Trauma! Genitourinary Injuries

aka Trauma Tribulation 021

You hate it when the rodeo comes to town. Not another bull rider! You’re starting to think that ‘rider’ is a misnomer… Your patient has received injuries to the right flank and groin. It could be messy. Hopefully you know your stuff when it comes to genitourinary trauma…


Questions

Q1. Which genitourinary injuries are life-threatening?

Answer and interpretation

Most genitourinary injuries can safely undergo delayed repair once the patient has been stabilized and other injuries dealt with. Renal pedicle injury is an exception.

Renal pedicle injury can lead to life-threatening hemorrhage and renal ischemia

This injury typically results from deceleration, resulting in the kidney swinging violently on its vascular pedicle. This can lead to thrombosis or complete detachment at the pedicle. Early surgical repair is needed to rescue the kidney, although nephrectomy is often the end result.


One of the nurses is standing by with a urine dipstick at the ready.


Q2. Can significant urinary tract injury occur without haematuria?

Answer and interpretation

Yes

Even severe injuries such as renal artery injury or ureteropelvic disruption may present without haematuria. About 5% of renal injuries and up to 20% of renovascular injuries lack haematuria.

Nevertheless, in general the greater the degree of haematuria the greater the risk of significant intra-abdominal injury (including non-urinary tract structures).


Q3. What is an acceptable amount of blood in the urine following urinary catheter placement?

Answer and interpretation

Hematuria with <5 RBCs/hpf* can be caused by urinary catheter insertion

If more blood than this is present, a significant injury to the urethra, bladder, ureters or kidney must be sought.

*red blood cells per high powered field


Bloods have been sent, including a urea and creatinine.


Q4. What are the 3 most likely reasons for a rising urea and creatinine in a patient with isolated urinary tract trauma?

Answer and interpretation

Probably these:

  • Renal impairment due to traumatic injury
  • Reabsorption of extravasated urine
  • Contrast induced nephropathy following diagnostic imaging

Q5. Which skeletal injuries are associated with genitourinary trauma?

Answer and interpretation

These skeletal injuries typically coincide with GU trauma:

  • Pelvic fractures
    — posterior urethrethal injury (above the urogenital diaphragm) and bladder injury
  • Perineal straddle injury
    — anterior urethral injury
  • Fracture of the lower posterior ribs, lower thoracic or lumbar vertebrae
    — renal or ureteral injuries

Q6. How would you recognize and manage a kidney injury?

Answer and interpretation

Recognition

  • Clinically significant injuries will have at least one of:
    — Macroscopic haematuria
    — Loin tenderness and/ or swelling
    — Haemodynamic instability
  • Fracture of the lower posterior ribs, lower thoracic or lumbar vertebrae may be present
  • CT abdomen with IV contrast is the investigation of choice (injury severity is graded I to V)
    — IVP (intravenous pyelogram) is an option if CT is unavailable or imaging needs to be carried out in the operating theatre, but is less sensitive and does not visualize non-urologic injuries
    – Renal angiography is rarely required

Management

  • Urology consult
  • Most renal injuries (Grades I to III, and most Grade IV injuries) can be managed conservatively, as they tend to heal spontaneously.
  • Surgical repair is needed for urinary extravasation or if ongoing bleeding or hemodynamic instability due to renal injury. Alternatives to operative repair are interventional radiology to embolise bleeding vessels or to stent dissected renal arteries, and urinary extravasation may be amenable to stenting.
  • Grade V injuries (avulsed kidneys) need operative intervention and often require nephrectomy.

Learn more:


Q7. How would you recognize and manage a urethral injury?

Answer and interpretation

Urethral injuries are graded on a I to V scale and include contusion, stretch, and partial or complete disruption.

Recognition

  • Mostly blokes (95%) due to the urethra being 4-5 times longer than in females
  • Associated with displaced fractures of the pelvic ring, particularly ‘butterfly fractures’
  • Gross hematuria, difficulty placing a urinary catheter
  • Classic clinical features are uncommon:
    — blood at the meatus
    — perineal / scrotal haematoma
    — high riding prostate on examination
  • Perform retrograde urethrogram prior to attempting catheterisation but delay until after the possibility of major pelvic bleeding has been excluded as any contrast extravasation will impact on the clarity of these potentially life saving scans.

Traditional teaching to perform retrograde urethrogram prior to attempted urinary catheterization if urethral injury is suspected is probably overly cautious. Urinary catheterization can be safely attempted using careful, gentle technique and there is little evidence that this causes extension of urethral lacerations or increased hemorrhage. Retrograde urethrogram is described here.

Management

  • Urology consult
  • Suprapubic catheterization may be required initially
  • Operative repair

Learn more:


Q8. How would you recognize and manage a bladder injury?

