1. Amit Sarnaik MD Scottish Rite Pediatric Emergency Department
Urogenital Trauma
Amit Sarnaik MD
Scottish Rite Pediatric Emergency Department

2. Genitourinary trauma
In multiple trauma patients, GU trauma is second in frequency (#1 CNS)- 10%
MOI: Blunt (90%) vs. Penetrating
MVC: most common
Falls, Sport related and direct blow
Most common Injury is to the kidney – 47%
Associated intra-peritoneal injuries
Penetrating – 80% vs. Blunt

3. Pediatric considerations
Renal injury more likely in children
Larger proportion of kidney to abdominal size
Retained fetal lobulations: Easier parenchymal disruption
Weaker abdominal muscles
Less ossified thoracic cage
Less developed perirenal fat and fascia

4. 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: absent in 50% of patients with vascular pedicle injuries and 30% penetrating injuries
Most common injuries
Parenchymal contusions and hematomas (60-90%)
Lacerations are less common (10%)

5. Classification of renal trauma
Grade I : 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
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

6. Grade 1,2 and 3 renal injuries

7. Grade 4 and 5 injuries

8. Renal Trauma: Management
Evaluate GU system only after life threatening conditions have been indentified
A urinalysis should be obtained in all patients with multisystem trauma or suspected isolated renal injury
Pediatric renal trauma patient – order a CXR, Abdominal and Pelvis X-rays

9. Renal trauma: Hematuria and Kidney injury
Gross hematuria
Microscopic hematuria with major mechanisms or signs of renal injury
Hematuria of > 20 RBC per hpf
Microscopic hematuria with shock ( relied upon in adult EM)

10. Imaging of renal trauma
CT with contrast is preferred study at most trauma centers - 98% sensitivity
Detection of associated injuries
3-D views and no dependence on renal vascularity 
Ultrasound – 70% sensitivity
Not accepted for the staging of renal trauma
Has been used for long term follow up
Alternative modality for the evaluation of the pregnant trauma patient

11. Imaging in renal trauma
IVP : used only if CT is not readily available
Provides rapid information about the overall functional and anatomic integrity of both kidneys
It can be obtained in the ED in an unstable patient or in the OR prior to surgery
IVP will only diagnose 5% contusions, 50% lacs, 29% pedicle injuries
Renal injury: non visual of calyceal, extravasation of contrast

12. Blunt Uro-genital trauma: Diagnostic evaluation
Blunt and Unstable:
Limited IVP
Blunt & Stable, major renal injury, none lower
CT scan
Blunt and Stable, Findings of lower tract injury
Cystourethrogram +/- upper tract evaluation
Blunt and Stable, Minor renal injury (Microscopic hematuria)
No CT, serial UA, delayed imaging
Tenderness, contusion, mass, gross hematuria, major mechanism of injury or associated injuries

13. Management of blunt renal trauma
Grades 1,2 and 3
Strict bed rest, analgesia, prophylactic antibiotics.
Limited activity on resolution of gross hematuria
Grades 4,5 – Management is controversial.
Depends upon hemodynamic status, degree of urinary extravasation, renal bleeding, associated injuries.
Many patients are being managed with serial hematocrit, vital signs and broad spectrum antibiotics

14. Complications from non operative management of Grade 4 and 5 renal trauma
Patients managed nonoperatively have a 50% complication rate
Persistent/recurrent hemorrhage
Extravasation and urinoma formation
Infection
Infarction
Segmental hydronephrosis
Neprectomy upto 20% immediate surgery, 10% in delayed surgical intervention

15. Penetrating Uro-genital trauma: Diagnostic evaluation
Penetrating and Unstable
Limited IVP
Penetrating & Stable, upper tract injury suspected
CT scan
Penetrating & Stable, findings of lower tract injury
Cystourethrogram +/- upper tract evaluation

16. Management of Penetrating renal trauma
Surgical
Vascular injury
Hemodynamic instability
Urinary extravasation
Non surgical
Hemodynamically stable + Isolated Low grade
Delayed bleeding may occur in 24% with grade 3-4

17. Complications of renal trauma
Short Term
Delayed hemorrhage
Urinary extravasation
Abscess formation
Obstruction secondary to clot formation
Long Term
HTN (<5%)
Hydronephrosis
Arteriovenous fistulas
Renal intestinal fistula
Stone formation

18. Ureteral Trauma
Ureteral injuries are uncommon, <1% of all urologic trauma
Blunt trauma usually involves the UPJ
Suspect ureter trauma if fracture of the transverse process of lumbar vertebra
Penetrating injuries along the ureter – 90% association with other intra-abdominal injuries
Stab wounds rarely cause ureteral injury, but 50% of GSW to abdomen have injury to the ureter

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

20. Ureteral Trauma CT and IVP has low sensitivity (33%)
Retrograde pyelogram may be more reliable

21. Bladder Trauma Blunt trauma secondary to MVC is most common cause
80% of injuries associated with pelvic fracture
Mortality rate 40% with bladder rupture (from assoc head injury)

22. Classification of bladder trauma
Extraperitoneal: associated with pelvic fractures.
Intraperitoneal: caused by blunt trauma to distended bladder.
Combined: GSW.

