Trauma and Fistulas

Question 1

When should you order imaging (CT a/p with contrast immediate and delayed imaging) in a BLUNT trauma patient when you are concerned about renal trauma?

Answer 1

Guideline 1: You should order imaging in a stable patient with gross hematuria or who is unstable (systolic < 90) AND with microscopic hematuria (of any level).

In a child order CT for any child with gross hematuria or microscopic hematuria > 50 RBC/HPF (no need to be hypotensive)

Question 2

What mechanism of injury should make you suspicious of renal injury, prompting you to order imaging (CT with contrast and with delayed imaging)?

Answer 2

Guideline 2: rapid deceleration injury, significant blow to flank, rib fractures, flank ecchymosis, or penetrating injury of abdomen, flank, or lower chest.

Question 3

In hemodynamically stable patients with renal injuries, what is first line management?

Answer 3

Guideline 4: non-invasive management strategies including hemodynamic monitoring, serial H/H, reduced activity (possible bedrest).

Question 4

How do you perform a one-shot IVP?

Answer 4

Inject 2 ml/kg contrast (150 ml max) into IV and take x-ray 10 minutes later

Question 5

You can initially observe a stable patient with renal parenchymal injury. When is prompt intervention warranted?

Answer 5

Guideline 6: Endoscopic or open surgery is warranted when there is concern for renal pelvis or proximal ureteral avulsion is expected (see large medial urinoma with contrast extravasation and no distal ureteral contrast on delayed imaging.

Question 6

When should you take a renal trauma patient to surgery?

Answer 6

Guideline 5: When they are hemodynamically unstable and fail to respond to resuscitation OR are hemodynamically unstable and have a large perirenal hematoma (> 4 cm), with a deep or complex renal laceration (grade 3-5 injury).

This can be surgery or angioembolization (if patient stable enough)

Question 7

What is the 2018 AAST Renal injury grading system?

Answer 7

Grade 1: subcapsular hematoma, with or without laceration

Grade 2: superficial laceration < 1 cm, not involving the collecting system
perirenal hematoma confined to the perirenal fat

Grade 3: laceration > 1 cm, not involving the collecting system
vascular injury or active bleed confined to the perirenal fascia

Grade 4: any laceration involving the collecting system with urinary extravasation OR complete UPJ disruption OR vascular injury to a segmental renal artery or vein OR segmental infarction OR active bleeding beyond the fascia (in the retroperitoneum)

Grade 5: Shattered kidney OR avulsion of the renal hilum or laceration of the main kidney or vein causing devasularization OR devascularized kidney with active bleeding

Question 8

What renal trauma patient needs follow up CT imaging in the hospital?

Answer 8

Guideline 7: AAST grade 4 or 5 OR signs of complications (fever, worsening flank pain, ongoing blood loss, abdominal distention)

Question 9

What patient with a renal injury needs urinary drainage with a ureteral stent (which can be augmented with a perc neph and/or drain and/or foley) during observation?

Answer 9

Guideline 8: enlarging urinoma on follow up imaging, fever, increasing pain, ileus, fistula or infection

Question 10

In what trauma patient should you suspect a ureteral injury?

Answer 10

Guideline 9: complex, multi system A/P trauma patients with complex fractures or rapid deceleration injury or high velocity GSW with trajectory near the ureter

You need delayed contrast imaging to detect ureteral injuries

Question 11

In cases where imaging is not an option because the patient went straight to surgery, what should you do if you suspect a ureteral injury?

Answer 11

Guideline 10: directly inspect the ureters with an open approach or retrograde ureterogram. Do not do a IVP in this case- it does not look at the ureters well enough

Question 12

If a ureteral injury is found in a stable patient, how should you proceed acutely?

Answer 12

Guideline 10: Repair the ureteral injury at the time of laparotomy, do not delay if the patient is stable

Question 13

If a ureteral injury is found in an unstable patient, how should you proceed?

