Genitourinary TraumaGenitourinary Trauma

TIM EVANSTIM EVANS VIRGINIA VIRGINIA

COMMONWEALTH COMMONWEALTH UNIVERSITYUNIVERSITY

January 28, 2015January 28, 2015

BackgroundBackground If injury to GU system identified, multi-If injury to GU system identified, multi-

organ injury is the rule.organ injury is the rule. Examples:Examples:

– If renal injury found following penetrating If renal injury found following penetrating trauma, 80-95% chance of other significant trauma, 80-95% chance of other significant injuryinjury

– If renal injury found following blunt trauma, 75% If renal injury found following blunt trauma, 75% chance of other significant injury foundchance of other significant injury found

Other injuries may be more immediately life Other injuries may be more immediately life threatening and thereforethreatening and therefore

GU injury diagnosis may be overlooked or GU injury diagnosis may be overlooked or delayeddelayed

CaseCase Patient #1 is a 25 year old male is struck in the Patient #1 is a 25 year old male is struck in the

flank with a baseball bat. His systolic blood flank with a baseball bat. His systolic blood pressure is always above 100 mm Hg and his pressure is always above 100 mm Hg and his exam is only remarkable for a flank hematoma exam is only remarkable for a flank hematoma without abdominal tenderness. His urinalysis without abdominal tenderness. His urinalysis shows no RBCs. shows no RBCs.

Patient #1 got pissed off at the guy who hit him so Patient #1 got pissed off at the guy who hit him so he shot Patient #2 in the flank. Patient #2 is he shot Patient #2 in the flank. Patient #2 is hemodynamically stable and does not have any hemodynamically stable and does not have any RBCs in his urineRBCs in his urine

Two Questions:Two Questions:– Do either of these reprobates need imaging?Do either of these reprobates need imaging?– Do we need more bat control legislation?Do we need more bat control legislation?

Renal TraumaRenal Trauma

Most common GU injury—65% of GU Most common GU injury—65% of GU injuriesinjuries

10% of abdominal injuries involve the 10% of abdominal injuries involve the kidneyskidneys

MechanismMechanism– 80-95% due to blunt force—MVC, falls, 80-95% due to blunt force—MVC, falls,

assaults, sporting eventsassaults, sporting events

Renal AnatomyRenal Anatomy

RetroperitonealRetroperitonealAdjacent to lower two Adjacent to lower two

thoracic and first four thoracic and first four lumbar vertebraelumbar vertebrae

Upper poles protected by Upper poles protected by ribs so lower poles ribs so lower poles more commonly more commonly injuredinjured

Right kidney inferior to Right kidney inferior to left and more left and more commonly injuredcommonly injured

Kidney mobile, hilum Kidney mobile, hilum more fixed—concern more fixed—concern with shearing injury with shearing injury with decelerationwith deceleration

When are you concerned about When are you concerned about renal injuries?renal injuries?

Mechanism of InjuryMechanism of Injury– Penetrating injuries of abdomen, back or Penetrating injuries of abdomen, back or

flankflank– Deceleration injuriesDeceleration injuries

Physical examPhysical exam– Tenderness of abdomen or flankTenderness of abdomen or flank– Ecchymosis of abdomen or flankEcchymosis of abdomen or flank

XrayXray– Fractures of lower ribs, thoraco-lumbar spineFractures of lower ribs, thoraco-lumbar spine

When are you concerned about When are you concerned about renal injuries?renal injuries?

Hematuria—over 95% of patients with Hematuria—over 95% of patients with renal trauma will have some degree of renal trauma will have some degree of hematuria (>5 rbc/hpf) hematuria (>5 rbc/hpf)

THE PRESENCE OR DEGREE OF THE PRESENCE OR DEGREE OF HEMATURIA DOES NOT CORRELATE WITH HEMATURIA DOES NOT CORRELATE WITH THE SEVERITY OF THE INJURYTHE SEVERITY OF THE INJURY– 25% of patients with gross hematuria have 25% of patients with gross hematuria have

minor injuriesminor injuries– 40% of the most serious renal injuries do not 40% of the most serious renal injuries do not

have any hematuriahave any hematuria

Indications for imaging for Indications for imaging for renal traumarenal trauma

Penetrating trauma in proximity to kidneys—the Penetrating trauma in proximity to kidneys—the presence or absence of hematuria in penetrating presence or absence of hematuria in penetrating trauma not predictive of injury, location of wound trauma not predictive of injury, location of wound is most important factoris most important factor