23. Bladder trauma: Diagnosis
Hematuria and dysuria typically seen at presentation
>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

24. Evaluation of bladder trauma
Pelvic X-rays
Retrograde cystogram
High suspicion and normal X-rays
No catheterization if blood at the urethral meatus or high-riding prostate
CT cystography is recommended over plain cystogram for patients undergoing CT for associated injuries

25. Management of bladder injuries
Extra peritoneal
Contusion = conservative management, +/- catheter
Manage with urethral cath or suprapubic drainage for 7-10 days.
Large tear = OR
Intraperitoneal - Go to OR.
Combined – Go to OR

26. 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

27. Blunt Anterior Urethral trauma
Due to direct trauma, usually isolated, low mortality
Bulbar injuries : common in straddle injury
Blood at the urethral meatus is present in 90% of anterior injuries
Perineal ecchymosis (butterfly), inability/difficulty voiding also possible
Retrograde urethrogram is diagnostic
Manage with 7-10 days of catheterization plus antibiotics
Severe injuries need urinary diversion

28. Blunt 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), inability/difficulty voiding
Retrograde urethrogram is diagnostic
Urology consultation
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

29. Female urethral trauma
Urethral injuries in girls
Rare, due to mobile short urethra
Associated with pelvic fractures or instrumentation
Managed with suprapubic drainage and elective repair

30. Penile Trauma Blunt trauma from toilet seat is common
Managed with warm soaks.
Tourniquet injuries
Exposure and removal of hair
Urethrocutaneous fistula and penile loss
Zipper entrapment.

31. Penile Trauma Penis fracture. Lacerations:
Traumatic rupture of corpus cavernosum.
Erect penis vs. hard surface.
Patient may hear a cracking sound with pain and edema.
Most required surgical evacuation of hematoma, ice packs, pressure dressing
Lacerations:
Involving the corporal bodies or the urethra require urologic consult
Superficial: simple repair

32. Perineal trauma Most common is straddle injury
Vulvar hematomas = ice packs and rest
Superficial lacerations treat with sitz baths
Deep lacerations: Extension into rectum or urethra

33. Straddle injury
Injury is caused by the compression of soft tissues against the bony margins of the pelvic outlet
Mechanisms:
Bicycle riding
Falls
Monkey bars

34. Straddle injury: Appearance
Straddle injuries typically are unilateral and superficial
Anterior portion of genitalia involved
Girls:
Mons, clitoral hood and labia minora anterior and lateral to hymen
Straddle injury to hymen and posterior fourchette is rare
Boys: Injury to penis or scrotum

35. Straddle injury vs Abuse
Infant younger than nine months
Perianal, rectal, vaginal, or hymenal injury without history of penetrating trauma
Extensive or severe trauma
Presence of non-urogenital trauma
Lack of correlation between history and physical findings
Abnormal genital secretions

36. Straddle injury: Treatment principles
Visibility of injury
Physician must be assured that the injury is properly inspected
Ability to void
Inability to void
Pain
Large hematoma
Urethral disruption

37. Treatment : Girls Vulvar hematoma: size dependant Vulvar lacerations
Ice packs, analgesia, sitz baths
Increasing size: Surgical drainage
Vulvar lacerations
Heal by secondary intention ( lateral wall of vestibule)
Repair of perineal lacerations under sedation
Vaginal injury: suspect if hymenal tear
Lacerations: superficial or deep - Repair
Hematomas: Observation
Small, medium and large” egg, orange, grapefruit
Superficial vag lac –ED repair
Deep vag lac – GYN or Urology, Intact hymen: vag injury is unlikely. Torn hymen- detailed vag exam

38. Treatment: Boys Urethral injury: Anterior vs. posterior
Testicular injury:
Depends on severity
Assessment with US and Urology
Scrotal injury
Hematoma, ecchymosis: Ice packs
Superficial lacerations: Repair in ED
Hematocele and scrotal swelling
Deep ( extension through Dartos): Urology
Penile injuries

39. Penile Trauma: Direct Injury
Causes and management
Falling toilet seat
Significant penile edema
Injury to corporal bodies or urethra is rare
Treatment: warm soaks, void in bath tub, Observation
Blunt trauma: Blood at urethral meatus
Urethral injury
Diagnosis: Retrograde urethrogram
Laceration to penile shaft
R/O urethral injury and injury to corporal bodies
Consult urology, urethrogram, exploration in ?? Cases
Simple laceration: Repair with chromic catgut

40. 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
Localized edema and pain are the most common complications
Significant injury, including skin loss or necrosis, is unusual.

