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Genitourinary Trauma

Genitourinary Trauma. François Dufresne McGill Emergency Medicine February 13 th 2002. The Case of Jeremy. 23 y.o male Driver, Seatbelted Frontal Impact, High Speed (  100Km/h) Airbag + Other driver dead Car completely destroyed Empty EtOH bottles in the OTHER car

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Genitourinary Trauma

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  1. Genitourinary Trauma François Dufresne McGill Emergency Medicine February 13th 2002

  2. The Case of Jeremy • 23 y.o male • Driver, Seatbelted • Frontal Impact, High Speed ( 100Km/h) • Airbag + • Other driver dead • Car completely destroyed • Empty EtOH bottles in the OTHER car • Patient was conscious at the scene. • On scene: BP=85/50 HR:120 RR:22 Sat:98%

  3. Jeremy… • A: Clear. C-spine protection. Backboard+ • B: A/E symetric. O2 Sat N. No crepitus. Trachea central. • C: BP:100/60 HR:100 Mentating well. • D: GCS=15 PERL. • Pt is exposed. • O2 - iv – monitor • Temperature N Capillary Glucose N

  4. Jeremy • AMPLE • C/O abdo. Pain + “hip” pain • C/O right lower leg pain • Secondary Survey • Spleen normal. Mild suprapubic tenderness. • Pelvic instability • Probable right tibial # • No gross blood at meatus. Rectal Normal. • “Doctor, can I put a Foley?”

  5. Jeremy • What are your concerns? • Foley? • What will be the usefulness of dipstick? • Dipstick good enough? U/A? • What if he has microscopic hematuria? • What if he has a pelvic fracture? • Any different if you had blood at meatus? • Urethrogram? Cystogram? Abdominal CT? • Worried about the kidneys? Bladder? • Does the low BP changes your suspicion for a GU injury?

  6. Introduction • GU Trauma overlooked • 10-20% of all injured patients • Long term morbidity • Impotence • Incontinence • Life-threatening injuries first

  7. Plan • Urethral Injury • Bladder Injury • Hematuria in Trauma • Kidney Injury

  8. Definitions • Upper tract • Kydney • Ureters • Lower tract • Bladder • Urethra • External genitalia

  9. Urethral Trauma • Almost exclusively in male • Significant morbidity • Stricture • Incontinence • Impotence • If unrecognized: • Converting partial to complete tear • Inaccurate assessment of U/O • Foley catheter implication Andrich DE et al. The nature of urethral injury in cases of pelvic fracture urethral trauma. Journal of Urology. 165(5):1492-5, 2001 May.

  10. Anatomy Bladder Symphysis

  11. Prostatic Membranous Bulbous Pendulous

  12. Posterior Urethra • Violent external force • Pelvic # in  90% • Pelvic # : 5-25% of Posterior urethral injury

  13. Clinical Features • Gross hematuria in 98% • Inability to void • Blood at urethral meatus • Pelvic / suprapubic tenderness • Penile / scrotal / perineal hematoma • Boggy / high-riding prostate/ ill-defined mass on rectal examination.

  14. Digital Rectal Exam in Trauma • Porter et al. Am Surg, 2001. • Prospective • Level II Trauma Center. • 423 patients. • DRE on all. • 7 (1.7%) pelvic fracture. NO Urethral injury • Prostate exam didn’t change management Porter, J.M. et al. Digital rectal examination for trauma: does every patient need one? Am Surg 67(5):438, May 2001.

  15. Posterior Urethral rupture From McAnich JW. In Tanagho EA, McAninch JW, editors: Smith’s general urology, ed 14, Norwalk, Conn, 1995, Appleton & Lange.

  16. Diagnosis:Retrograde Urethrogram • Pretest KUB film • Supine position • Injection of 25ml of water-soluble contrast • Different techniques • X-ray when 10ml left and after 25ml • Post-voiding x-ray.

  17. Retrograde Urethrogram

  18. Retrograde Urethrogram:Interpretation • Contrast extravasation + Contrast in bladder • Contrast extravasation only PARTIAL Tear COMPLETE Tear

  19. Partial Tear

  20. Complete Tear

  21. Management • Partial tear • careful passage of 12-14 Fr. Foley. • If any resistance: Urology • Complete tear: • Urology + suprapubic cath. • If Foley already there and suspect tear: • LEAVE FOLEY IN PLACE • Small tube alongside the foley • Angiocath 16-gauge • Modified urethrogram

  22. Management…by Urology • Controversial • Complete VS Partial • Posterior VS Anterior • Foley X 3-14 days • Suprapubic catheters • Surgical approach / Endoscopy • Delayed repair usually

  23. Foley Catheter • NO if you suspect a urethral injury • Most of urethral injuries: Pelvic # or Gross hematuria • Initial bladder effluent MUST be looked at. • Danger to convert partial into complete • Successful passage  complete tear • NEVER REMOVE A FOLEY WHEN YOU SUSPECT A PARTIAL TEAR AFTERWARDS. • ANY colored urine other that yellow = BLOOD until proven otherwise

