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

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

3. 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?

4. 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?

5. 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

6. 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

7. 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

8. Case 1 Basic Investigations
Urinalysis
Mee, S. J. Urology 141:
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

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

10. 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

11. Renal laceration

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

13. 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?

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

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

16. Urethrogram techniques

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

19. Urethrogram

20. Urethrogram

21. Urethrogram

22. Urethrogram

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

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

25. Cystogram

26. Cystogram

27. CT cystogram

28. CT cystogram

29. CT cystogram

30. Case 2 Management Surgical repair Intraperitoneal bladder rupture
Some Urethral repairs

31. 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?

32. 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

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

34. 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

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

36. 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

37. 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?