Genitourinary trauma Flashcards
Discuss anatomy of the kidney
Retroperitoneal organs that are encapsulated by fibrous tissue known as Gerota’s fascia
They lie against the psoas muscles are surround by the ribs apart from the inferior pole leaving them well protected.
Isolated renal injury is rare
Children with compartively larger kidneys weaker abdominal muscles and less rigid chest wall children are at higher risk of injury
Discuss the anatomy of the bladder
Intra-abdominal organ until the age of 6 when it descends into the pelvis thus is classified as a extraperitoneal organ
Posteriorly the bladder connects to the ureters on the superior aspect
Discuss the anatomy of the penis
Composed of two paired corpora cavernosa along the dorsal aspect and a corpus spongiosum along the ventral surface.
The corpus cavernosa are filled with venous sinusoids that surround a central artery and engorge with blood during an erection
The cropus spongiosum surrounds the urethrea
Each of the three is surrounded by seperate fascial sheaths which are referred to as the tunica albuginea.
Buck’s fascia the deep fascia of the penis imediatley surrounds the three structures and multiple other superficial layers surround Buck’s fascia
Discuss renal injury
As it is fixed in space only by the renal pelvis and the pedicle the kdiney is prone to acceleration and deceleration injuries
- Laceration and contusions generally occur due to direct trauma where as renal artery avulsions can occur from deceleration mechanims.
Gross hematuria necessitates investigation into renal trauma – the degree of hematuria however does not correlate well with degree of injury - and trauma can be present in the absence of hematuria.
Renal injury reqruing intervention is rare in the abcesnce of significant mechanisms and haematuria
-Flank tenderness, echymosis, mass, loss of flank contour obviosuly fracutred ribs and abdomninal tenderness could all indicate renal injury
Discuss Grades of Renal trauma as per the american asscoiation for the surgery of trauma
Grade 1: contusion or haematoma - microscopic or gross haematuria
- subcapsular, non expanding without parenchymal laceration
Grade 2: -Haematoma - non exapanding perirenal haematoma confirmed to the renal retroperitoneum
-Laceration -<1cm parenchymal depth of renal cortex wihtout urinary extravasation
Grade 3 - Laceration >1cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
Grade 4 - laceration: parenchymal laceration extenging through the renal cortex, medulla, collecting system \
-Vascular main renal artery or vein injury with contained haemorrhage
Grade 5 - completely shattered kdiney
Vascular - avulsion ofrenal hilum that devascularizes the nkidney
Discuss IX of renal injury
Lab - 95% of all clinically signifiacnt renal injury have haematuria defined as > 5RBC
-Creatinine drawn within one hour of injury reflects preinjury creatinine and is useful as a baseline
Imaging - Microscopic haematuria in blunt trauma wihtout shock is not an indication for renal imaging (together they are). Patient with gross haematuria do require further imaging targeting the entire urinary tract
-CT is nearly 100% sensitive and specific – laceration, haematomas, extravsation of contrast are seen well on arterial venous phases - collected system injury will need delayed phase imaging 10 minutes post contrast
Ultrasound can demonstrate injury but has lower sensitivity and specificity than ct
Discuss management of renal injury
ABCD
Grade1-3 may be able to be managed conservatively grade 4-5 will require surgery
Therapeutic options for blunt renal trauma include nephrectomy , ureteric stenting, percutaneous drainage and arterial emboization. - Recently the focus has been on nonopertiave therapy and increased renal salvage. Renal salvage rate in paeds is 99% treated with nephrostomy and stents if needed
Penetrating renal injury is almost always take for laparotomy
IN general all patient with renal trauma should have consideration for ABs to avoid future UTI and perinephric abscess formation
Discuss complciations of renal trauma
Infection - UTI, perinephric abcess
urinary leak with resultant urinoma
Renal function loss - grade 3,4,5 are assocaited with a 15%,30% and 65% decrease respectively
HTN
Discuss ureteral injuries
Blunt injuries to the ureter either directly or from compression against fracture bony structures or be deceleration
Signs suggestive of ureteral injury include flank ecchymosis and occasionally gross haematuria
Discuss IX of ureteral
haematuria is not a reliable indicator of ureteral trauma becuase it si present in only 50% of patients. - Blunt ureteral trauma is rare and further investigation is reserved for patient with uynepxlained persistent haematuria or evidence of injury adjacent to the ureter such as retroperitoneal vascular injury vertebral injury or penetrating injury near the flank
CT with contrast is the best modality - IV pyelopgraphy/urography and retrograde pyelopgraphy have been supplanted - delayed phase again to ensure contrast in renal sysetm
Discuss management of ureteral injuries
ABCD
with minor injuries inclduign contusions and parital laceraton ureteral stenting is typically sufficient.
Howevere debridement with anastomosis may be necessary wtih loss of a segment
Nephrostomy for unstable patient and uretral re-implantation are both options
Complications include urinoma, infection and fistula formation.
Discuss bladder injuries
Can range from mural contusions to rupture whic are defined as laceration through the enteire wall
Rupture can be further categorised into intraperitoneal and extraperitoneal
Intraperitoneal rupture is usually caused by a full bladder rupturing its dome (weakest point) leading to urine extravasating into the peritoneum
Unlike injury to the ureter haematuria is the hallmark of bladder injuries noted in 75% of patient with blunt and >90 in those with penetrating injury
Other signs include abdominal tenderness, blood at the urethral meatus, inability to void and ecchymosis in the perineum thigh or abdomen
Discuss investigation of bladder trauma
CT with contrast does not sufficiently distend the bladder to evaluate for mural defects leading to false negatives.
Retrograde stress cystography must be performed – this involves diluting 30mls of contrast ina 500 ml bag of warmed saline
-This is instilled via a foley catheter ( only inserted if clinician is confident nil urethral injury is present). By distending the bladder mural thrombi that have formed will be dislodged allowing the extravasation of urine.
US shows promise nil sens or spec at present
Discuss management of bladder injury
Contusions and EBR are usually management conservatively with foley catheter as long as uncomplciated by other injury,.
IBR and penetrating injury have an extremely low rate of healing without intervention adn require surgical repair. –Without intervention high rates of infection, and fistula formation. Intraperitoneal urine extravasation can lead to infection, ileus and chemical peritonitis
IBR injuries have a 20% mortality which is 12x as much as seen with EBR
Discuss Urethral trauma
The classic presentation of posterior urethral injury includes blood at the urethral meatus, urinary retention and a high riding prostate. Swelling or echymosis at the perineumor penis (butterfly bruising - seen with anterior injuries indicate violation of Buck’s Fascia)
