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Genitourinary Trauma

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Topic updated on 06/19/17 11:05am

 Snapshot
  • A 28-year-old male was hit by a car while crossing the road. He sustained abrasions to the face, hands, and bruising over both iliac crests. Blood pressure is 90/55 mmHg and pulse is 110/min. Two large bore IVs are inserted and he was given 1L of Lactated Ringer's, and 2L of crossmatched pRBCs. Scrotal and perineal ecchymosis and swelling, blood at the urethral meatus, and bladder distension up to the umbilicus are present. AP radiographs of the pelvis reveal pelvic fracture (bilateral pubic rami fracture). Retrograde cystourethrogram shows a torn posterior urethra; a suprapubic catheter and a pelvic binder are applied. 
Introduction
  • Genitourinary trauma involves kidney, bladder, and/or urethra
  • 80% is from blunt trauma (MVCs, assaults, falls, crush) vs 20% penetrating (GSW/SW)
  • Blunt trauma to genitourinary organs is associated with pelvic fracture in 97% cases
  • Urethral injury etiology can be divided by posterior and anterior urethra
    • posterior: junction of membranous and prostatic urethra is common site of injury
      • due to shearing force on fixed membranous and mobile prostatic urethra
    • anterior: straddle injury causing crush injury to bulbar urethra against pubic rami
    • iatrogenic: instrumentation, penile fracture
Presentation
  • History
    • mechanism of injury
    • hematuria, blood on underwear
    • dysuria, urinary retention
  • Physical exam
    • abdominal/flank pain, CVA tenderness, upper quadrant mass, perineal lacerations
    • DRE: sphincter tone, position of prostate, presence of blood
    • scrotum: ecchymoses, lacerations, testicular disruption, hematomas 
    • females: bimanual/speculum exam
    • bladder
      • if extraperitoneal rupture: pelvic instability, suprapubic tenderness from mass of urine or extravasated blood
      • if intraperitoneal rupture: acute abdomen
    • urethra
      • flank, scrotal or perianal swelling and bruising
      • gross hematuria
      • high-riding or nonpalpable prostate
      • penile or scrotal swelling or ecchymosis
      • blood in the urethral meatus 
Evaluation
  • Pelvis: radiograph with AP, inlet, and outlet views
  • Urethra: retrograde urethrogram (RUG)
    • if blood at meatus, do NOT insert Foley catheter; perform RUG first
  • Bladder: urinalysis, urethrogram, retrograde cystoscopy +/- cystogram
  • Ureter: retrograde ureterogram
  • Kidney: intravenous pyelogram, CT scan (if hemodynamically stable)
Management
  • Primary and secondary survey with resuscitation (massive transfusion protocol for hemodynamically unstable patients 
  • Pelvis: mechanical stabilization of pelvis
    • pelvic binder  
      • at the level of the greater trochanters
    • external fixator 
      • reduces pelvic volume
    • FAST (Focused assessment with sonography for trauma) exam to assess for intra-abdominal fluid
      • If positive, emergent trip to OR to stop bleeding
      • If negative, can perform diagnostic peritoneal aspirate (DPA) to look for blood
        • If DPA positive, to OR to stop bleeding
        • If DPA negative or not performed (some hospitals do not have this available), can defer OR and continue pelvic stabilization, external fixation, angiography/embolization, or resuscitative endovascular balloon occlusion of the aorta
    • Pelvic angiography and embolization of bleeding vessels may also be performed in hemodynamically stable patients who have evidence of active bleeding on a CT scan of the abdomen/pelvis
      • only stops arterial bleeding
      • does NOT address venous bleeding or bony hemorrhage
  • Urethra: based on location of tear seen on retrograde urethrogram
    • anterior: conservative management
      • if voiding limited: suprapubic cystostomy and antibiotics
    • posterior: suprapubic cystostomy (avoid catheterization) +/- surgical repair
  • Bladder: based on extra vs intraperitoneal rupture
    • extraperitoneal
      • if minor, Foley catheter drainage
      • if major, surgical repair
    • intraperitoneal
      • drain abdomen and surgical repair
  • Ureter: ureterouretostomy
  • Kidney: depends on grade of hematoma / laceration and HD stability
    • minor: conservative management
    • major: surgical repair


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