Gross hematuriaGross hematuria Microscopic hematuria (>3-5 RBC/HPF) with Microscopic hematuria (>3-5 RBC/HPF) with

hemodynamic instability—systolic BP<90 at any hemodynamic instability—systolic BP<90 at any timetime

Persistent microscopic hematuriaPersistent microscopic hematuria ?Significant deceleration mechanisms?Significant deceleration mechanisms ?Proximal injuries with blunt mechanisms?Proximal injuries with blunt mechanisms

Mee SL, et al: Radiographic Assessment of Renal Trauma: A ten-year prospective study of patient Mee SL, et al: Radiographic Assessment of Renal Trauma: A ten-year prospective study of patient selection. J Urol 141:1095, 1989selection. J Urol 141:1095, 1989

When When notnot to image in to image in patients with concern for patients with concern for

renal traumarenal trauma Patients with microscopic hematuria Patients with microscopic hematuria

who have always been who have always been hemodynamically stablehemodynamically stable

Patients who are not Patients who are not hemodynamically stablehemodynamically stable

No significant renal injuries missed

Miller KS, McAninch JW: Radiographic assessment of renal trauma. Our 15-year experience. J Urol 1995;154:352-355

1 renal repair

Without

Imaging

1004

Imaged-

Significant injury 3

Imaged-

Contusion

581

Microhematuria and no shock

Gross hematuria or

Microhematuria and shock (SBP<90

mmHg) all imaged-422

Significant renal injuries

78

Renal repair

34

Imaging techniquesImaging techniques Contrast enhanced CT—the best test, up to Contrast enhanced CT—the best test, up to

98% accurate, not great for renal vein injuries98% accurate, not great for renal vein injuries IVP—perhaps useful in the OR to determine function IVP—perhaps useful in the OR to determine function

of contralateral kidney before contemplated of contralateral kidney before contemplated nephrectomynephrectomy

Angiography—better than CT for defining injuries to Angiography—better than CT for defining injuries to renal artery and vein, also used therapeutically to renal artery and vein, also used therapeutically to embolize or stent artery injuryembolize or stent artery injury

Ultrasound—30% false negative rate for injury, used Ultrasound—30% false negative rate for injury, used to look for two kidneys, free fluidto look for two kidneys, free fluid

Contrast Enhanced Ultrasound—perhapsContrast Enhanced Ultrasound—perhaps MRI—not first line due to time, sensitivity similar to MRI—not first line due to time, sensitivity similar to

CT, can be used for follow up studiesCT, can be used for follow up studies

AAST Kidney Injury Severity AAST Kidney Injury Severity ScaleScale

AAST Kidney Injury Severity AAST Kidney Injury Severity Scale—Revision 2011Scale—Revision 2011

Grade IV Grade IV - originally encompassed contained - originally encompassed contained injuries to the main renal artery and vein, and injuries to the main renal artery and vein, and collecting system injuries. Revision: adds collecting system injuries. Revision: adds segmental arterial and venous injury, and segmental arterial and venous injury, and laceration to the renal pelvis or ureteropelvic laceration to the renal pelvis or ureteropelvic junction. Multiple lacerations into the collecting junction. Multiple lacerations into the collecting system used to be considered a shattered kidney system used to be considered a shattered kidney (Grade V), but now remains Grade IV. (Grade V), but now remains Grade IV.

Grade VGrade V - originally included main renal artery or - originally included main renal artery or vein laceration or avulsion, and multiple collecting vein laceration or avulsion, and multiple collecting system lacerations (shattered kidney). The revised system lacerations (shattered kidney). The revised classification includes only vascular injury (arterial classification includes only vascular injury (arterial or venous) and includes laceration, avulsion or or venous) and includes laceration, avulsion or thrombosis. thrombosis.

