Topic 11.

Traumatic injuries of kidneys, urinary tract and male genitals

1. Staging of blunt and penetrating renal injuries.
• Stages of blunt and penetrating renal injuries:
• - The American Association for the Surgery of Trauma
staging system of renal trauma
• Grade I
• Contusion, subcapsular haematoma; intact renal capsule
• Grade II-
• Minor laceration of the cortex, not involving the medulla or
collecting system
• Grade III-
• Major laceration extending through the cortex and
medulla, but not involving the
• collecting system
• Grade IV-
• Major laceration extending through the cortex, medulla
and collecting system
• Grade V-
• Shattered kidney (essentially multiple lacerations which
split the kidney into multiple fragments) or renal pedicle avulsion or renal artery thrombosis.

2. Clinical presentation, diagnosis and treatment of blunt renal damage. Indications for nonoperative
management of isolated renal injuries.
• Blunt renal damage
• Clinical presentation
• The best sign of blunt kidney injury is blood in the urine
(“hematuria”). Sometimes seen with the naked eye.
• Blunt trauma kidney injuries may show no outside signs. Or bruises may be seen over the back or
abdomen where
the kidneys are.
• Diagnosis-
• Computerized Tomography
• A computerized tomography (CT) scan with intravenous
(IV) contrast (a special dye) is the best way to assess kidney
injury.
• Ultrasound
• Ultrasound can also be used to diagnose kidney trauma.
•
• Intravenous Pyelogram
• Intravenous pyelogram (IVP) uses x-rays to show how dye
moves through your urinary system. IVP can show how the kidneys are working. The dye is injected
into a vein in your arm.
• Treatment-
• It depends on the condition of the patient, how bad the
kidney injury is, and if there are other injuries.—
• 1. If the patient is stable and there’s no injury to other organs, the trauma might be treated
without surgery. The patient will rest in the hospital until no more blood is seen in his/her urine.
• 2. If a patient isn’t stable and is losing a lot of blood from the kidney, surgery may be done.
• The aim of surgery is to fix and preserve the injured kidney. Sometimes a kidney is too badly
injured, so it may need to be removed
• 3. Today, Many serious injuries can be treated with minimally invasive techniques. Using
angiographic embolization. Using this method, surgeons can reach the arteries of the kidneys
through large blood vessels in the groin to stop bleeding.
•
3. Indications for different surgical measures of renal injuries.
• Indications for surgery of renal injuries.
• - Relative indications for surgery include devitalized renal
tissue with urinary leakage, coexisting bowel or pancreatic injuries, failed percutaneous or
endoscopic management of persistent urinary leakage, infected urinoma or perinephric abscess, and
failed angiographic management of renal vascular injuries.
4. Etiology, clinical presentation, diagnosis and treatment of ureteral injuries.
• Ureteral damage -
• Causes
• - Duplication of the ureter
• - Ureterocele
• - Retroperitoneal fibrosis
• - An abnormality where the ureter connects to the bladder
or the kidney,
• Other possible causes
• Various causes inside (intrinsic) or outside (extrinsic) the
ureter can lead to ureteral obstruction, including:
• * Ureteral stones
• * Severe constipation, which happens primarily in children
but also occurs in adults
• * Cancerous and noncancerous tumors
• * Internal tissue growth, such as endometriosis in females
• * Long-term swelling of the ureter wall, usually due to
diseases such as tuberculosis or a parasite infection called
schistosomiasis

• Diagnosis
• 1.Blood and urine tests.
• 2.Ultrasound
• 3.Voiding cystourethrogram
• 4.Renal nuclear scan.
• 5.Cystoscopy
• 6,Computerized tomography (CT) scan
• 7.Magnetic resonance imaging (MRI).
• Treatment
• Drainage procedures recommended:
• * A ureteral stent,
• * Percutaneous nephrostomy,
• * A catheter,
• Surgical procedures
• * Endoscopic surgery,
• * Open surgery,
• * Laparoscopic surgery,
• * Robot-assisted laparoscopic surgery,
5. Treatment of the minor incomplete ureteral lacerations.
• . Ureteral lacerations treatment :
• - [ ] If a partial laceration is identified, it can be debrided
and primarily repaired over a stent. A major pelvic ureteral injury is managed with distal ureter
ligation and reimplantation into the bladder. This may require psoas hitch and/or Boari flap.
6. Bladder injuries, types, clinical presentation.
• Bladder injuries-
• Types- The two basic types of damage to the bladder by
trauma are bruises and tears.
• Blunt injury (a bruise) is damage caused by blows to the
bladder. Penetrating injury (a tear) is damage caused by
something piercing through the bladder.
• Symptoms
• * Blood in the urine in blunt trauma
• * Hard to start urinating
• * Weak urine stream
• * Painful urination
• * Fever

