Genitourinary Trauma

Question 1

What is the mechanism and presentation of penile fracture?

Answer 1

• Mechanism
  
  • tunica albuginea thins out during erection
  • Blunt trauma shears tunica
  • Sudden increase in intracavernosal pressure
• Presentation
  
  • Popping sound
  • Acute penile pain and swelling
  • “Eggplant Deformity”
  • Rapid detumesence
  • +/- Hematuria (approx 10% associated urethral injury)

Question 2

What is the management of penile trauma?

Answer 2

• Prompt surgical exploration is indicated if penile fracture is suspected
  
  • Ultrasound or MRI is reserved only when the diagnosis of penile fracture is equivocal following history and physical exam
• If a patient with a penile fracture has gross hematuria, inability to void, or blood at the meatus evaluation of the urethra with cystoscopy or retrograde urethrogram must be performed

Question 3

When is penile reimplantation indicated?

Answer 3

• Prompt penile replantation is indicated in patients with traumatic penile amputation
• A microscopic reanastomosis of the paired dorsal arteries, dorsal vein, and nerves prevents postoperative complications such as penile sensation loss, urethral stricture, and skin necrosis
• Psychiatric consultation should be strongly considered in cases of self mutilation

Question 4

What is the diagnostic procedure for renal trauma?

Answer 4

• Diagnostic imaging is indicated with gross hematuria or microscopic hematuria with transient hemodynamic instability
• Intravenous contrast enhanced Ct scan of the abdomen and pelvis should be performed when there is a possible renal injury

Question 5

What are the indications for radiologic assessment in the case of flank trauma?

Answer 5

• Flank/abdominal penetrating trauma
• Blunt trauma with gross hematuria
• Blunt trauma with microhematuria and shock
• Deceleration injuries
• Pediatric injuries with any hematuria

Question 6

Describe the grading of renal trauma.

Answer 6

• Grade 1: contusion/subcapsular hematoma
• Grade 2: < 1 cm parenchymal lesion
• Grade 3: > 1 cm parenchymal lesion s urinary extravasation
• Grade 4: deep laceration involving collecting system or injury to main renal vasc c contained hemorr
• Grade 5: shattered kidney or renal hilar avulsion

Question 7

What is the management of renal trauma?

Answer 7

• Non-invasive management should be implemented in patient with renal injury and hemodynamic stability
• Immediate intervention is required in patients with renal injury who are hemodynamically unstable despite appropriate resuscitation
• Urinary extravasation and renal injury can be observed in the hemodynamically stable patient with an intact collecting system (i.e. no UPJ disruption)
• If fever, chills, ileus, increasing urinoma, fistula, or infection develop than urinary drainage via ureteral stent or percutaneous nephrostomy tube is indicated

Question 8

What are the absolute indications for renal exploration following trauma?

Answer 8

• Non-viable tissue
• Persistent renal bleeding
• Life threatening bleeding
• UPJ Rupture
• Extracapsular urine extravasation
• Incomplete staging
• Renal pedicle avulsion
• Expanding retroperitoneal hematoma

Question 9

What is the diagnostic procedure for ureteral injury?

Answer 9

Intravenous contrast enhanced Ct scan of the abdomen and pelvis should be performed when there is a possible ureteral injury

Question 10

What is the temporary management of ureteral injury?

Answer 10

Patient s with ureteral injury usually have other life- threatening injuries and temporary urinary drainage with percutaneous nephrostomy can be used with repair in delayed fashion.

Question 11

What is the management of ureteral trauma?

Answer 11

• Endoscopic ureteral injuries (iatrogenic) should be managed with ureteral stent and/or percutaneous nephrostomy tube drainage
• Ureteral injuries proximal to the iliac vessels should be repaired primarily when possible
  
  • If long segment injury is apparent percutaneous nephrostomy tube drainage followed by delayed repair should be considered
  • Bowel interposition, transureteroureterostomy (TUU) or autotransplant can be considered
• Ureteral injuries distal to the level of the vessels should repaired with reimplant of the ureter
  
  • Psoas hitch can be used to gain length as can a bladder flap(boari) for extended distal ureteral injures

Question 12

What are the contraindications to TUU?

Answer 12

Contraindications to TUU include a history of stone disease or previous ureteral malignancy

Question 13

What is the etiology and mechanism of scrotal trauma?

Answer 13

• Etiology
  
  • sports injuries
  • assault
  • motor vehicle accidents
• Mechanism
  
  • testis entrapped against bony structure
    
    • 50kg force to cause rupture

Question 14

What is the surgical management of blunt scrotal trauma?