Grade I-Renal contusionGrade I-Renal contusion

Grade I-Subcapsular Grade I-Subcapsular HematomaHematoma

Grade II-Small Cortical Grade II-Small Cortical LacerationLaceration

Grade III-Major Renal Grade III-Major Renal LacerationLaceration

Grade IV-Major Laceration Grade IV-Major Laceration involving Collecting Systeminvolving Collecting System

Grade IV- Multiple Renal Grade IV- Multiple Renal LacerationsLacerations

Grade IV-“Shattered” Grade IV-“Shattered” KidneyKidney

Grade V- Avascular Left Grade V- Avascular Left KidneyKidney

Trauma

Blunt

Hematuria

Microscopic (>5 RBC/HPF)

No shock

Image with concern for

other organs

Clinical

follow-up

Hematuria (Gross or microscopic)

Associated with shock

(SBP <90)

Unstable

Abdominal exploration

Single-shot

IVP on table

Abnormal or inconclusive

Renal exploration

Penetrating

Injury in proximity to kidney

Stable

CT scan with IV contrast

Grades III-V

Selective renal

exploration

Management of Renal Management of Renal InjuriesInjuries

Grade I—homeGrade I—home Grade II-IV—admit, observeGrade II-IV—admit, observe Grade V—observe, vascular repair/stent, Grade V—observe, vascular repair/stent,

or nephrectomyor nephrectomy

Only absolute indications for surgery are Only absolute indications for surgery are persistent renal bleeding with persistent renal bleeding with hemodynamic instability, active hemodynamic instability, active extravasation of IV contrast, expanding or extravasation of IV contrast, expanding or pulsatile perirenal hematoma suggesting pulsatile perirenal hematoma suggesting Grade V vascular injuryGrade V vascular injury

Complications of Renal Complications of Renal InjuriesInjuries

Mortality 3%Mortality 3% ComplicationsComplications

– First six weeksFirst six weeks Hemorrhage/shockHemorrhage/shock Sepsis/abscessSepsis/abscess ATNATN

– LateLate Renovascular HTN 1-4%Renovascular HTN 1-4%

CASECASE

30 year old s/p cystoscopic removal 30 year old s/p cystoscopic removal of distal ureteral stone. Now with of distal ureteral stone. Now with flank pain and nausea. T 39 C, flank pain and nausea. T 39 C, diffuse abdominal and flank diffuse abdominal and flank tenderness noted.tenderness noted.

U/A--negativeU/A--negative

Diagnosis? Studies?Diagnosis? Studies?

Ureteral TraumaUreteral Trauma

Accounts for 1% of urologic traumaAccounts for 1% of urologic trauma Most commonly iatrogenic following Most commonly iatrogenic following

GU, gynecologic, vascular or GU, gynecologic, vascular or colorectal surgerycolorectal surgery

If following external trauma, 80-95% If following external trauma, 80-95% due to penetrating mechanism, due to penetrating mechanism, usually GSWusually GSW

Ureteral AnatomyUreteral Anatomy

Thin, mobile tubes Thin, mobile tubes running between running between renal pelvis and renal pelvis and posterior superior posterior superior angle of bladderangle of bladder

Retroperitoneal in Retroperitoneal in abdomenabdomen

Protected from Protected from injury by size and injury by size and mobilitymobility

When are you concerned about When are you concerned about ureteral injuries?ureteral injuries?

Recent GU, gynecologic, vascular or Recent GU, gynecologic, vascular or colorectal procedure colorectal procedure

Penetrating (usually GSW) trauma to Penetrating (usually GSW) trauma to abd, back, flank abd, back, flank

Deceleration mechanismsDeceleration mechanisms Suspicion raised with injuries to iliac Suspicion raised with injuries to iliac

vessels, urinary bladder, sigmoid vessels, urinary bladder, sigmoid colon, thoracolumbar dislocations, colon, thoracolumbar dislocations, lumbar spine (including process) lumbar spine (including process) fracturesfractures

Hematuria following ureteral Hematuria following ureteral injuriesinjuries

Ureteral injury following iatrogenic cause—10-Ureteral injury following iatrogenic cause—10-15% of patients with hematuria15% of patients with hematuria

Hematuria absent in 30-60% of identified ureteral Hematuria absent in 30-60% of identified ureteral injuries from external violenceinjuries from external violence

Hematuria following penetrating trauma—a study Hematuria following penetrating trauma—a study of 71 ureteral injuries of 71 ureteral injuries – 32% without hematuria32% without hematuria– 40% with gross hematuria40% with gross hematuria– 28% with microscopic hematuria28% with microscopic hematuria

Brandes SB, et al: Ureteral injuries from penetrating trauma, J Trauma Brandes SB, et al: Ureteral injuries from penetrating trauma, J Trauma 36:766, 1994.36:766, 1994.

