1. GENITOURINARY TRAUMA Mark Boyko EM

2. Objectives 1.Key aspects of GU trauma in an anatomical approach: External Genitalia Urethral Injury Bladder Injury Ureteral Injury Renal Injury

3. GU Trauma 80% of GU trauma is BLUNT trauma Very rarely is life threatening, so take a step back and move through your systems anatomically Assessing for concomitant pelvic fracture is one of the most important points

4. Eur J Emerg Med. 2004 Aug;11(4):223-4. A human bite to the scrotum: a case report and review of the literature. Kerins M, Greene S, O'Connor N. Emergency Department, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK. mkerins_fahey@hotmail.com Human bites to the scrotum are rare and can be associated with a high morbidity rate if poorly managed. We report a case of a human bite to the scrotum that was successfully treated with a 5-day course of antibiotics, surgical debridement and healing by secondary intention. Kerins MGreene SO'Connor N Anything can happen…

5. External Genitalia Trauma here is rare in females In males, injury is often obvious Look for swelling, ecchymoses, deformity Testicular torsion can occur with trauma Testicular rupture occurs in 50% of patients with a direct blow to a testicle, have a low threshold to ultrasound

6. Male External Genitalia Penile Fracture –Usually a ‘sexual accident’ –Immediate pain, often hear a ‘popping sound’, early swelling –Is a rupture of the tunica albuginea surrounding the corpora cavernosa –20% association with urethral injury –Requires operative repair

7. Question A penile fracture is classically described using what vegetable?

8. Penile Fracture ‘Eggplant Deformity’

9. Urethral Injuries Again, rare in females In males, divided into ‘anterior’ and ‘posterior’ urethra, divided by urogenital diaphragm

10. Urethral Injury In males, 25% of all pelvic fractures have urethral injury (vs only 5% in females), more commonly the posterior division Gross hematuria and pelvic fracture = posterior urethral injury until proven otherwise The big 4 clues to urethral injury: –Blood at meatus –Gross hematuria –Inability to void –Ecchymoses, swelling of penis

11. Question What 4 things are necessary before you can attempt to pass a foley catheter?

12. The Great Foley Debate Textbook answer: 4 things allowing you to pass a foley safely: 1. No pelvic and suprapubic tenderness / # 2. No penile, scrotal, or perineal hematoma 3. No blood at the urethral meatus 4. No abnormal findings on DRE

13. The Great DRE Debate Textbook answer: –‘high riding prostate’ or boggy prostate is concerning for a posterior urethral injury –blood causes the prostate to lift superiorly

14. Is any of this true?? EM Rap 2008 The Great Foley Debate: –Initial concept came from 1977 paper by a British urologist entitled “A Personal View of Immediate Management of Pelvic Fracture and Ureteral Injury” - no references –UCLA retrospective review of 7 years trauma patients, 46 urethral injuries, 50% of blind passes were successful –The ‘classic’ signs of urethral injury were extremely non-sensitive –One small retrospective review of 13 cases of urethral injury demonstrated no evidence that a blind attempt to insert a urinary catheter worsened the initial injury. –No case reports that passing a foley caused/worsened urethral injury The Great DRE Debate: -same UCLA retrospective review, 0 had ‘high riding prostates’ -UCLA 1400 trauma patients, more false + DRE’s than true + (for tone, for sensation, for blood)

15. Urethral Injury - Imaging If any concern for a urethral injury, do a retrograde urethrogram Will either be: Normal ‘Partial’ urethral injury (some dye in bladder, some extravascation) ‘Complete’ urethral injury (no dye in bladder)

17. Urethral Injury - Management If no concern for injury, or retrograde urethrogram normal, put a foley in. If a partial urethral tear, textbooks say one careful attempt to pass a 12- or 14-Fr Foley can be undertaken. Most urologists disagree with this, and wish to be consulted. If a complete tear – suprapubic catheter, urology consult for operative repair.

18. Bladder Injury Question: Which part of the bladder is the weakest and most likely to rupture? A) Trigone B) Lateral walls C) Dome (superior wall) D) Posterior wall

20. Bladder Injury 80% of bladder injuries associated with pelvic # Injuries classified as: Contusions Intra-peritoneal ruptures (through the dome) Extra-peritoneal ruptures (seen exclusively with pelvic fractures)

21. Bladder Injury Signs GROSS hematuria (95% of cases) Microscopic hematuria with a pelvic fracture No pelvic fracture + No gross hematuria excludes injury to bladder What about pelvic # and microscopic hematuria? --> Do a retrograde CT cystography

22. Bladder Injury - Imaging Retrograde cystography (either CR or CT) is imaging modality of choice Very sensitive

23. Bladder Injury

24. Bladder Injury - Management Contusions – conservative Intra-peritoneal – operative repair Extra-peritoneal – many are now managed non-operatively with an indwelling foley catheter, will usually heal spontaneously.

25. Ureteral Injury Extremely rare, gunshot is most common No reliable Phx findings! Usually a retrograde diagnosis Urinalysis is normal 25% of the time, do not rely on it Being suspicious for it is the only way you will catch it Imaging: Delayed CT with IV contrast Management: Requires OR

26. Renal Injury 90% blunt trauma, 10% penetrating Again, relax. ‘Something else will kill them’ (less than 0.1% of trauma death)

27. Classification of Renal Injury

28. Hematuria and Renal Injury Poor correlation with degree of injury Microscopic hematuria on its own is not a concern. Repeat urinalysis in 3 weeks You should image if the following: Microscopic hematuria with shock GROSS hematuria Rapid deceleration without hematuria or shock (rare, but important) Penetrating trauma in the region

29. Renal Imaging CT with IV contrast is 90-100% SENS Remember, FAST ultrasound is not good for solid organ injury, do not use it in this setting Formal ultrasound not as sensitive as CT

30. Renal Injury - Management If no ‘rapid’ deceleration mechanism (how rapid?) and no gross hematuria, can d/c home with f/u urinalysis Grade I and II injuries  non-operative. ‘Bed rest’ until gross hematuria clears. Grade III and up  decision point for urology

31. Ask Me For References Questions?