1. IN THE NAME OF GOD Genitourinary Trauma
Ali Ariafar. M.D
Urology- Oncoloy Fellowship
Shiraz university of medical sciences

2. Renal Trauma
Three to 10% of trauma patients have GU involvement; 10-15% of trauma patients with abdominal injuries have GU involvement.
In patients with GU trauma, symptoms are nonspecific and may be masked by or attributed to other injuries.
In blunt trauma, history is obtained regarding the time and mechanism of injury, position of the patient, speed of the vehicle, and use of restraints.
In penetrating trauma, knowing the size of the stabbing weapon or the caliber of the gun and the distance from which it was discharged aids assessment..
Renal injuries are the most common injuries of the urinary System( 45% of all GU injuries)
Renal injuries are most commonly from motor vehicle accidents (MVAs).

3. Renal Trauma
The most important indicator of renal trauma is gross or microscopic hematuria. however the degree of hematuria and the severity of renal injury do not correlate consistently
Blunt trauma is cause 80% of renal injuries among patients with gross hematuria, notable renal trauma is present in 25%
less than 1% of patients with microhematuria have substantial renal injury
The absence of hematuria, although rare, does not exclude renal injury because it is absent in 5% of patients and 36% renal vascular injury

4. Renal Trauma
Flank ecchymosis or mass indicates a retroperitoneal process but is not specific to renal injuries and rarely occurs acutely.
Suspect renal injury when fractures of lower ribs and/or spinal processes are observed and/or when a history of sudden deceleration or significant lateral force on the patient exists.
Trajectory of the bullet or penetrating object helps indicate the possibility of renal injury.
Presence of abdominal, visceral, solid organ, or vascular injury indicates renal injury, as these injuries coexist with renal injuries in 34% of patients with blunt trauma and in up to 80% of patients with penetrating trauma.

5. Renal Trauma Renal Injury Scale Grade Injury Description
I microscopic or gross hematuria, urologic studies normal subcapsular hematoma, non-expanding without parenchymal laceration
II non-expanding perirenal hematoma confined to renal retroperitoneum, or laceration < 1.0 cm parenchymal depth of renal cortex without urinary extravasation
III laceration > 1.0 cm parenchymal depth of renal cortex without
urinary extravasation or collecting system rupture
IV parenchymal laceration extending through the renal cortex, medulla, and collecting system, or main renal artery or vein injury with contained hemorrhage
V completely shattered kidney or avulsion of renal hilum which devascularizing the kidney

6. Renal Injury Scale

7. Renal Trauma Lab Studies:
Complete blood count (CBC) to obtain hematocrit level and platelet count
Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to check for coagulopathy; may be unnecessary in young, otherwise healthy patients
BUN and serum creatinine: Elevation of BUN without elevation in creatinine indicates urine reabsorption.
Urinalysis to diagnose hematuria
Blood type and crossmatch

8. Renal Trauma
Indications for Radiographic Assessment in suspected renal trauma
penetrating trauma to flank or abdomen regardless of the degree of hematuria (microscopic or gross)
in all adult patients with blunt abdominal trauma with gross hematuria
in all adult patients with blunt abdominal trauma with microscopic hematuria and associated shock (<90 mm Hg)
deceleration injuries from history
major intra-abdominal injuries with microhematuria
pediatric flank or abdominal trauma with any degree of hematuria

9. Renal Trauma Radiographic Staging IVP - double dose
CT Scan - best method of staging - radiographic study of choice
Ultrasound
Angiography - used for suspected renovascular injury

10. Renal Trauma
Most renal injuries (80%) are minor and do not require surgical intervention
Absolute Indications for Surgery
Signs and symptoms of persistent bleeding
Unstable vital signs
Decreasing hemoglobin
Expanding flank mass  
Relative Indications for Surgery
Urinary Extravasation
Renovascular injury
Incomplete staging
Nonviable tissue

11. Renal Trauma Complications Persistent urinary extravasation
Delayed renal bleeding
Perinephric abscess
Hypertension
Arteriovenous fistula
Hydronephrosis

12. Grad 1

13. Grade 2

14. Grade 3

15. Grade 4

16. Grade 4-5

17. Grade 5(UP avultion)

18. Grade 5(shattered kidney)

19. Grade 5(devascularization)

20. Grade 5(devascularization)

21. Surgery

22. Ureteral trauma
Ureteral injury is rare but may occur, usually during the course of a difficult pelvic surgical procedure or as a result of stab or gunshot wounds
Occur in less than 4% of penetrating trauma and less than 1% of blunt trauma
Hystrectomy was responsible for the majority of surgical injury(54%) followed by colorectal surgury (14%)

23. Ureteral Injury Diagnosis fever flank pain nausea and vomiting
Hematuria (25-45% have no microhematuria)
fever
flank pain
nausea and vomiting
acute peritonitis
Paralytic ileus
Watery discharge from the wound or vagina