IMAGING FOR URETERAL IMAGING FOR URETERAL INJURIESINJURIES

Most injuries diagnosed during laparotomy Most injuries diagnosed during laparotomy and no imaging ever doneand no imaging ever done

Contrast CT with delayed imaging—most Contrast CT with delayed imaging—most common findings are extravasation of common findings are extravasation of contrast into medial perirenal space and contrast into medial perirenal space and absence of contrast in distal ureter if absence of contrast in distal ureter if transected transected

Retrograde pyelogramRetrograde pyelogram IVP—one shot IVP done in OR for IVP—one shot IVP done in OR for

penetrating traumapenetrating trauma

Delayed CT images showing Delayed CT images showing extravasation of urine from ureteral extravasation of urine from ureteral

injuryinjury

Blunt trauma

Gross hematuria, or microhematuria with deceleration or hypotension or associated injuries

Unstable, to OR

Intraoperative one-shot IVP

Normal

Consider other sources for

hematuria (bladder, urethra, kidney)

Penetrating trauma

Stable, to CT + contrast + delayed films

Potential ureteral injury (ureteral nonopacification or extravasation)

Unstable, to OR

Gross or micro-hematuria

Yes No

Intraoperative

One-shot IVP

Normal

Bullet/knife wound in vicinity of ureter

Explore ureter and repair

Stent removal

6 weeksAfter stent removal consider periodic renogram or surveillance ultrasound (defect hydronephrosis to rule out recurrence

Abnormal

American Association for the Surgery of American Association for the Surgery of Trauma (AAST)Trauma (AAST)

Ureter Injury Severity Scale Ureter Injury Severity Scale

GradeGrade DescriptionDescription

II HematomaHematoma Contusion or hematoma without Contusion or hematoma without devascularization devascularization

IIII LacerationLaceration <50% transection<50% transectionIIIIII LacerationLaceration >50% transection>50% transectionIVIV LacerationLaceration Complete transection with <2 cm Complete transection with <2 cm

devascularizationdevascularization

VV LacerationLaceration Avulsion with >2 cm devascularizationAvulsion with >2 cm devascularization

MANAGEMENT OF MANAGEMENT OF URETERAL INJURIESURETERAL INJURIES

TreatmentTreatment– Stents—Grade 1Stents—Grade 1– Surgery—Grade 2 and aboveSurgery—Grade 2 and above

ComplicationsComplications– Ureteral strictureUreteral stricture– FistulaFistula– Retroperitoneal fibrosisRetroperitoneal fibrosis– Abscess/SepsisAbscess/Sepsis

Intraoperative recognition

Minor ureteral injury Major ureteral injury

Stent Primary stented ureterourostony, psoas hitch, or flap with or without kidney mobilization

Ureteral stent 6 weeks

Follow-up retrograde pyelography and stent removal or replacement as needed

Consider placement of percutaneous nephrostomy in rare case of extremely long injury

After stent removal consider periodic renogram or surveillance ultrasound to rule our recurrence

Consider endoscopic methods (laser, balloon)

Primary stented ureteroureterostomy

Postoperative recognition

CT with contrast (+ delayed films) + retrograde pyelography

Minor ureteral injury

Ureteral stent 6 weeks

Follow-up retrograde pyelography and stent removal or replacement as needed

Success

Fail

After stent removal consider renogram or surveillance ultrasound to rule out recurrence

Consider endoscopic methods (laser, balloon)

Primary stented ureteroureterostomy, psoas hitch or flap

Consider autotransplant or ileal loop in rare case of extremely long injury

Major ureteral injury

Attempted retrograde stent placement

Success

Percutaneous nephrostomy and anterograde stent placement, if possible

Fail, wait

6 weeks

CaseCase

Urinary Bladder TraumaUrinary Bladder Trauma

Mechanisms of InjuryMechanisms of Injury– Blunt—up to 85% of casesBlunt—up to 85% of cases

70-95% of patients with bladder injuries will 70-95% of patients with bladder injuries will have pelvic fractureshave pelvic fractures