7. Diagnosis and treatment of the bladder injuries.

• Diagnosis and treatment of bladder injuries:
•
• Diagnosis
• A health care provider diagnoses bladder injury by placing
a tube ("catheter") into the bladder and taking a series of X- rays. X-rays of the urethra may be taken
before the catheter is put in, to see if it is damaged. Before the X-rays are taken, the bladder is filled
with a liquid that will make it visible on the X-rays.
• Treatment
• -Contusion-The only sign will be bloody urine. Your health
care provider may just leave a wide catheter in the bladder so clots can pass. Once the urine
becomes clear, the catheter will be taken out if there aren’t any other reasons to leave it in.
• Intraperitoneal Rupture
• . This tear can be sewn closed with surgery..
• -Extraperitoneal Rupture
• repaired with surgery.
• -Penetrating Injuries
• usually fixed with surgery.
8. Differential diagnosis of intraperitoneal bladder rupture from the extraperitoneal bladder rupture.
• Differential diagnosis
• - Extraperitoneal rupture
• - The majority of extraperitoneal rupture cases are associated with a pelvic fracture. This may be
due to the deceleration injury and fluid inertia combined with the shearing frictional force that
develops when the pelvic ring is fractured or deformed. Sometimes the extraperitoneal rupture may
be due to perforation by bone fragments. With extraperitoneal rupture, the contrast will extravasate
the bladder base and confined to the perivesical space.
• -Intraperitoneal rupture
- The bladder dome is well supported and is often the site of intraperitoneal rupture. The mode of
injury is an increase in intravesical pressure and compression from the adjacent pelvis.
Intraperitoneal bladder rupture can occur following steering wheel trauma and a direct blow. Urine
will drain into the abdominal cavity, and the diagnosis is not always easy

9. Management of intraperitoneal and extraperitoneal bladder ruptures.

• . Management of intraperitoneal and extraperitoneal bladder rupture:
• - The management of bladder rupture depends on its anatomical location. Extraperitoneal lesions
are managed conservatively with prolonged bladder drainage, while intraperitoneal ruptures are
usually closed surgically. A conservative approach may be effective and successful even for
intraperitoneal lesions, but patients must be warned beforehand that failure of conservative
treatment is a real possibility.

10. Urethral injuries: classification, clinical presentation, diagnosis, treatment.

• Causes
• Trauma to the anterior urethra can be caused by straddle
injuries—coming down hard on something between your legs, such as a bicycle seat or crossbar, a
fence, or playground equipment.
• Trauma to the posterior urethra can be caused by pelvic fractures from:
• * Car crashes
• * Crush injuries
• * Falls from very high heights
• * Bullets or knives
• -For females, urethral injuries can also be caused by sexual
assault.

• Diagnosis
• If you have blood at the end of the penis or in the urine or
can’t pass urine after an injury to the urethral area, you
should see a health care provider right away.
• - Your health care provider may try to pass a tube ("catheter") through your urethra. Not being
able to pass a tube into the urethra is the first sign of urethral injury. An x-ray is done after squirting
a special dye into the urethra. The dye is used to be seen on an x-ray. X-rays are taken to see if any
of the dye leaks out of the urethra inside your body. This would mean there’s an injury. An x-ray of
the urethra is often done after a pelvic fracture, because urethral injury is common in these cases
(about 1 in 10
cases).
• Treatment-
• Many cases of anterior urethral injury need to be fixed right
away with surgery. Minor of these injuries can be treated with a catheter through the urethra into
the bladder. This keeps urine from touching the urethra so it can mend. The catheter is often left in
place for 14 to 21 days.
11. Make an examination order for suspected urethral and bladder injuries.
• . Examination order for urethral injuries:
• -Urethral injury should be suspected in the setting of pelvic
fracture, traumatic catheterization, straddle injuries, or any penetrating injury near the urethra.
Symptoms include hematuria or inability to void.
• Physical Examination
• Physical examination may reveal blood at the meatus or a
high-riding prostate gland upon rectal examination.