24. Ureteral Injury Imaging IVP—non-diagnostic in 33-100%
No ideal study
IVP—non-diagnostic in %
Finding subtle on both IVP and CT
Delayed function
Ureteral dilation/deviation
Retrograde—only to delineate extent of injury
Antegrade—only if retrograde not possible

25. Ureteral Injury Treatmen Complications LOWER URETERAL INJURIES
MIDURETERAL INJURIES
UPPER URETERAL INJURIES
Complications
Stricture
Urinoma
Pyelonephritis
fistula formation.
peritonitis

27. Bladder Trauma
Bladder injuries mostly occur in blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures; 15% occur with penetrating trauma and blunt mechanism without a pelvic fracture (ie, full bladder blowout).
Obstetric and gynecologic complications are the most common etiology of bladder injuries during open surgery

28. Bladder Trauma Bladder injuries:
classified into contusions, extraperitoneal and intraperitoneal ruptures  
10% of patients with pelvic fractures will have a bladder injury  
>80% of patients with bladder injuries have an associated pelvic fracture  
gross hematuria in the trauma setting requires imaging of both upper and lower urinary tract

29. CLINICAL INDICATORS OF BLADDER INJURY
Suprapubic pain or tenderness
Inability to void or low urine output
Clots in urin
Abdominal distention or ileus
Free intraperitoneal fluid on CT or ultrasound examination

30. Indication for cystography
Gross hematuria with pelvic fracture(29% have bladder rupture)
penetrating injuries of the buttock, pelvis, or lower abdomen with any degree of hematuria
cystography is nearly 100%
accurate for bladder injury

31. Cystogram finding Extraperitoneal rupture:
Dense, flame-shaped collection of
contrast material in the pelvis
Intraperitoneal rupture:
contrast material surrounding loops of
bowel

32. Extrapritoneal rupture of bladder

33. Intrapritoneal rupture of bladder

34. Bladder Trauma
Intraperitoneal ruptures usually associated with full bladder and seatbelt injury or sudden blunt injury to lower abdomen
Bladder injury occurs at dome of bladder where there is peritoneal covering
All intra-peritoneal bladder injures should be repaired operatively  
Extraperitoneal injuries usually associated with pelvic fractures - mechanism of action is secondary to shearing forces or bony spicules penetrating bladder  
Most extraperitoneal bladder injuries may be treated with catheter drainage alone however relative indications for surgery include:
Continued bleeding
Presence of bone in bladder
Concomitant laparotomy

35. Complications
Unrecognized bladder injuries may manifest as acidosis, azotemia, fever and sepsis, low urine output, peritonitis, ileus, urinary ascites, or respiratory difficulties.
Unrecognized bladder neck, vaginal, and rectal injury associated with the bladder rupture can result in incontinence, fistula, stricture, and difficult delayed major reconstruction.
Severe pelvic fractures may cause a transient or permanent neurologic injury and result in voiding difficulties despite an adequate bladder repair.

36. Urethral Trauma divided into posterior and anterior urethral injuries
anterior urethral injuries caused by blunt (straddle injury to perineum) or penetrating injury - usually have scrotal penile swelling and blood at the meatus  
posterior urethral injuries occur in 2-5% of patients with pelvic fractures  
blood at the meatus is the best sign in both injuries however, must have high index of suspicion  
in posterior urethral injuries may also get inability to void, a high riding prostate, scrotal swelling and ecchymosis, and "butter fly" bruising in perineum  
in suspected urethral injury - must do retrograde urethrogram prior to inserting catheter

37. Urethral Trauma
posterior urethral injuries occur commonly at bulbomembranous junction  
penetrating anterior urethral injuries usually best dealt with debridement and possible immediate reconstruction  
blunt anterior urethral injuries usually best dealt with catheter stenting +/- suprapubic tube insertion  

38. Urethral Trauma Imaging Studies:
Plain radiograph of the pelvis to assess presence and extent of bony injury
Retrograde urethrogram
This is indicated prior to the insertion of a Foley catheter when urethral injury is suspected.
Retrograde cystogram
250 cc are introduced through the Foley catheter.
If the patient reports no discomfort, another 150 cc are introduced, and the catheter is clamped.

39. Urethral Trauma

40. Urethral Trauma
Management of urethral injuries - Related to type of injury sustained, but basic principles apply
Drain the bladder with a suprapubic catheter percutaneously or open to prevent further extravasation.
Initial urethral repair is not recommended because of risk of hemorrhage, impotence, and infection of pelvic hematoma.
Commence definitive management of urethral injuries after stabilizing the patient and attending to associated injuries, if present.
Repair can be performed as immediate primary closure, delayed primary closure (10-14 d), or late primary closure (>3 mo).