Answer 13

Guideline 10b: The patient is unstable, you need to clip the ureter to prevent extravasation and place a nephrostomy tube or externalize a ureteral catheter secured to the proximal defect.

Question 14

How do you manage a ureteral contusion found in surgery?

Answer 14

Guideline 10c: You may choose to place a ureteral stent or you may choose to repair it primarily depending on viability and scenario- approach is up to surgeon

Question 15

How do you manage an incomplete ureteral injury diagnosed postoperatively or in the delayed setting?

Answer 15

Guideline 11a: Recommended that you try to place a retrograde ureteral stent

Guideline 11b: If its not possible to pass a ureteral stent, place a percutaneous nephrostomy with delayed repair

Question 16

How should you initially manage a ureterovaginal fistula?

Answer 16

Guideline 11c: Place a ureteral stent when possible, if this fails then you may consider surgical intervention (ureteral implantation).

Stent rates are highly successful in 65-100% of cases

Question 17

How should you surgically repair a ureteral injury proximal to the iliac vessels?

Answer 17

Guideline 12a: a spatulated, tension free anastomosis over a ureteral stent is advised after all non-viable ureter as been removed

Question 18

How should you surgically manage a ureteral injury distal to the iliac vessels?

Answer 18

Guideline 12b: you should manage with ureteral reimplantation or primary repair over a stent when possible. May require a boari flap or psoas hitch

Question 19

How should you surgically manage an endoscopic ureteral injury?

Answer 19

Guideline 13a: Place a ureteral stent when possible. If this isn’t possible or fails to divert the urine, place a nephrostomy tube +/- periureteral drain unless

Guideline 13b: you may manage this with open repair if the above endoscopic measures fail to adequately divert the urine.

Question 20

How should you manage a stable patient with gross hematuria and a pelvic fracture or a mechanism concerning for bladder injury such as pelvic ring fractures?

Answer 20

Guideline 14 a/b: You should perform a retrograde cystogram (either CT or plain film). You do this by letting contrast drain in by gravity through a foley to 300 ml or whenever patient is uncomfortable. Then take a plain film. Drain all the contrast and take one more plain film.

Urethra should be cleared first to allow for placement of a foley if needed

Question 21

How should you manage intraperitoneal or extraperitoneal bladder injuries?

Answer 21

Guideline 15-17: Place a foley and let heal by itself in uncomplicated extraperitoneal bladder injuries

Perform surgical repair with 2 layer absorbable sutures in complicated extraperitoneal and intraperitoneal bladder injuries

Leave catheters in for 2-3 weeks and follow up cystography should be done to ensure the bladder injury has completely healed.

If an uncomplicated extraperitoneal bladder injury hasn’t healed by 4 weeks, you should consider taking the patient back for a formal bladder repair

Question 22

After bladder repair, should you place a suprapubic tube for good urinary drainage?

Answer 22

Guideline 18: NO, suprapubic tubes are generally not required- a foley catheter is all that is needed

( of course there are exceptions to the above: urethral injury, poorly mobilizing persons, really complex bladder repairs or severe hematuria)

Question 23

What should you do if you see blood at the urethral meatus after pelvic trauma?

Answer 23

Guideline 19: A retrograde urethrogram! (exception is gently trying to place a well-lubricated catheter if patient is unstable- must be single attempt and “experienced” team member only)

To do a retrograde urethrogram: place patient in oblique (if possible due to pelvic injuries) with foley or 60 ml luer lock syringe in meatus or foley with balloon filled with 1-2 ml water, with penis on stretch pass 20 ml undiluted contrast slowly into bladder

If a catheter was placed with blood at the urethral meatus, prior to removing the catheter, you should do a periurethral RUG.

Question 24

What is the preferred management for pelvic fracture urethral injuries?

Answer 24

Guideline 20 a/b: This is placing a percutaneous or open suprapubic tube (14F or larger) and guidelines state this should be done promptly

Primary endoscopic alignment is associated with a longer clinical course

However, Guideline 22 says you can try primary realignment in stable patients but this attempt should not be prolonged (and again, not encouraged)

Question 25

If a patient needs open reduction internal fixation for a pelvic fracture, can you place a SPT nearby?