• Examination order for bladder injuries:

• Physical Examination
• An abdominal examination may reveal distention,
guarding, or rebound tenderness. Absent bowel sounds and signs of peritoneal irritation indicate
possible intraperitoneal bladder rupture. A rectal examination should be performed to exclude rectal
injury, and in males, to evaluate prostate location. If the prostate is "high riding" or elevated,
proximal urethral disruption should be suspected. In the setting of motor vehicle collision or crush
injury, bilateral palpation of the bony pelvis may reveal abnormal laxity or mobility, indicating an
open-book fracture or disruption of the pelvic girdle.
• If blood is present at the urethral meatus, suspect a urethral injury. Perform retrograde
urethrography to assess the integrity of the urethra. It is crucial that urethral integrity be confirmed
before attempting to blindly pass a urethral catheter.
12. Testis injuries: types, symptoms, treatment.
• Testis injuries
• Types of Testicular Injury-
• Rupture or fracture.
• Contusion.
• Torsion.
• Hematoceles.
• Dislocation.
• Epididymitis.
• Degloving.
• Symptoms of Testicular Injury
• - substantial pain in the scrotum.
• -sometimes pain in the abdomen,
• Other symptoms
• * Nausea (especially common with testicular torsion)
• * Bruising or discoloration of the scrotum
• * Swelling of the scrotum
• * Blood in the urine
• * Difficulty urinating
• * Fever
• Diagnosing Testicular Injuries
• medical history.
• other information-
• •When the injury occurred
• * How it happened
• * How you felt after the injury
• * How you feel now
• * If you've ever had other problems with your penis,
scrotum, or testicles
• * Ultrasound imaging
• * MRI
• * Exploratory surgery
• Treating Testicular Trauma
• Treatments for some types of testicular trauma include:
• * Placing an ice pack against your scrotum
• * Resting and avoiding strenuous activity
• * Medication to treat pain and inflammation
• * Antibiotics to prevent or treat infection

13. Penile injuries: types, clinical presentation, diagnosis and treatment.

• Penile injuries-
• Classifications-
• Type I -injury includes distal portion of the penis with
proximal part of the penis being preserved.
• Type II -injury includes severe injury on shaft of penis with
penile crus being preserved.
• Type III -injury includes the injury when urethral
catheterization is necessary with external urethral part
being preserved.
• Type IV -injury includes the injury when suprapubic
cystostomy is needed
• other classification -adult or pediatric injury, iatrogenic.
• Diagnosis
• -medical history and a physical exam,
• -blood and urine tests.
• -urologist may gently place a fiber optic camera into your
urethra to check for damage. You might also have an X-ray
study called a "retrograde urethrogram."
• This is performed by injecting a special dye through the
urethra and then taking X-rays. If the X-ray shows the dye leaking outside the urethra, it may suggest
damage to that part of the urinary tract.
• -ultrasound (sound waves)
• -MRI (radio waves in a strong magnetic field).

• Treatment
• For Serious Trauma
• For the rare cases where part of the penis has been
accidentally cut off, the amputated part should be wrapped in gauze soaked in sterile salt solution
and placed in a plastic bag. The plastic bag should then be put into a second bag or cooler with an ice
water slush. Do not place any amputated organ into ice water, as the water and direct contact with
ice is harmful to tissue. If the penis can be reattached, the lower temperature of the slush will
increase the chances of success. It may be possible to reattach the penis even after 16 hours.
• -For massive injuries to the penis, urologists, rebuild the penis.
• -The treatment for a penis “fractured” during sex is most often surgery.