Answer and interpretation

Bladder injury is graded on a I to V scale, but is more practically categorized as:

  • Contusion or hematoma
  • Intraperitoneal rupture
  • Extraperitoneal rupture

Recognition

  • Usually associated with pelvic fractures — further investigation is essential if there is macroscopic hematuria in a patient with a pelvic fracture
  • Penetrating trauma close to the bladder
  •  Classic triad:
    — hematuria
    — suprapubic pain
    — inability to void
  • Pregnant women and intoxicated patients (full bladders!) are at higher risk
  • Investigation involves a retrograde cystogram or CT cystography
    — Contrast injected via urethral catheter
    — Delay until after life-threatening pelvic injuries are excluded or stabilised

Management

  • Urology consult
  • Bladder contusion and hematomas can be observed
  • Intraperitoneal rupture requires laparotomy and surgical repair
  • Extraperitoneal rupture can often be managed with simple catheterisation (usually about 10 days)

Learn more:


Q9. How would you recognize and manage a penile fracture?

Answer and interpretation

Penile fracture is rupture of the corpus cavernosus due to a tear in the tunica albuginea.

Recognition

  • Usually the result of vigourous uncoordinated sexual intercourse, but can also occur from fall or direct trauma.
  • Suggestive history: sudden detumescence of a previously erect trauma following a loud “crack” at the time of blunt trauma.
  • Penile hematoma, difficulty voiding.
  • Urethral and corpus spongiosum injury (5-20%) is suggested by:
    — blood at the meatus
    — inability to pass urine, or
    — extravasation of urine

Management

  • Urology consult
  • Surgical repair

Q10. How would you recognize and manage a penile amputation?

Answer and interpretation

Recognition

  • No explanation needed, surely!

Management

  • Urology consult
  • Apply direct pressure to bleeding stump (avoid tourniquet!), provide analgesia and wrap the amputated part in dry sterile gauze before placing in ice (avoid direct contact of the amputated part with ice)
  • Surgical reimplantation (ideally <6 hours warm ischemic time) or reconstruction

Q11. How would you recognize and manage a scrotal injury?

Answer and interpretation

The main concern is testicular rupture.

Recognition

  • Blunt trauma to the scrotum such as a kick or fall
  • Scrotal hematoma and tenderness
  • Scrotal ultrasound is the investigation of choice

Management

  • Urology consult
  • Reduce a dislocated (luxed) testicle in the ED (i.e. replace it into the scrotal sac)
  • Surgical repair for testicular rupture, hematocoele, non-reducible testicular dislocation and scrotal degloving.

Unsurprisingly, your rodeo victim has blood in his urine. Where do you go from here?


Q12. What is your decision making approach to the investigation of a patient with microscopic hematuria following blunt abdominal trauma?

Answer and interpretation

If the patient is asymptomatic the yield of injuries requiring intervention in this setting is extremely low.

  •  no further imaging is needed
  • arrange repeat urinalysis (e.g. in a week’s time) and close follow up by a GP

Some experts advocate imaging in pediatric patients with asymptomatic hematuria following blunt abdominal trauma as they are more vulnerable to significant renal injury. Cut off values vary, with values from 5 to 50 RBCs/hpf being suggested.

If the patient is significantly symptomatic, they may have associated non-urinary intrabdominal or retroperitoneal injury.

Symptomatic patients should have a CT abdomen with IV contrast.

Learn more:


Q13. What is your decision making approach to a patient with macroscopic haematuria following blunt abdominal trauma?

Answer and interpretation

These patients need:

CT abdomen with IV contrast and CT cystogram

50% of such patients have renal injuries, and a further 15% have injuries to other intra-abdominal organs.

Also perform:

  • Retrograde urethrogram if urethral injury is suspected

The character of the bloody urine suggests what type of injury is present (from The Trauma Professional’s Blog) — but is not diagnostic:

  • Faint hematuria, primarily shades of pink, is usually associated with renal injury or a bladder contusion.
  • A moderate amount of darkly bloody urine is frequently associated with extraperitoneal bladder injury.
  • A small amount of very dark, bloody urine may mean an intraperitoneal bladder injury.
  • Scant and very dark blood in the catheter suggests a urethral injury or a catheter balloon inflated in the urethra.

Learn more:


References
  • Fildes J, et al. Advanced Trauma Life Support Student Course Manual (8th edition), American College of Surgeons 2008
  • Legome E, Shockley LW. Trauma: A Comprehensive Emergency Medicine Approach, Cambridge University Press, 2011.
  • Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice (7th edition), Mosby 2009. [mdconsult.com]
  • Ramchandani P, Buckler PM. Imaging of genitourinary trauma. AJR Am J Roentgenol. 2009 Jun;192(6):1514-23. Review. PubMed PMID: 19457813. [Fulltext]
  • Sklar DP, Diven B, Jones J. Incidence and magnitude of catheter-induced hematuria. Am J Emerg Med 1986;4:14–16. PMID: 3947427

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CLINICAL CASES

Trauma Tribulation

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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