Answer 25

guideline 21: YES. There is no evidence this increases risk of hardware infection

Question 26

After urethral injury, how long should patients be monitored for?

Answer 26

Guideline 23: Monitor patients for at least a year for stricture, ED, and incontinence. They recommend monitoring for stricture with a combination of uroflow, cystoscopy, and/or retrograde urethrogram

Good luck getting this population of young, otherwise healthy guys back in your clinic.

Question 27

A guy gets stabbed in his penis, how should you treat this?

Answer 27

Guideline 24: Penetrating trauma to the anterior penis should be treated with prompt surgical repair

Question 28

How should you manage straddle injury?

Answer 28

Guideline 25: Prompt urinary drainage by SPT or quick primary realignment- do not attempt any immediate surgical reconstruction as the injury has an indistinct border. Stricture formation is high so these patient should be monitored via uroflow, cysto or RPG

Question 29

When should you suspect a penile fracture?

Answer 29

guideline 26: you must suspect penile fracture when a patient presents with penile ecchymosis, swelling, pain, cracking or snapping sound during intercourse or manipulation and immediate detumescence

Question 30

How do you work up penile fracture?

Answer 30

Guideline 27 & 28: No workup is needed if the history and physical exam is consistent. Otherwise may consider a penile US or MRI with equivocal signs and symptoms of penile fracture

Question 31

Which patients with penile fracture should be evaluated for urethral injury?

Answer 31

Guideline 29: You must perform evaluation for concomitant urethral injury in patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria or inability to void (or bilateral corporal rupture)

Concomitant urethral injuries occur in 10-15% patients with penile fracture

Question 32

After scrotal injuries, which patients should go directly for surgical exploration and which patients should undergo testicular US with dopplers?

Answer 32

Guideline 30a-c: US for blunt injuries, prompt surgical exploration with repair or orchiectomy for penetrating scrotal injuries (US is not as sensitive)

Surgeons should perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvageable) in patients with suspected testicular rupture

Question 33

What should you do in general when a high risk for sexual, urinary or reproductive side effects are anticipated in urethral or scrotal or penile trauma patients?

Answer 33

Guideline 33: Clinicians should initiate ancillary psychological, interpersonal, and/or reproductive counseling and therapy (mental health therapist and/or reproductive counseling or treatment)

Question 34

How do you recognize compartment syndrome in LE? How do you assess?

Answer 34

5 “P”s

Pain
Paresthesia
Pulselessness
Paralysis
Pallor

Check pulses, cap refill
Assess strength of extremity
Sensation of leg/foot

Question 35

Patient presents with incontinence 6 weeks after abdominal hysterectomy, what else would you like to know? What tests would you consider?

Answer 35

is leakage continuous?
associated with straining/coughing/laughing
urgency, frequency, nocturia

UA, UCX

CTU (fistula/injury)

Cystogram

Double die/tampon test

Question 36

Most common cause of vesicovaginal fistula in developing countries? Developed countries?

Answer 36

Traumatic obstructed child birth

Iatrogenic (0.1-4% during pelvic operations)

Hysterectomy (60-75%)
Malignant hysterectomy (3-5%)
C-section (6%)

Question 37

Important factors when considering fistula repair?

Answer 37

diagnose and treat any underlying infections and r/o neoplasms and foreign bodies

ensure appropriate bladder size/function

ID fistula tract and adjacent structures

Optimize patient nutrition and overall health

Question 38

Repair options for fistula? Broad?

Answer 38

Conservative management, for fistula < 3 mm tracts that have not epithelialized, foley

Surgery

(uninfected can do w/in 2 weeks, otherwise wait 8 weeks)

Question 39

Surgical Approaches? Interposition flap options?

