveal free abdominal fluid in the case of an intraperitoneal bladder injury, but cannot differentiate urine from blood. So, FAST examination is less reliable in patients at high risk for bladder injury
Jones AE, Mason PE, Tayal VS, Gibbs MA. Sonographic intraperitoneal fluid in patients with pelvic fracture: two cases of traumatic intraperitoneal bladder rupture. J Emerg Med 2003; 25:373
lacks sensitivity for renal trauma and should not be relied upon to exclude significant injury

51. Zipper entrapment…Ow!

52. Penile Trauma: Zipper Injury
Most common genital injuries in prepubertal boys.
Typically involve the foreskin or redundant penile skin and may occur during the zipping or unzipping process
edema and pain are the most common complications
Significant injury, including skin loss or necrosis, is unusual.

53. Zipper Injury: Treatment
Mineral oil: Allows tissue to slide freely
Entrapment release —  depends upon the site
Entrapment of penile skin between the zipper teeth (and not the zipper mechanism)
Release by cutting the cloth of the zipper - results in separation of the zipper teeth
Local anesthesia or sedation usually is not necessary for this procedure.

54. Skin in teeth…

55. Vs. in the zipper mechanism …I think we’ll need sedation for this one…

56. Zipper injury: Treatment
The median bar may be cut with wire cutters, bone cutters, or a mini hacksaw
mechanism will fall apart releasing the skin

57. Zipper injury: Treatment
Thin blade of a small flathead screwdriver
Place between faceplates on the side of the mechanism in which the skin is not entrapped
Rotate toward the median bar
This widens the gap and (hopefully) release the skin

58. a. Retrograde urethrogram b. Foley catheter placement
An 8 yo boy is brought to the ED after getting hit by a car
while riding his bicycle. On exam, he has stable vital signs, GCS of 15, and his abdomen is soft without tenderness. Blood is noted at the urethral meatus and he is unable to void. Which of the following is the most appropriate for management?
a. Retrograde urethrogram
b. Foley catheter placement
c. Abdominal ultrasound
d. Intravenous pyelogram (IVP)
e. Ice packs and ibuprofen

59. A 13 yo boy comes to the ED with back pain after playing ice
hockey. He was checked and hit his back onto the boards. He
noted gross hematuria a few hours afterwards. On exam, he has
normal vital signs. His right flank shows a small ecchymosis on
inspection. His abdomen is soft without tenderness. His
urinalysis shows numerous RBCs per high power field. Which
of the following tests is most appropriate in this patient?
a. Intravenous pyelogram (IVP)
b. Ultrasonography
c. Cystourethrogram
d. Abdominal CT
e. Serial urinalyses

60. An 8 yo boy presents to the ED after his penile skin got
caught in the zipper of his pants. On exam, his foreskin is caught in the zipper mechanism. Management includes:
a. Cutting the median bar of the zipper
b. Dissecting the skin free
c. Applying ice before unzipping over the entrapped skin
d. Moving the zipper back and forth after local anesthesia
e. Performing a dorsal slit procedure

61. Conclusion (finally….)
Suspect GU trauma in all cases of pelvic fx (and some lumbar)
Even miroscopic hematuria can = significant GU trauma in peds
Don’t cath if there’s blood at the meatus
Image with CT contrast (or CT cysto for bladder or RUG for urethra)
Kids bladders and kidneys are more susceptible to injury than Santa’s
And…Make your boys wear underwear