Urogenital Trauma

1. 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

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

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

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 • 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

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

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. • 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 • 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

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