Answer 14

• Surgical Management
  
  • Salvage rate highest with timely exploration
  • 25/30 (83%) salvaged
  • 4/5 not salvaged > 48 hours after injury (Buckley 2006)
  • < 72 hours 80 - 90% salvage rate
  • > 9 days salvage rate < 33% (Gross et al, Lupetin et al)
• Spermatic cord injuries
  
  • Vas deferens repair
  • Delayed if multiple injuries
  • Ligation of injured vessels
• Hematocele
  
  • > 5cm in size

Question 15

What is the surgical management of penetrating scrotal trauma?

Answer 15

• Surgical exploration (debridement and tunical closure) should be performed in patients with suspected tunical rupture following blunt trauma
• Scrotal ultrasound is reserved for cases where the diagnosis of tunical rupture is equivocal from the history and physical exam
• Surgical exploration should be performed in all patients with penetrating scrotal trauma
• Gunshot wounds
• Stab wounds
• Exploration
  
  • Hematoma evacuation, debridement, primary closure of tunica albuginea
  • Corporal injuries
  • Spermatic cord evaluation
• Higher rate of testis salvage for GSW as compared to stab wounds (75% to 23%)

Question 16

What is the epidemiology of bladder injury?

Answer 16

• National Trauma Database (2002 – 2006)
  
  • 75% of reported bladder injury involves men
  • •57% of injuries are in patients < 40 years old (Diebert 2011)
• Blunt trauma accounts for 51-86% of cases
  
  • MVC (50.5%), pedestrian versus automobile (29.1%), falls (14.5%)
• Penetrating bladder trauma
  
  • GSW (88%)
  • 4% of all abdominal GSW involve bladder

Question 17

What are the most common causes of bladder trauma?

Answer 17

• Obstretric / gynecologic most common cause during open surgery
• Pelvic fracture
• 3.6% of pelvic fractures have associated bladder injury
• 90% of blunt bladder injury associated with pelvic fracture
  
  • Men with higher incidence of pelvic fracture
• Extraperitoneal injury (55-78%) more common than intraperitoneal injury (17-39%)

Question 18

What are the diagnostic procedures for bladder trauma?

Answer 18

• Gross hematuria in the hemodynamically stable patient following pelvic trauma requires a retrograde cystogram
• Gravity cystogram
  
  • 350 - 400cc contrast
  • Pre and post drainage films
    
    • fluoroscopy
  • CT cystogram in retrograde fashion

Question 19

What is the surgical management of bladder trauma?

Answer 19

• With gross hematuria in the hemodynamically stable patient following trauma a retrograde cystogram should be performed
• Intraperitoneal bladder injuries should be surgically repaired in the setting of blunt or penetrating trauma
• Uncomplicated extraperitoneal bladder injury can be managed with catheter drainage
• Complicated extraperitoneal bladder injury (concomitant bladder neck injury, rectal injury, vaginal injury, bony spicules on bladder wall) should be surgically repaired

Question 20

Why are men more likely to get urethral trauma?

Answer 20

• Urethral injuries
  
  • 4% of all GU trauma (Carter 1983, Lowe 1988)
  • Men are 5X more likely than women to sustain urethral injury
    
    • Longer length of urethra, reduced mobility of urethra
    • Bladder neck injury is most common in prepubescent boys
  • Retrograde urethrography should be performed in patients with blood at the urethral meatus after pelvic trauma

Question 21

How does a pelvic fracture lead to urethral trauma?

Answer 21

• Pelvic fracture related urethral injury (PFUI)
  
  • 10% of males with pelvic fracture
    
    • 6% of females
  • Etiology
    
    • Fractured pubic bone and anchored prostate tear away from membranous urethra

Question 22

What are some of the complications of urethral trauma?

Answer 22

• Complications of urethral injury can be devastating to men
  
  • urethral stenosis
  • incontinence
  • sexual dysfunction
  • infertility
  • and psychological

Question 23

What is the management of urethral trauma?

Answer 23

• Retrograde urethrography should be performed in patients with blood at the urethral meatus after pelvic trauma
• Urinary drainage is necessary after pelvic fracture related urethral injury (PFUI)
  
  • An attempt may be made to perform endoscopic primary realignment in PFUI however placement of a suprapubic catheter and delayed urethral repair is the standard of care
• Prompt repair of penetrating trauma to the anterior urethra should be performed
  
  • Stage repair with suprapubic tube secondary to blast effect or large defects
• Prompt urinary drainage is necessary for patients with straddle injury (blunt trauma) to the anterior urethra
• Posterior urethral injury
  
  • Blunt trauma
    
    • Endoscopic realignment attempt
  • Gold standard is suprapubic tube and staged repair in 4-6 months