6-10% of patients with pelvic fractures will 6-10% of patients with pelvic fractures will have bladder injurieshave bladder injuries

– Penetrating—up to 15% of casesPenetrating—up to 15% of cases– Surgical/CystoscopySurgical/Cystoscopy

Urinary Bladder AnatomyUrinary Bladder Anatomy

Empty bladder is a Empty bladder is a pelvic organ and pelvic organ and protected by pelvic protected by pelvic bonesbones

With distention, With distention, becomes an becomes an abdominal organ and abdominal organ and more prone to injury more prone to injury due to direct traumadue to direct trauma

Peritoneum covers Peritoneum covers superior surface of superior surface of bladderbladder

When are you concerned about When are you concerned about a bladder injury?a bladder injury?

Clinical PresentationClinical Presentation– Suprapubic painSuprapubic pain– Difficulty voidingDifficulty voiding

Gross Hematuria—incidence approaches 100%Gross Hematuria—incidence approaches 100% Microscopic Hematuria possible with Microscopic Hematuria possible with

penetrating trauma, spontaneous bladder penetrating trauma, spontaneous bladder rupturerupture

X-rayX-ray– Widened symphysis pubis is stongest predictorWidened symphysis pubis is stongest predictor– Pelvic, sacrum, iliac, ramus fracturesPelvic, sacrum, iliac, ramus fractures– Widening of SI jointWidening of SI joint

Diagnostic StudiesDiagnostic Studies

Retrograde cystogramRetrograde cystogram Retrograde CT cystogramRetrograde CT cystogram

Either one follows urethogram if Either one follows urethogram if concern for urethral injury existsconcern for urethral injury exists

Indications for CystographyIndications for Cystography

Blunt Trauma in close proximity to Blunt Trauma in close proximity to bladder with gross hematuriabladder with gross hematuria

Pelvic fractures from blunt mechanism Pelvic fractures from blunt mechanism with any degree of hematuriawith any degree of hematuria

Penetrating Trauma in proximity to the Penetrating Trauma in proximity to the bladder bladder

Penetrating trauma with any degree of Penetrating trauma with any degree of hematuriahematuria

Technique for CystogramTechnique for Cystogram Retrograde Retrograde

urethrogram if urethrogram if indicatedindicated

Urinary catheterUrinary catheter 100 cc contrast100 cc contrast Plain filmPlain film 200-250 cc contrast 200-250 cc contrast

(5cc/kg)(5cc/kg) Plain filmPlain film Empty bladderEmpty bladder Plain filmPlain film Sensitivity for bladder Sensitivity for bladder

rupture near 100% if rupture near 100% if each step performedeach step performed

Retrograde Cystogram--Retrograde Cystogram--NormalNormal

Retrograde Cystogram—Retrograde Cystogram—Post-Void, NormalPost-Void, Normal

CT CystogramCT Cystogram

Same technique as Same technique as for plain for plain cystogram, no cystogram, no need to do post need to do post void studyvoid study

Sensitivity also Sensitivity also approaches 100%approaches 100%

Extraperitoneal Bladder Extraperitoneal Bladder RuptureRupture

50-90% of bladder 50-90% of bladder rupturesruptures

Usually associated Usually associated with pelvic fracturewith pelvic fracture

Usually treated Usually treated with with urethral/suprapubiurethral/suprapubic catheterc catheter

Retrograde Cystogram—Retrograde Cystogram—Extraperitoneal RuptureExtraperitoneal Rupture

Retrograde Cystogram—Retrograde Cystogram—Extraperitoneal RuptureExtraperitoneal Rupture

CT Cystogram—Extraperitoneal CT Cystogram—Extraperitoneal RuptureRupture

CT Cystogram with CT Cystogram with Extraperitoneal RuptureExtraperitoneal Rupture

CT Cystogram with CT Cystogram with Extraperitoneal Rupture with Extraperitoneal Rupture with

Sagittal ViewSagittal View

Intraperitoneal Bladder Intraperitoneal Bladder RuptureRupture

15-35% of bladder 15-35% of bladder rupturesruptures

Bladder usually Bladder usually distended at time distended at time of traumaof trauma

