Genitourinary Trauma Introduction GU Trauma overlooked

Transcription

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

2 Urethral Injury Plan Bladder Injury Kidney Injury Upper tract Kydney Ureters Lower tract Bladder Urethra External genitalia Definitions

3 Urethral Trauma Almost exclusively in male Significant morbidity Stricture Incontinence Impotence If unrecognized: Converting partial to complete tear Inaccurate assessment of U/O Anatomy Bladder Symphysis

4 Prostatic Membranous Bulbous Pendulous Posterior Urethra Violent external force 90% of Post: Urethra Injury Pelvic # 5-25% of Pelvic # = Posterior urethral injury

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

6 Diagnosis: Retrograde Urethrogram Pretest KUB film Supine position Injection of 25ml of water-soluble contrast Different techniques Retrograde Urethrogram

7 Retrograde Urethrogram: Interpretation Contrast extravasation + Contrast in bladder PARTIAL Tear Contrast extravasation only COMPLETE Tear Partial Tear

8 Complete Tear Management Partial tear careful passage of 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

9 Anterior Urethra More common than posterior Direct trauma Usually NO pelvic Fracture Blood at meatus Unable to micturate Penile/Scrotal/Perineal Contusion Hematoma Fluid collection Sleeve Hematoma

10 Butterfly Hematoma Anterior Urethral Rupture

11 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: No.1 cause Complication Pelvic/abdominal wall abscess/necrosis Peritonitis Intra-abdominal abscess Sepsis / Death

12 Types of rupture Extraperitoneal Most common % = associated with Pelvic Fracture Intraperitoneal Extravasation of urine in abdomen Sudden force to full bladder Associated injuries +++ Mortality (20%)

13 Clinical Presentation McConnel et al. Rupture of the bladder. Urol Clin North Am Carroll et al. Major bladder trauma: Mechanisms of injury and a unified method of diagnosis and repair. Journal of Urology % : 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

14 Treatment Penetrating injuries: OR Blunt Intraperitoneal: Almost all OR Extraperitoneal: Urethral cath. drainage x 7-10 days. Gross «Hematuria»: False + Alphamethyldopa Ibuprofen Levodopa Metronidazole Nitrofurantoin Phenazopyridine Phenolphtalein-containing laxatives Rifampin Beets/berries

15 Kidney Injury Retroperitoneal organ Cushioned by perinephric fat Gerota s fascia Along T10 - L4 Ribs Fixed only through pedicle. 1.2L of blood / min Kidney Injury Blunt trauma: 80-90% Rapid deceleration / Direct blow MUST be suspected if 1. Trauma to back / flank / lower thorax / upper abdomen 2. Flank pain / Hematuria / Ecchymosis over the flanks 3. low rib Fracture 4. Lumbar transverse process Fracture

16 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; Grade I Contusion Hematuria Urologic studies N Hematoma Subcapsular Non expanding Parenchyma N

17 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

18 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: ; August 1995.

19 Pedicule Injury Investigation IVP Used to be intial exam of choice. Very poor sensitivity for penetrating injury Limitation in staging renal injuries Not 1 st choice anymore. Only if pt unstable. Contrast CT Study of choice if stable More sensitive and specific for staging Detects other abdominal injuries

20 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

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