41. Zipper Injury: Treatment
Mineral oil: Allows tissue to slide freely
Entrapment release — The procedure for entrapment release depends upon the site of entrapment within the zipper.
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.

42. Zipper Injury : Treatment
Entrapment of penile skin in the zipper mechanism (which consists of two faceplates connected with a median bar)- More difficult to release.
Sedation may be necessary to complete procedures
Local anesthesia usually is adequate for older children.

43. Zipper injury: Treatment
Recommended technique:
The median bar may be cut with wire cutters, bone cutters, or a mini hacksaw
Allows the mechanism to fall apart and leads to release of the entrapped skin
Alternate technique:
Thin blade of a small flathead screwdriver
Placed between the faceplates on the side of the mechanism in which the penile skin is not entrapped.
The blade is then rotated toward the median bar
This widens the gap between the faceplates, releasing the skin

46. Penile Injury: Strangulation
Constriction ring: Hair, fiber, thread
Pitfall: Local edema may hide the ring of hair
Treatment:
Division of hair &release of constriction
May require GA and urologic consultation
Complication
Urethrocutaneous fistula
Penile loss: case report
Occasional report as form of sexual abuse

47. Scrotal Trauma Mechanisms of trauma Direct blow
Straddle injury: Impingement of testis against the pubic bone
Penetrating injuries: Rare
Spectrum of scrotal trauma
Minimal scrotal swelling to testicular rupture with blood filled scrotum
Suspicion of testicular rupture: surgical exploration
Best salvage of ruptured testis
Rare presentation of testicular torsion

48. Scrotal trauma: hematocele
Hematocele: Blood within tunica vaginalis
May represent severe testicular injury
Ecchymosis of scrotal wall in setting of trauma
Sonography:
Identifies fluid collection in the tunica
Blood more echogenic than hydrocele fluid
Treatment: Surgical exploration to drain large hematoceles as well as testicular repair if ruptured

49. Scrotal trauma spectrum
Intratesticular hematoma or laceration of tunica
Ultrasound : Assists to determine location of blood
Intact Tunica: Surgery not necessary
? Testicular laceration: surgical exploration
Traumatic epididymitis
Results from blunt trauma
Initial pain, then pain free, then pain returns
Scrotal erythema, edema, epididymal tenderness
Ultrasound: rules out severe injury
Treatment: Supportive
Scrotal laceration
Evaluate testis and spermatic cord for injury
Simple laceration: Hemostasis and chromic sutures

50. Scrotal injuries: Urology intervention
Large testicular hematoma may need drainage
Delay in surgery may lead to ischemic necrosis, secondary infections, disruption of testicular function
Testicular rupture with tear of the tunica albuginea requires surgical exploration.
Salvage more likely if repaired within 24h
Laceration to scrotum through the dartos
All penetrating testicular injuries

51. Testicular torsion
Scrotal pain and swelling – common presenting symptom in ED
Acute scrotum
Acute testicular torsion – rapid pickup is vital for salvage
Salvage rate drops when repair delayed beyond 6-8 hours after acute event
Acute scrotum – Testicular torsion is the working diagnosis until proven otherwise

52. Testicular torsion: Stats
1 out of every 4000 males before age of 25
Peak incidence: 13 years of age
Another peak:
Perinatal period.
Newborn born with hard, necrotic testis.
Hard or discolored scrotum
Salvage not possible
Rare: after age of 30 yrs

53. Testicular torsion: Cause
Basic mechanism – Movement of testis that is abnormally fixed in tunica vaginalis
Infants: Lack of fixation of tunics in the scrotum. Extravaginal torsion
Bell Clapper deformity: Tunica vaginalis has abnormally high attachment to spermatic cord
Testis not fixed. Prone to torsion
Allows testis to lie transversely and rotate
Found in most cases. Commonly bilateral

54. Bell Clapper deformity

55. Testicular torsion: Clinical features
PAT:
Appearance: Crying, irritable, uncomfortable
WOB: Normal
Circulation: Normal systemic
Other findings:
History of pain in past
Acute onset pain in groin or scrotum
Nausea and vomiting
High riding testis, Transverse lie of testis
Diffuse testicular pain, absent cremasteric reflex

56. Testicular torsion: Complications
Delay in re-establishing blood flow – loss of testicular function
Delay
Patient presentation
Physician taking his or her time to establish diagnosis
Testicular salvage:
80-90%: within 8 hours of acute pain
<20%: for delay up to 12 hrs

59. Diagnostic studies
Lab studies: not sufficient to make definitive diagnosis
Ultrasound with Doppler:
Readily available, non invasive and highly accurate
Any uncertainty: Indicates surgical exploration
Testicular scintigraphy:
PPV of 95%
Access may not be easy at all times
High index of suspicion: Do not delay surgical procedure to confirm suspicion with a diagnostic study.