  24. Prostatic Membranous Bulbous Pendulous

  25. Anterior Urethra • More common than posterior • Direct trauma • Usually NO pelvic # • Blood at meatus • Unable to micturate • Penile/Scrotal/Perineal • Contusion • Hematoma • Fluid collection

  26. Sleeve Hematoma

  27. Butterfly Hematoma

  28. Anterior Urethral Rupture

  29. Anterior Urethra:Management • NO Foley if injury suspected • Retrograde Urethrogram • Urology: • Surgical Treatment

  30. Bladder Trauma • Adult: Extraperitoneal organ • Bladder dome = weakest point • Blunt: 60-85% • MVA: #1 cause • Important to recognize • Pelvic/abdominal wall abscess/necrosis • Peritonitis • Intra-abdominal abscess • Sepsis / Death

  31. Types of rupture • Extraperitoneal • Most common • Pelvic # in 89-100% • Bladder rupture in 5-10% of all pelvic # • Intraperitoneal • Extravasation of urine in abdomen • Sudden force to full bladder • Associated injuries +++ Mortality (20%)

  32. Clinical Presentation • McConnel et al. Rupture of the bladder. Urol Clin North Am. 1982. • Carroll et al. Major bladder trauma: Mechanisms of injury and a unified method of diagnosis and repair. Journal of Urology. 1984. • 98% : Gross hematuria • 2%: Microscopic hematuria + Pelvic # • 100%: Gross hematuria • 85% Pelvic # • Morey AF et al. Bladder rupture after blunt trauma : guidelines for diagnostic imaging. Journal of Trauma-Injury Infections & Critical Care. 51(4): 683-6, 2001 Oct.

  33. Investigation • Cystography: Gold standard • CT Cystography : New trend • Peng et al. AJR 1999. • Prospective study • 55 patients. 5 bladder rupture • Cystography VS. CT cystography • Ruptures confirmed by Surgery • 100% sensitive and specific Peng et al. CT cystography versus conventional cystography in evaluation of bladder injury. AJR 1999; 173:1269-1272.

  34. Investigation… Deck et al. Journal of Urology, 2000. • Retrospective study • 316 patients with CT Cystography • Sensitivity/Specificity = 95% and 100% • But 78% and 99% for intraperitoneal rupture • Comparable to Cystography alone • Identifies other injuries Deck AJ et al. CT Cystography for the diagnosis of traumatic bladder rupture. J Urol, Jul. 2000; 164(1); 43-6.

  35. Standard Helical CT • Pao et al. Acad Radiol 2000. • With IV contrast • Misses bladder rupture • 100% sensitive if “free fluid” criteria used. • Can R/O bladder injury if NO free fluid. • Not specific. • Not accepted as diagnostic tool. Pao et al. Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 2000; 7:317-324.

  36. Treatment • Penetrating injuries: OR • Blunt • Intraperitoneal: Almost all OR • Extraperitoneal: Urethral cath. drainage x 7-10 days.

  37. Hematuria • Hardeman and al. Journal Urol, 1987. • Prospective study • 506 patients • IVP in all. CT/arteriography/O.R. PRN • Shock: BPs<90 at any time • 25 Injuries • ALL had either • Gross hematuria • Shock + microhematuria Hardeman et al. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. The Journal of Urology. 38:99-101, 1987.

  38. Hardeman et al. … • 365 (52 %) had microhematuria only • 174 D/C’ed , F/U and no problem • 191 admitted • 1 renal contusion (Grade I) • 2 minor lacerations (Grade II) • No complication Hardeman et al. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. The Journal of Urology. 38:99-101, 1987.

  39. Mee et al. Journal Urol, 1989 • Prospective • 1146 patients • IVP = Gold standard • ALL significant renal injuries had either: • Gross hematuria • Microscopic hematuria + shock • Intensity of hematuria  Severity of injury Mee et al. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. Journal of Urology. 141(5):1095-8, 1989 May.

  40. Gross « Hematuria »: False + • Alphamethyldopa • Ibuprofen • Levodopa • Metronidazole • Nitrofurantoin • Phenazopyridine • Phenolphtalein-containing laxatives • Rifampin • Beets/berries

  41. Microscopic hematuria… • 8 major studies • 3406 adult blunt trauma with microscopic hematuria and NO shock. • 0.23% major renal injuries (gradeII) • No imaging necessary for that group • F/U 3-4 weeks to R/O underlying pathology. • BUT…

  42. Microscopic hematuria… • Patients with pelvic # often excluded from studies. • Penetrating trauma excluded. • Pediatric population excluded • « Rapid Deceleration injuries » • Urinalysis on FIRST urine.

  43. Dipstick vs. U/A • Daum et al. AM J Clin Pathol, 1988. • Prospective • 178 patients • Abdominal Trauma • Dipstick AND Microscopic examination Daum et al. Dipstick evaluation of hematuria in abdominal trauma. Am J Clin Pathol, 1988; 89:538-542.

  44. Daum et al.

  45. Dipstick vs. U/A • Chandhoke et al. J Urol, 1988. • Prospective study • 339 patients • Suspected blunt renal trauma • Dipstick AND microscopic examination Chandhoke et al. Detection and significance of microscopic hematuria in patients with blunt renal trauma. J.Urol. 140: 16-18, 1988.

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