41. Complication
Stricture
incontinence
Erectile dysfunction

43. Penile Trauma Penis fracture Penis amputation Gun-shot
Animal and Human Bites

44. Penis Fracture Mechanism buckling injury to rigid penis
The tunica albuginea is a bilaminar structure (inner circular, outer longitudinal)
The outer layer determines the strength and thickness of the tunica
When the erect penis bends abnormally, the abrupt increase in intracavernosal pressure cause transverse laceration

45. Etiology Sexual intercourse(94%) Masturbation
Rolling over or falling on to the erect penis
Self-inflicted fractures during masturbation (69%in Kermanshah)

46. Diagnosis and sign/symptom
The diagnosis of penile fracture is made by history and physical examination
Popping sound, followed by pain, rapid detumescence, and discoloration and swelling of the penile shaft.
Eggplant deformity (Buck's fascia remains intact)
Deviates to the side opposite the tunical tear.
“Rolling sign” firm, mobile, discrete, tender swelling over which the penile skin can be rolled

47. Imaging Cavernosography urethrography Ultrasonography
MRI (highly accurate )

48. False fracture Rupture of the dorsal penile artery or vein
Tear of suspensory ligament

49. Penis fracture

50. Penis fracture

51. Outcome and Complications.
Immediate surgical reconstruction results in faster recovery, decreased morbidity, lower complication rates, and lower incidence of long-term penile curvature
Conservative management of penile fracture results in penile curvature in more than 10% of patients, abscess or debilitating plaques in 25% to 30%, and significantly longer hospitalization times and recovery

52. Gunshot Wounds.
77% to 80% of victims have significant associated injuries
Urethral injuries have been reported in 15% to 50%
Treatment principles include immediate exploration, copious irrigation, excision of foreign matter, antibiotic prophylaxis, and surgical closure.

53. Gunshot

54. Animal and Human Bites
Initial management of dog bites includes copious irrigation, débridement, and immediate primary closure along with prophylactic broad-spectrum antibiotics(penicillin V-chloramphenicol)
Human bites produce potentially contaminated wounds that often should not be closed primarily
Tetanus and rabies immunizations

55. Amputation rare, usually the result of genital self-mutilation.
65 to 87% of patients performing genital self-mutilation are psychotic
microsurgical repair achieve good results.
Successful reimplantation is possible after 16 hours of cold ischemia time or 6 hours of warm ischemia
Adequate erectile function(more than 50%) is possible with both technique,
complications such as urethral strictures, skin loss, and sensory abnormalities are all much higher without microvascular repair. Normal penile sensation returns in 0% to 10% of patients after macroscopic replantation whereas sensation is present in more than 80% of microscopic replantations

56. Penile amputation in the initial stage of replantation.

57. Partial penile amputation.
Repair of partial penile amputation

58. Testis trauma blunt trauma (about 75% of cases)
Penetrating injuries(25%)
1.5% of blunt testis injury and 30% of penetrating scrotal trauma involves both gonads
Most penetrating scrotal trauma (72% to 83%) is associated with nongenitourinary injuries

59. Etiology
The most common cause of blunt testicular trauma is sports injuries
The second most common cause of testicular trauma is a kick to the groin. Less common etiologies include motor vehicle accidents, falls, and straddle injuries.
The most common cause of penetrating testicular injuries is a gunshot wound to the genital area. Other causes include stab wounds, self-mutilation, animal bites (usually dog), and emasculation

60. Sign -Symptom exquisite scrotal pain and nausea.
Swelling and ecchymosis
Scrotal hemorrhage and hematocele
tenderness to palpation
degree of hematoma does not correlate with the severity of testis injury

61. Imaging
Ultrasonography CT
MRI

62. disrupted tunica albuginea intratesticular hematoma

63. Differential diagnosis of testis rapture
Hematocele without rupture,
Torsion of the testis or an appendage (5% of torsions are precipitated by trauma)
Reactive hydrocele,
Hematoma of the epididymis or spermatic cord
Intratesticular hematoma.
Dislocation after trauma.

64. Management
MAJOR scrotal injuries: Early exploration and repair of testis injury is associated with increased testis salvage, reduced convalescence and disability, faster return to normal activities, and preservation of fertility and hormonal function
Minor scrotal injuries: managed with ice, elevation, analgesics, and irrigation and closure in some circumstances

65. Indication of surgical exploration
tunica albuginea rupture
Significant intratesticular hematomas
Significant hematoceles (up to 80% are due to testis rupture )
Penetrating scrotal injuries

66. Surgical repair

67. Complications Testicular infarction Testicular torsion
Testicular or epididymal abscess
Infertility
Testicular necrosis
Testicular atrophy

68. Outcome
Testis salvage rates exceed 90% with exploration and repair within 3 days of injury versus orchiectomy rates threefold to eightfold higher with conservative management and delayed surgery
Testis salvage rates with conservative management are as low as 33%, with delayed orchiectomy rates between 21% and 55%
Penetrating testis trauma is associated with gonad salvage in only 32% to 65% of cases