Historically treated Historically treated surgicallysurgically

Conservative Conservative management management possiblepossible

Retrograde Cystogram—Retrograde Cystogram—Intraperitoneal RuptureIntraperitoneal Rupture

Retrograde Cystogram—Retrograde Cystogram—Intraperitoneal RuptureIntraperitoneal Rupture

Retrograde Cystogram—Retrograde Cystogram—Intraperitoneal RuptureIntraperitoneal Rupture

Retrograde Cystogram—Retrograde Cystogram—Intraperitoneal RuptureIntraperitoneal Rupture

CT Cystogram-Intraperitoneal CT Cystogram-Intraperitoneal RuptureRupture

CT Cystogram—Intraperitoneal CT Cystogram—Intraperitoneal RuptureRupture

American Association for the Surgery of Trauma (AAST)American Association for the Surgery of Trauma (AAST)

Bladder Injury Severity ScaleBladder Injury Severity Scale

Grade Grade DescriptionDescription

II HematomaHematoma Contusion, intramural hematomaContusion, intramural hematoma LacerationLacerationPartial thicknessPartial thickness

IIII LacerationLaceration Extraperitoneal bladder wall laceration <2 cmExtraperitoneal bladder wall laceration <2 cmIIIIII LacerationLaceration Extraperitoneal (>2 cm) or intraperitoneal (<2 cm)Extraperitoneal (>2 cm) or intraperitoneal (<2 cm)

bladder wall lacerationbladder wall laceration

IVIV LacerationLaceration Intraperitoneal bladder wall laceration >2 cmIntraperitoneal bladder wall laceration >2 cmVV LacerationLaceration Intraperitoneal or extraperitoneal bladder wallIntraperitoneal or extraperitoneal bladder wall

laceration extending into the bladder neck or ureteral laceration extending into the bladder neck or ureteral orifice (trigone)orifice (trigone)

Urinary Bladder RupturesUrinary Bladder Ruptures

Patients may have both intra- and Patients may have both intra- and extra-peritoneal bladder rupturesextra-peritoneal bladder ruptures

20-40% Mortality for 20-40% Mortality for – Associated InjuriesAssociated Injuries– HemorrhageHemorrhage– SepsisSepsis

CaseCase

22 year old male 22 year old male engaging in engaging in sexual activitysexual activity

Hears and feels Hears and feels snap, crack and snap, crack and poppop

No more sexNo more sex Diagnosis? Diagnosis?

Penile FracturePenile Fracture

Urethral InjuriesUrethral Injuries

10% of all injuries to GU system10% of all injuries to GU system Potentially most debilitating GU injury due Potentially most debilitating GU injury due

to complicationsto complications Rare in womenRare in women Mechanism of InjuryMechanism of Injury

– Blunt trauma such as mvc, bike accidents, Blunt trauma such as mvc, bike accidents, straddle mechanismsstraddle mechanisms

– Often associated with pelvic fracturesOften associated with pelvic fractures– Rarely penetrating traumaRarely penetrating trauma– Occasionally iatrogenicOccasionally iatrogenic

Urethral AnatomyUrethral Anatomy

Anatomy Anatomy based on based on relation to relation to urogenital urogenital diaphragmdiaphragm– PosteriorPosterior

ProstaticProstatic MembranousMembranous

– AnteriorAnterior BulbousBulbous PenilePenile

Posterior Urethral InjuriesPosterior Urethral Injuries

80-90% occur in 80-90% occur in combination with combination with pelvic fracturepelvic fracture

10-25% of pelvic ring 10-25% of pelvic ring fractures disrupt fractures disrupt posterior urethra as posterior urethra as puboprostatic puboprostatic ligaments are torn or ligaments are torn or stretchedstretched

Associated with Associated with bladder injuries and bladder injuries and vaginal lacerationsvaginal lacerations

Anterior Urethral DisruptionAnterior Urethral Disruption

Usually due to direct Usually due to direct blunt force trauma blunt force trauma such as saddle injurysuch as saddle injury

Does not cause high Does not cause high riding prostate as riding prostate as injury is below the injury is below the urogenital diaphragmurogenital diaphragm

Ureteral injury present in Ureteral injury present in 10-38% of penile 10-38% of penile fractures (rupture of fractures (rupture of one or both tunica one or both tunica albuginea, fibrous albuginea, fibrous covering of corpus covering of corpus cavernosa) cavernosa)

When do you worry about When do you worry about urethral injuries?urethral injuries?

