230. GU Trauma

Question 1

Renal Trauma

• indications for radiologic assessment
• grading 1-5
• indications for renal surgery
• other growing tx

Answer 1

Radio: Penetrating trauma (any); Blunt trauma with either (1) gross hematuria, (2) microhematuria and shock; Deceleration injury; Pediatric injury with ANY hematuria

1: subcapsular hematoma
2: small cortical defect
3: large cortical defect
4: opening to collecting system
5: defect of renal A/V

Surgery: Life threatening bleed, expanding retroperitoneal hematoma, UPJ rupture, Renal pedicle avulsion

Renal Angioembolization: for intrarenal false aneurysms, AV fistulas, major injuries (renal ruptures, shattered kidneys, pedical avulsions)

Question 2

Bladder Trauma

• dx w/ indications
• two types
• mgmt
• most common causes, demographics

Answer 2

Dx: CYSTOGRAM (ddx extra vs intra peritoneal, films pre/post drainage)
- indication: gross hematuria (hemo stable)

1. Intraperitoneal: urine flows up into peritoneum, contrast outlines loops of bowel
2. Extraperitoneal: urine drains down pelvic floor

Mgmt:
Extra: Uncomplicated: only urethral catheter drainage alone
Complicated (bladder neck injury, bone spicules, rectal/vaginal injury): Surgical repair
Intra: surgical repair

75% Male, 57% <40yo
Most: Blunt Trauma (MVC)
If penetrating, usually GSW
Extraperitoneal more common (55-78%)

Question 3

Urethral Trauma

• dx w/ indications
• types
• management
• demo, cause

Answer 3

Dx: RUG (retrograde urethrogram)

• blood at urethral meatus after trauma
• do BEFORE catheter placement to localize injury
• uncommon (4% trauma), Men much more likely due to longer urethra, reduced mobility, more risky behavior

1. Post Urethral Injury (membranous, prostatic): due to pelvic fracture, may lead to urethral stenosis, incontinence, sex dysfx, infertility
   tx: GOLD STD: suprapubic tube and delayed repair in 4-6mo
2. Ant Urethral Injury (fossa navicularis, penile, bulbar): if blunt: urethral catheter drainage, if penetrating: immediate surgical repair

Question 4

Penile Trauma

• Fracture: mech, CP, etiology, tx
• Penetrating Wound: etiology, tx
• Amputation: tx

Answer 4

Fracture:
Mech: tunica albuginea thins out when erect, blunt trauma shears tunica, sudden increase in intracavernosal pressure
CP: popping sound, “Eggplant deformity” due to swelling/pain, rapid detumescence, hematuria (assoc urethral injury)
E: coitus, masturbation, freak accident
tx: surgical exploration

Penetrating Wound
E: GSW, stab (assoc urethral injuries)
Tx: Surgical exploration: deglove, irrigate, debride, eval urethra

Amputation: replantation with microvascular re-anastamoses

Question 5

Scrotal Trauma

• dx
• blunt trauma: mech, CP, Dx sign, mgmt

Answer 5

Dx: Testicular US

Blunt Trauma
mech: testis entrapped against bony structure (50kg force causes rupture)
CP: pain, scrotum firm, tender, ecchymosis
Breach in T.A. NOT needed to rupture testicle
Dx: US: heterogeneous pattern w/in testicular parenchyma with loss of contour
Mgmt: surgical exploration (high salvage rate if early)

Question 6

Ureteral Trauma

• dx
• tx
• causes
• demo
• most common cause
• assoc

Answer 6

Dx: retrograde/anterograde pyelogram (IV contrast CT)
tx: Uretero-ureterostomy (remove damaged part and re-ligate)
Cause: RARE, mostly penetrating (GSW), if blunt due to MVC/deceleration
Demo: most are young men (assoc with violence)
MOST COMMON CAUSE: IATROGENIC (manage with ureteral stent/percutaneous nephrostomy tube = easy bc already in OR)

Assoc injury to colon, small intestine, blood vessels