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Published byOlav Sigvald Endresen Modified over 5 years ago
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Management of Lower Urinary Tract Trauma – A Practical Perspective
Jeremy Grummet St Vincent’s Hospital Melbourne
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Scenario 1 Called to ED at 2am to see Mr F-W Male, 30
Buck’s night for mate at Amanda’s Steak and Grill
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Scenario 1 Decided to drive home thinking only had 6 beers in 4 hrs
Forgot about Depth Charges in each one Mistook phone booth for freeway entrance
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Scenario 1 Slight confusion (shaving cream and D cups)
Stable: BP 110/70, HR 100 Suprapubic pain, tender
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Scenario 1 IDC had been inserted by ED staff Gross haematuria in bag
PXR shows stable pelvic #
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Scenario 1 Suspect LUT injury Order cystogram
Radiology reg: Cystogram NAD, presumed bladder contusion Admit for observation
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Scenario 1 3 days later, more generalised abdo pain
Continued gross haematuria Febrile Rigid abdomen Exploratory laparotomy
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Scenario 1 Intraperitoneal bladder rupture Infected urine Repaired SPC
No other injury found
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Scenario 1 IV AB Prolonged ileus TPN D/C 3 weeks later
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Issues Raised Initial assessment Investigation Treatment
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Initial Assessment When suspect LUT trauma, must bear in mind:
Risk of multiple trauma Anatomical sites Mechanism of injury Physical signs Safety of catheterisation
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Risk of Multiple Trauma
Bladder trauma series of 51 pts: Mortality 22% (Carroll 1984) None due to bladder injury itself Must suspect other life-threatening injuries E.g. Massive haemorrhage 2° to unstable pelvic #
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Anatomical Sites Bladder Posterior urethra (prostatic/membranous)
Anterior urethra (distal to urogenital diaphragm)
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Mechanism of Injury Blunt vs Penetrating
Implications for further assessment Blunt far more common 66-88% in US bladder studies (Carroll 1984, Cass 1987) Likely more so in Australia (100% - small series) (Chan 1994)
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Blunt Bladder Trauma Mechanism
85-90% bladder rupture pelvic # (Morey 2001) Usu. burst or shear (intra- and extra-peritoneal (Corriere 1988) Occ. 2° to spicules from pelvic # if extraperitoneal MVA, esp. if been drinking Fall from height
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Posterior Urethra Trauma Mechanism
Blunt pelvic # Membranous urethra passes through urogenital diaphragm attached to pubic rami Shear usu. at prostatomembranous junction
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Anterior Urethra Trauma Mechanism
More common than posterior urethra trauma Straddle injuries, e.g. fall off bicycle “Common in Texas if pt is kicked with the toe of a boot” (Campbell’s Urology) Urethra crushed against inf. symphysis
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LUT Physical Signs Gross haematuria Pelvic # Inability to void
15% all pelvic # bladder/urethra injury Inability to void Suprapubic tenderness
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LUT Physical Signs Blood at meatus Perineal swelling/haematoma
High riding prostate or indistinct landmarks on PR exam
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LUT Physical Signs Problems (not covered well in texts):
Signs alert you to LUT injury, but do not differentiate well between bladder and urethra E.g. Inability to void
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LUT Physical Signs Absence of a sign does not always exclude LUT injury E.g. Does pt with pelvic # and unable to void but no other signs have urethral injury?
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LUT Physical Signs Cannot determine ability to void when pt obtunded
head trauma intoxication How to assess for haematuria in such a pt?
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Catheterisation Often not a priority in trauma setting
Risk: Conversion of partial urethral tear to complete When safe if suspect LUT trauma?
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Catheterisation When NOT safe: Blood at meatus
Pelvic # + gross haematuria/unable to void/perineal haematoma (Chan 1994)
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Investigations CXR, PXR RUG indicated when catheterisation unsafe
20-30 ml water-soluble contrast
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RUG – Posterior Rupture
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RUG – Disrupted Diaphragm
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Cystography Performed retrograde Commonly preceded by RUG
Indications controversial A former recommendation: all trauma pts with macro- or micro-haematuria (Cass 1987)
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Cystography Problems:
Pts in series not stratified to blunt vs penetrating Not stratified by degree of haematuria 2/3 pts had bladder contusion only Expensive
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Cystography More recent studies show that in pts with pelvic #, risk of bladder rupture if: Gross haematuria: 13-55% Microscopic haematuria: 0-1% (True for blunt trauma, but lower threshold if penetrating)
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Cystography Current absolute indication for blunt trauma cystography: pelvic # + gross haematuria (Morey 2001) Softer indications: e.g. micro-haematuria in combination with suprapubic tenderness and inability to void
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Cystography Technique crucial
Papers advise at least ml contrast Less may not expand bladder enough to open up tear Post-drainage film Filling film may obscure extravasation
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Types of Bladder Rupture
As mentioned before, intra-and extra-peritoneal Extra-peritoneal twice as common Occ. combined
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Extra-peritoneal Rupture
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Extra-peritoneal Rupture
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Intra-peritoneal Rupture
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CT Cystography Appears to be as good as cystography
Indicated when injury to other abdominal organs also suspected Again, must ensure adequate distension with contrast Conventional cystography still preferred when only looking for bladder rupture
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IVP When unable to perform cystography due to urethral injury
Still need to exclude concomitant bladder trauma IVP
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Treatment – Intraperitoneal Bladder Rupture
Surgery Transperitoneal repair Keep suprapubic cystostomy extraperitoneal Use absorbable sutures
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Treatment - Extraperitoneal Bladder Rupture
Controversial Proponents of surgical repair: Avoid pelvic haematoma Repair intravesically – midline incision Peritoneotomy
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Treatment - Extraperitoneal Bladder Rupture
Other option is catheterisation only Only if uninfected urine and no other reason for exploratory surgery Series of 41 extraperitoneal ruptures Healing in all pts with no complications (Corriere 1988)
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Treatment – Posterior Urethral Injury
Highly controversial Range from immediate repair to suprapubic cystostomy and delayed repair In between, immediate urethral catheter railroading and delayed repair good results (Devine 1989) Need urologist experienced in urethral reconstruction
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Treatment – Anterior Urethral Injury
Suprapubic cystostomy catheter Any strictures usu. not severe enough to warrant surgical reconstruction
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Mr F-W Similar presentation: Haemodynamically stable
Too concussed/drunk to void Tender suprapubically Pelvic # on PXR
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Mr F-W You arrive before a catheter has been inserted
After ABCs, how would you manage pt? Panel
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Conclusions Think of LUT trauma in the trauma pt
Conversely, suspect other more life-threatening injuries in pt with LUT trauma, and manage accordingly
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Conclusions Never catheterise before obtaining a negative RUG when blood at meatus Think carefully before catheterising when NO blood at meatus Ensure proper cystography or CT cystography technique
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Conclusions Refer to urologist preferably once LUT injury suspected, certainly for treatment As a general rule, avoid instruments as shown at beginning of presentation
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