Genitourinary Tract Injuries

Welcome back to Med On The Go! This week we discuss genitourinary tract injuries commonly seen in the emergency room setting. Before we start, I'd like to invite you to visit our Facebook page www.facebook.com/drolimedonthego/ and help us by pressing "like". As usual, this blog post is also available in podcast form; subscribe to Med On The Go With Dr. Oli on iTunes, Google Play, or Podbean to make sure you never miss an episode. If you'd like to further support us, please visit www.patron.podbean.com/medonthego for more details.

Now let's dive into this week's topic:

Genitourinary tract injury secondary to trauma can occur any where within the genitourinary tract by a variety of mechanisms.

·      Blunt trauma—often associated with pelvic fractures

o   Upper tract

§  Renal

·      Contusions (minor injury—parenchymal ecchymoses with intact renal capsule)

·      Parenchymal tears/lacerations—non-communicating (hematoma), communicating (urine extravasation, hematuria)

§  Ureter: rare, at uretero-pelvic junction

o   Lower tract

§  Bladder—gross hematuria usually suggests bladder injury

·      Extraperitoneal rupture of bladder from pelvic fracture fragments

·      Intraperitoneal rupture of bladder from trauma and full bladder

§  Urethra

·      Posterior urethral injuries: MVCs, falls, pelvic fractures

·      Anterior urethral injuries: blunt trauma to perineum, straddle injuries/direct strike

o   External genitalia

·      Penetrating trauma—damage to kidney, bladder, ureter (rare), external genitalia

·      Acceleration/deceleration injury—renal pedicle injury—high mortality rate (laceration and thrombosis of renal artery, renal vein, and their branches).

·      Iatrogenic injury—ureter and urethra damage secondary to instrumentation

History

·      Mechanism of injury

·      Hematuria (microscopic or gross), any blood on underwear

·      Dysuria, urinary retention

·      History of hypotension

Physical examination

·      Abdominal pain, flank pain, CVA tenderness, upper quadrant mass, perineal lacerations

·      DRE: sphincter tone, position of prostate, presence of blood

·      Scrotum: ecchymoses, lacerations, testicular disruption, hematomas

·      Bimanual exam, speculum exam

·      Extraperitoneal bladder rupture: pelvic instability, suprapubic tenderness of mass of urine or extravasated blood

·      Intraperitoneal bladder rupture: acute abdomen

·      Urethral injury: perineal ecchymosis, scrotal hematoma, blood at penile meatus, high riding prostate, pelvic fractures

Investigations—in gross hematuria, the GU system is investigated from distal to proximal (i.e. urethrogram, cystogram… etc.)

·      Urethra: retrograde urethrography

·      Bladder: urinary analysis, CT scan, urethrogram +/- retrograde cystoscopy +/- cystogram (distended bladder and post-voiding)

·      Ureter: retrograde ureterogram

·      Renal: CT scan (best, if hemodynamically stable), intravenous pyelogram

Management

·      Urology consultation

·      Renal injury

o   Minor injuries—conservative management such as bed rest, hydration, analgesia, antibiotics

o   Major injuries—admit

§  Conservative management with frequent reassessments, serial urine analysis +/- re-imaging

§  Surgical repair (exploration, nephrectomy) for hemodynamically unstable patients or those who continue to bleed > 48hrs, major urine extravasation, renal pedicle injury, all penetrating wounds and major lacerations, infections, renal artery thrombosis

·      Ureter injury—ureterouretostomy

·      Bladder injury

o   Extraperitoneal

§  Minor rupture—Foley drainage for 10~14 days

§  Major rupture—surgical repair

o   Intraperitoneal—drain abdomen and surgical repair

·      Urethral injury

o   Anterior—conservative treatment, consider Foley catheter or suprapubic cystostomy and antibiotics for those who cannot void

o   Posterior—suprapubic cystostomy (AVOID CATHERIZATION) +/- surgical repair