60. Testicular torsion: Differential
Torsion of appendix testis or appendix epididymis
Epididymitis
Orchitis
Incarcerated Inguinal Hernia
Scrotal trauma
Hydrocele
Varicocele
HSP/ Kawasaki disease
Scrotal cellulitis
Testicular tumors

61. Management Analgesia: IV narcotic
Manual detorsion: Can preserve testicular viability and provide time
Twist affected testis outwardly
Successful detorsion: Relief of pain and visible lengthening of cord structures
More than 360o detorsion may be required
Surgery
Non viable testis: Orchiectomy
Viable testis: Orchiopexy
Exploration of unaffected testis

62. Torsion of testicular appendage: Appendix testis or Appendix epididymis
Average age: 10 years
Clinical features:
Sudden onset pain limited to scrotum
No abdominal or urinary symptoms
Point tenderness at superior aspect of testis in early stages
Blue dot: visible tender nodule in 20% cases

64. Diagnosis and Management
Testicular scan and Ultrasound
Increased blood flow
Inflammation at superior aspect of testis
Treatment
Expectant
Analgesics
Any doubt about diagnosis
Urology consultation for exploration

65. Phimosis & Paraphimosis
Phimosis: Tightness of distal foreskin
Cannot withdraw to expose the glans
Not to be confused with penile adhesions
Paraphimosis: Foreskin is retracted behind glans and left there – swollen, retracted foreskin
Venous congestion & edema: reduction to normal position is difficult

66. Paraphimosis: Treatment
Manual reduction: Application of ice and steady local compression
Local anesthesia: Penile block
Pressure on glans (turning a sock inside out)
Surgical reduction: Failure of manual reduction (2-3 attempts)
Surgical division of foreskin
Circumcision: after a few weeks
Prevention: Education of uncircumcised male

67. Improving success of manual reduction
Wrap the penis in plastic and apply ice packs
Use compressive elastic dressings
Apply direct circumferential manual compression
Granulated sugar
Hyaluronidase therapy - directly into several sites of the edematous prepuce.
Puncture of the edematous site
Hyaluronidase breaks down hyaluronic acid in connective tissue and enhances fluid diffusion between tissue planes, decreasing preputial swelling and resulting in almost immediate resolution of the edema

69. 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

70. 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

71. A 6 yo girl comes to the ED after sustaining an injury to the
perineum. The patient was climbing on a tree when she fell
approximately 4 feet landing on a large rock. She complains of
pain and bleeding from vaginal area. She has been refusing to
urinate due to pain. A 1-cm superficial vulvar laceration is noted
at 3 o’clock with small amount of oozing blood. The hymen
appears intact. The most appropriate management is:
a. Surgical exploration under general anesthesia
b. Laceration repair under local anesthesia
c. Consultation with the child protection team
d. Supportive care and sitz baths
e. Placing a Foley catheter and hospitalization

72. A 13 yo boy comes to the ED after sustaining a straddle
injury to his scrotum while riding his bicycle. He is able to
urinate without difficulty and has no gross hematuria. There is
no trauma to the abdomen. On exam, he has normal vital signs.
His right hemi-scrotum is swollen and ecchymotic. There is
marked tenderness on palpation. There is no ecchymosis or
swelling of the penis, and no blood per meatus. The
management includes:
a. Pelvic x-ray
b. Needle aspiration
c. Retrograde urethrogram
d. Scrotal ultrasound
e. No intervention is needed

73. 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

74. A 16 yo boy comes to the ED with left-sided groin pain and
scrotal swelling that began 4 hours prior to arrival. He also
reports mild lower abdominal pain and nausea. On exam, his left
scrotum is erythematous, moderately swollen and diffusely
tender on palpation. A cremasteric reflex cannot be elicited.
There is mild tenderness on palpation of lower abdomen. The
most appropriate management of this patient is:
a. Scrotal ultrasound
b. Immediate surgical exploration
c. Ceftriaxone and doxycycline
d. Trimethoprim/sulfamethoxazole
e. Incision and drainage

75. and penis pain since the morning of presentation. There is no
A 3 yo uncircumcised boy presents to the ED with swelling
and penis pain since the morning of presentation. There is no
history of trauma. He is able to void without difficulty. On
exam, his foreskin is retracted and swollen, and the glans
appears swollen. Which of the following would be the most
appropriate initial treatment?
a.Oral antibiotics
b. Manual reduction
c. Topical antibiotic
d. Circumcision
e. Warm sitz baths