Urogenital Trauma Liping Xie Department of Urology First

Urogenital Trauma Liping Xie Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University

Urogenital Trauma Three to 10% of trauma patients have GU involvement; 10 -15% of trauma patients with abdominal injuries have GU involvement. Ø Renal & Ureteral Injury Ø Bladder Injury Ø Urethral Injury Ø Injuries of the external genitalia

Renal Injury

Renal Injury Ø Renal injuries constitute 45% of all GU injuries; Ø Most renal injuries (80%) are minor and do not require surgical intervention; Ø Renal trauma can happen in both blunt or penetrating trauma; Ø Renal injuries are most commonly from motor vehicle accidents (MVAs; (

Renal Injury Scale

Renal Injury Physical examination: Ø Flank ecchymosis or mass indicates a retroperitoneal process but is not specific to renal injuries and rarely occurs acutely. – The most important indicator of renal trauma is gross or microscopic hematuria. – The absence of hematuria, although rare, does not exclude renal injury because it is absent in 5% of patients.

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

CT Staging for Renal Injury Right renal stab wound (Grade IV) Left renal laceration

Management of Renal Injury

Surgical Management for Renal Injury

Ureteral Injury

Ureteral Injury Ø Ureteral injuries after external violence are rare, occurring in less than 4% of cases of penetrating trauma and less than 1% cases of blunt trauma. Ø Ureteral injuries after external violence, unlike renal injuries, are difficult to detect with the usual array of diagnostic tools.

Ureteral Injury Excretory urography demonstrating extravasation in the upper right ureter consequent to stab wound (Arrow)

Surgical Management for Ureteral Injury

Bladder Injury ØBladder injuries classified into contusions, extraperitoneal and intraperitoneal ruptures ; Intraperitoneal (20%) Rupture Extraperitoneal (80%) A full bladder is more likely to become injured than an empty one.

Bladder Injury Ømostly occur in blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures ; Ø 15% occur with penetrating trauma and blunt mechanism without a pelvic fracture (ie, full bladder blowout. ( Øgross hematuria in the trauma setting requires imaging of both upper and lower urinary tract

Bladder Injury

Diagnosis Cystogram and CT are helpful diagnostic tools. Cystogram (left) shows extraperitoneal bladder rupture with extravasation into scrotum. CT(right) reveals intraperitoneal bladder rupture with contrast material surrounding bowel loops

Surgical Mangement of Bladder Rupture

Urethra Injury

Urethra Injury Ø Almost exclusively in male Ø Most common in straddle injure Ø Significant morbidity – Stricture – Incontinence – Impotence Ø Foley catheter implication

Urethra Injury Posterior UrethraØ Gross hematuria in 98% Ø Inability to void Ø Blood at urethral meatus Ø Pelvic / suprapubic tenderness Ø Penile / scrotal / perineal hematoma Ø Boggy / high-riding prostate/ ill-defined mass on rectal examination. Anterior UrethraØ More common than posterior Ø Direct trauma Ø Usually NO pelvic injury Ø Blood at meatus Ø Unable to micturate Ø Penile/Scrotal/Perineal – Contusion – Hematoma – Fluid collection

Urethra Injury High Riding Prostate on DRE EXTRAVASATION OF URINE

Diagnosis Urethrogram is the best diagnostic tool-

Urethrogram

Urethrogram Contrast extravasation + Contrast in bladder PARTIAL Tear Contrast extravasation only COMPLETE Tear

Urethrogram retrograde urethrography via meatus Extravasation of contrast medium with the “missing” bladder indicates a complete tear of the urethra

Management of Urethral Injury Ø Partial tear – careful passage of 12 -14 Fr. Foley. – If any resistance: Urology Ø Complete tear: – Urology + suprapubic cath. Ø If Foley already there and suspect tear: – LEAVE FOLEY IN PLACE Initial urethral repair is not recommended because of risk of hemorrhage, impotence, and infection of pelvic hematoma.

Management of Urethral Injury Surgical Repair Bank’s Method

Injuries of the external genitalia Ø Penis – Penetrating, skin avulsion and amputation repaired surgically – “fracture” repaired and drained surgically Ø Scrotum/testes – Hematocele and contusion (mild) or rupture (severe, needs exploration) – Penetrating injuries need exploration

Injuries of the external genitalia Penile fracture scrotal hematoma after straddle injure