SymptomsSymptoms– Abdominal/Perineal PainAbdominal/Perineal Pain– Difficulty urinating—females can present with incontinenceDifficulty urinating—females can present with incontinence

Posterior—unable to urinatePosterior—unable to urinate Anterior—dysuria, small amountsAnterior—dysuria, small amounts

SignsSigns– Gross hematuriaGross hematuria– Blood at urethral meatusBlood at urethral meatus– Perineal swelling/ecchymosisPerineal swelling/ecchymosis– Vaginal lacerationsVaginal lacerations– Inability to pass urinary catheter (gentle attempt) Inability to pass urinary catheter (gentle attempt) – Abnormal prostate examAbnormal prostate exam

AbsentAbsent High ridingHigh riding BoggyBoggy

X raysX rays– Pelvic FracturesPelvic Fractures

Retrograde UrethrogramRetrograde Urethrogram

If urethral injury suspected, you may try If urethral injury suspected, you may try one gentle attempt at passing urinary one gentle attempt at passing urinary catheter—if it does not pass easily, don’t catheter—if it does not pass easily, don’t pushpush

Perform urethrogram—instill 10-30 cc of Perform urethrogram—instill 10-30 cc of contrast retrograde through urethracontrast retrograde through urethra

Complete disruption—contrast Complete disruption—contrast extravasates and none reaches bladderextravasates and none reaches bladder

Partial disruption—contrast extravasates Partial disruption—contrast extravasates and some reaches bladderand some reaches bladder

American Association for the Surgery of Trauma (AAST) American Association for the Surgery of Trauma (AAST) Urethra Injury Severity ScaleUrethra Injury Severity Scale

II ContusionContusion Blood at urethral meatus; urethrography Blood at urethral meatus; urethrography normalnormal

IIII Stretch InjuryStretch Injury Elongation of urethra without extravasation on Elongation of urethra without extravasation on urethrography urethrography

IIIIII Partial Partial Extravasation of urethrography contrast at injury Extravasation of urethrography contrast at injury site with site with DisruptionDisruption contrast visualized in the bladder contrast visualized in the bladder

IVIV CompleteComplete Extravasation of urethrography contrast at Extravasation of urethrography contrast at injury site injury site DisruptionDisruption without contrast visualization in without contrast visualization in the bladder; <2 cmthe bladder; <2 cm

of urethral separationof urethral separation

VV Complete Complete Complete transection with >2 cm urethral Complete transection with >2 cm urethral separation, orseparation, or DisruptionDisruption extension into the prostate or extension into the prostate or vaginavagina

Grade* Injury Type Description

Normal UrethrogramNormal Urethrogram

Grade III-Partial Urethral Grade III-Partial Urethral DisruptionDisruption

Grade III Partial Urethral Grade III Partial Urethral DisruptionDisruption

Grade IV or V Complete Grade IV or V Complete Urethral DisruptionUrethral Disruption

Grade V Complete Urethral Grade V Complete Urethral DisruptionDisruption

Urethral Trauma Urethral Trauma

DiagnosisDiagnosis– Retrograde UrethrogramRetrograde Urethrogram

TreatmentTreatment– Catheter, Stent, Primary anastomosisCatheter, Stent, Primary anastomosis

ComplicationsComplications– StrictureStricture– ImpotenceImpotence– IncontinenceIncontinence

CaseCase

Testicular TraumaTesticular Trauma

Mechanism—fall, Mechanism—fall, kick, sportskick, sports

Symptoms—pain, Symptoms—pain, N/V, lightheaded, N/V, lightheaded, remorseremorse

Diagnosis—Diagnosis—laceration, laceration, contusion, fracture, contusion, fracture, dislocationdislocation

Testicular TraumaTesticular Trauma

Diagnosis—Color flow Doppler ultrasoundDiagnosis—Color flow Doppler ultrasound ManagementManagement

– Contusion—rest, ice, analgesia, F/UContusion—rest, ice, analgesia, F/U– Laceration, dislocation, rupture--operativeLaceration, dislocation, rupture--operative

Penile AmputationPenile Amputation

Penile AmputationPenile Amputation

Penile Resurrection!Penile Resurrection!