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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

Genitourinary Trauma

François Dufresne

McGill Emergency Medicine

February 13th 2002

the case of jeremy
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%
jeremy
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
jeremy4
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?”
jeremy5
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?
introduction
Introduction
  • GU Trauma overlooked
  • 10-20% of all injured patients
  • Long term morbidity
    • Impotence
    • Incontinence
  • Life-threatening injuries first
slide7
Plan
  • Urethral Injury
  • Bladder Injury
  • Hematuria in Trauma
  • Kidney Injury
definitions
Definitions
  • Upper tract
    • Kydney
    • Ureters
  • Lower tract
    • Bladder
    • Urethra
  • External genitalia
urethral trauma
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.

anatomy
Anatomy

Bladder

Symphysis

slide11

Prostatic

Membranous

Bulbous

Pendulous

posterior urethra
Posterior Urethra
  • Violent external force
  • Pelvic # in  90%
  • Pelvic # : 5-25% of Posterior urethral injury
clinical features
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.
digital rectal exam in trauma
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.

posterior urethral rupture
Posterior Urethral rupture

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

diagnosis retrograde urethrogram
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.
retrograde urethrogram interpretation
Retrograde Urethrogram:Interpretation
  • Contrast extravasation + Contrast in bladder
  • Contrast extravasation only

PARTIAL Tear

COMPLETE Tear

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

slide24

Prostatic

Membranous

Bulbous

Pendulous

anterior urethra
Anterior Urethra
  • More common than posterior
  • Direct trauma
  • Usually NO pelvic #
  • Blood at meatus
  • Unable to micturate
  • Penile/Scrotal/Perineal
    • Contusion
    • Hematoma
    • Fluid collection
anterior urethra management
Anterior Urethra:Management
  • NO Foley if injury suspected
  • Retrograde Urethrogram
  • Urology:
    • Surgical Treatment
bladder trauma
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
types of rupture
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%)
clinical presentation
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.
investigation
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.

investigation39
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.

standard helical ct
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.

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

hardeman et al
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.

mee et al journal urol 1989
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.

gross hematuria false
Gross « Hematuria »: False +
  • Alphamethyldopa
  • Ibuprofen
  • Levodopa
  • Metronidazole
  • Nitrofurantoin
  • Phenazopyridine
  • Phenolphtalein-containing laxatives
  • Rifampin
  • Beets/berries
microscopic hematuria
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…
microscopic hematuria47
Microscopic hematuria…
  • Patients with pelvic # often excluded from studies.
  • Penetrating trauma excluded.
  • Pediatric population excluded
  • « Rapid Deceleration injuries »
  • Urinalysis on FIRST urine.
dipstick vs u a
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.

dipstick vs u a50
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.

kidney injury
Kidney Injury
  • Retroperitoneal organ
  • Cushoned by perinephric fat
  • Gerota’s fascia
  • Along T10 - L4
  • Ribs 10-12
  • Fixed only through pedicle.
  • 1.2L of blood / min
kidney injury53
Kidney Injury…
  • Blunt trauma: 80-90%
  • Rapid deceleration / Direct blow
  • MUST be suspected if
    • Trauma to back / flank / lower thorax / upper abdomen
    • Flank pain / low rib #
    • Hematuria / Ecchymosis over the flanks
    • Sudden decelaration / Fall from height.
    • Lumbar transverse process #
lumbar transverse process fractures
Lumbar Transverse Process Fractures
  • Prospective study (1994-1999)
  • Lumbar spine #
  • 191 patients
  • Transverse # in 29%
  • Abdominal organ injuries 47% vs. 6%
  • Kidney: 1/3
  • Liver: 1/3
  • Spleen: 1/4

Abdominal organ injuries 47% vs. 6%

Kidney: 1/3

Miller et al. Lumbar transverse process fractures: a sentinel marker of abdominal organ injuries. Injury. 31:773; 2000.

classification of injury
Classification of Injury
  • 5 Classes of Renal Injury :

Organ Injury Scaling

Committee

Moore et al. Organ Injury Scaling: Sleen, Liver and Kidney, The Journal of Trauma, 29: 1664; 1989.

grade i
Grade I
  • Contusion
    • Hematuria
    • Urologic studies N
  • Hematoma
    • Subcapsular
    • Non expanding
    • Parenchyma N
grade ii
Grade II
  • Hematoma
    • Perirenal
    • Nonexpanding
  • Laceration
    • < 1.0 cm
    • Renal cortex only
    • No urinary extravasation
grade iii
Grade III
  • Laceration
    • > 1.0 cm
    • Renal cortex only
    • No urinary extravasation
    • Intact collecting system
grade iv
Grade IV
  • Laceration
    • Renal cortex
    • Renal medulla
    • Collecting system
  • Vascular
    • Main renal artery/vein injury with contained hemorrage.
grade v
Grade V
  • Completely shattered kidney.
  • Avulsion of renal hilum (pedicule) which devascularizes kidney.

Kennon et al. Radiographic assessment of renal trauma: our 15-year experience. The Journal of Trauma, 154: 353-355; August 1995.

organ injury severity scale
Organ Injury Severity Scale
  • Validated lately: Journal of Trauma, 2001
  • Predicts the need for surgery
  • Need for surgery ; nephrectomy rates:
    • Grade I: 0 ; 0%
    • Grade II: 15 ; 0%
    • Grade III: 76 ; 3%
    • Grade IV: 78 ; 9%
    • Grade V: 93 ; 86%

Santucci et al. Validation of the American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney. J Trauma; 50:195-200; 2001.

investigation63
Investigation
  • IVP
    • Used to be intial exam of choice.
    • Very poor sensitivity for penetrating injury
    • Limitation in staging renal injuries
    • Not 1st choice anymore. Only if pt unstable.
  • Contrast CT
    • Study of choice if stable
    • More sensitive and specific for staging
    • Detects other abdominal injuries
management64
Management
  • Penetrating trauma:
    • Imaging for ALL (9%: NO hematuria)
  • Blunt trauma Imaging:
    • Gross hematuria
    • Microscopic hematuria (5 RBC/hpf) + shock (BPs90)
    • Any child with > 50 RBC / hpf
management65
Management…
  • Absolute indication for Surgery:
    • Uncontrollable renal hemorrage
    • Multiply lacerated, shattered kidney
    • Main renal vessels avulsed
    • Penetrating injuries usually
  • Grade I-II
    • conservative
  • Grade III-IV
    • Conservative if stable hemodynamically vs. surgery
  • Grade V
    • Surgery

Grade V

back to jeremy
Back to Jeremy…
  • First urine: Dipstick +++ (15 RBC/hpf)
  • Pelvic x-ray: Straddle #
jeremy69
Jeremy…
  • First urine: Dipstick +++ (15 RBC/hpf)
  • Pelvic x-ray: Straddle #
  • Keypoints…
    • BP: 85/50 on scene
    • Microhematuria
    • Pelvic #
  • NO FOLEY
jeremy70
Jeremy…
  • Urology consulted
  • Retrograde urethrogram: N
  • CT cystogram: N
  • Contrast CT to look for renal injury: Grade II renal injury.
conclusion
Conclusion
  • No Foley if you suspect urethral trauma
  • Gross hematuria OR microhematuria + Shock = GU Trauma.
  • Pelvic # + Microhematuria GU investigation
  • Don’t remove Foley if you suspect a partial tear of urethra afterwards.
  • Microhematuria alone : No imaging …but F/U.
  • In peds: Imaging for ALL hematuria.
the end
The End

The End