Genitourinary Trauma

François Dufresne

McGill Emergency Medicine

February 13th 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• Patient was conscious at the scene.• On scene: BP=85/50 HR:120 RR:22 Sat:98%

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

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?”

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

• GU Trauma overlooked

• 10-20% of all injured patients

• Long term morbidity– Impotence– Incontinence

• Life-threatening injuries first

Plan

• Urethral Injury

• Bladder Injury

• Hematuria in Trauma

• Kidney Injury

Definitions

• Upper tract– Kydney– Ureters

• Lower tract– Bladder– Urethra

• External genitalia

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

Bladder

Symphysis

Prostatic

Membranous

Bulbous

Pendulous

Posterior Urethra

• Violent external force

• Pelvic # in 90%

• Pelvic # : 5-25% of Posterior urethral injury

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

• 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

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

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

Retrograde Urethrogram:Interpretation

• Contrast extravasation + Contrast in bladder

• Contrast extravasation only

PARTIAL Tear

COMPLETE Tear

Partial Tear

Complete Tear

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

• Controversial

• Complete VS Partial

• Posterior VS Anterior

• Foley X 3-14 days

• Suprapubic catheters

• Surgical approach / Endoscopy

• Delayed repair usually

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

Prostatic

Membranous

Bulbous

Pendulous

Anterior Urethra• More common than posterior• Direct trauma• Usually NO pelvic #• Blood at meatus• Unable to micturate• Penile/Scrotal/Perineal

– Contusion– Hematoma– Fluid collection

Sleeve Hematoma

Butterfly Hematoma

Anterior Urethral Rupture

Anterior Urethra:Management

• NO Foley if injury suspected

• Retrograde Urethrogram

• Urology:– Surgical Treatment

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

• 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

• 98% : Gross hematuria• 2%: Microscopic hematuria + Pelvic #

• 100%: Gross hematuria• 85% Pelvic #

•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.

•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

• 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.

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

• 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

• Penetrating injuries: OR

• Blunt– Intraperitoneal: Almost all OR– Extraperitoneal: Urethral cath. drainage

x 7-10 days.

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. …

• 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

• 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 +

• Alphamethyldopa• Ibuprofen• Levodopa• Metronidazole• Nitrofurantoin• Phenazopyridine• Phenolphtalein-containing laxatives• Rifampin• Beets/berries

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 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

• 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.

Daum et al.

Dipstick (Sensitivity)

Microscopy Trace 1+ 2+ 3+

5 RBC/hpf 100% 92% 84% 62%

10 RBC/hpf 100% 96% 92% 81%

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.

Chandhoke et al.

Dipstick (Sensitivity)

Microscopy Trace 1+ 2+ 3+

5 RBC/hpf 98% 89% 76% 51%

10 RBC/hpf 98% 92% 82% 59%

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 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

• 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

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

Abdominal organ injuries 47% vs. 6%

Kidney: 1/3

Classification of Injury

• 5 Classes of Renal Injury :

Organ Injury Scaling

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

Grade I

• Contusion– Hematuria

– Urologic studies N

• Hematoma– Subcapsular

– Non expanding

– Parenchyma N

Grade II

• Hematoma– Perirenal

– Nonexpanding

• Laceration– < 1.0 cm

– Renal cortex only

– No urinary extravasation

Grade III

• Laceration– > 1.0 cm

– Renal cortex only

– No urinary extravasation

– Intact collecting system

Grade IV

• Laceration– Renal cortex

– Renal medulla

– Collecting system

• Vascular– Main renal artery/vein

injury with contained hemorrage.

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.

Pedicule Injury

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.

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

Management

• Penetrating trauma:– Imaging for ALL (9%: NO hematuria)

• Blunt trauma Imaging:– Gross hematuria– Microscopic hematuria (5 RBC/hpf)

+ shock (BPs90)– Any child with > 50 RBC / hpf

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…

• First urine: Dipstick +++ (15 RBC/hpf)

• Pelvic x-ray: Straddle #

Kozin, Berlet. Handbook of Common Orthopaedic Fractures, 4th ed., 2000.

Jeremy…

• First urine: Dipstick +++ (15 RBC/hpf)

• Pelvic x-ray: Straddle #

• Keypoints…– BP: 85/50 on scene– Microhematuria– Pelvic #

• NO FOLEY

Jeremy…

• Urology consulted

• Retrograde urethrogram: N

• CT cystogram: N

• Contrast CT to look for renal injury: Grade II renal injury.

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 EndThe End