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 Andrich DE et al. The nature of urethral
injury in cases of pelvic fracture
– Incontinence urethral trauma. Journal of Urology.
165(5):1492-5, 2001 May.
– Impotence
• If unrecognized:
– Converting partial to complete tear
– Inaccurate assessment of U/O
• Foley catheter implication
 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
PARTIAL Tear

• Contrast extravasation only

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
•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 #

•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.

• 100%: Gross hematuria

• 85% Pelvic #
 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
Miller et al. Lumbar transverse process
• Liver: 1/3 fractures: a sentinel marker of
abdominal organ injuries. Injury.
• Spleen: 1/4 31:773; 2000.
 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
• 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% Santucci et al. Validation of the
American Association for the
– Grade III: 76 ; 3% Surgery of Trauma Organ Injury
Severity Scale for the Kidney. J
– Grade IV: 78 ; 9% Trauma; 50:195-200; 2001.

– Grade V: 93 ; 86%
 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 (BPs90)
– Any child with > 50 RBC / hpf
 Management…
• Absolute indication for Surgery:
– Uncontrollable renal hemorrage
– Multiply lacerated, shattered kidney
– Grade V
Main renal vessels avulsed
– Penetrating injuries usually
• Grade I-II
– conservative
• Grade III-IV
– Conservative if stable hemodynamically vs. surgery
• Grade V
– Surgery
 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 End