Answer 39

Transvaginal vs. Transabdominal

Flaps:

Peritoneal

Martius (posterior blood supply via posterior labial artery from internal pudendal artery)

Rectus muscle

Question 40

Describe fistula repair for vesicovaginal fistula:

Answer 40

1. ID fistula tract
   
   1. Wide dissection of the bladder from vagina
   2. Use of healthy, viable tissue for re-approximation
   3. Close fistula with absorbable suture and a second perpendicular imbricating layer of pubocervical fascia
2. Advance a segment of vaginal epithelium past the fistula the provides a third layer and avoid overlapping suture lines
3. An interposition flap can be incorporated, such as Martius flap

Question 41

First actions in trauma survey?

Answer 41

A=airway and c-spine
B=breathing
C=circulation/stop bleeding
D=disability/neuro status
E=exposure and environment

Labs Chem 18, CBC, PT/PTT, ABG, T&C, tox screen, UA

C-spine
CXR
KUB
FAST (focused assessment with sonographic trauma)

unconscious (NGT/ET tube)

Question 42

MVC stable with pelvic fracture, blood at meatus, has not voided, perineal butterfly ecchymosis, next steps?

Answer 42

RUG

Abdomen/Pelvis CT to assess extent of injuries

Question 43

Describe RUG

Answer 43

Foley with 1-2 mL in fossa navicularis
Toomey syringe
Position penis at 90 degree angle and oblique
Slowly inject contrast

Question 44

Patient with pelvic fracture, on RUG contrast doesn’t pass into prox bulbar urethra, what is this? what do you do?

Answer 44

pelvic fracture urethral distraction defect
likely with urinary retention

1. Pass foley (not blind in documented disruptions)
2. Primary realignment (endoscopic)
3. SPT (immediate)
4. Needs cystogram after drainage

Question 45

For intraperitoneal bladder rupture, what do you do? if there is a pelvic hematoma?

Answer 45

ex-lap, repair bladder in 2 layers, if cannot localize, enter at dome, inspect interior, identify UOs, pelvic drain

survey other organs for injury (bowel, liver, spleen)

if pelvic hematoma–avoid opening it due to risk of bleeding
if opened, pack, inform anesthesia, txf PRN, consult ortho for pelvic fx
if still does not stop, consider IR for embolization

Question 46

After primary endoscopic realignment how long do you keep foley?

Answer 46

4 weeks, peri-cath RUG prior to removal

cystogram if bladder injury

Question 47

Longer term complications of posterior urethral injury?

Answer 47

impotence
incontinence
urethral stricture

Question 48

Indications for CT imaging for blunt trauma in adults? peds?

Answer 48

gross hematuria
micro hematuria + shock (SBP < 90 mm Hg)
mechanism of injury or PE findings concerning for renal injury (rapid decel, rib fx, rib ecchymosis)

peds: >50 RBC/hpf or rapid decel

Question 49

Urethral injury grading system

Answer 49

Question 50

When placing foley or SPT for urinary drainage, remember this:

Answer 50

send UA and CX

perform cystogram to assess bladder integrity (blood at meatus or voided blood)

Question 51

Indications for renal exploration:

Answer 51

hemodynamic instability from ongoing bleeding
expanding pulsatile RP hematoma
high grade injuries in solitary kidney
high velocity penetrating trauma

Question 52

Indication for bladder repairs:

Answer 52

all intraperitoneal bladder perforations
complicated extraperitoneal bladder ruptures (i.e. bone fragments including into bladder, bladder neck involvement, concurrent rectal or vaginal laceration)
extraperitoneal bladder ruptures in patients undergoing other intraabdominal pelvic open surgical interventions (e.g. pelvic repair)

Question 53

Describe trauma renal exploration:

Answer 53

1. Supine, midline xiphoid to pubis incision
2. Obtain vascular control wo disturbing RP hematoma
   
   1. Transverse colon on the chest under moist sponges
   2. Expose root of small bowel mesentery, lift up and to right
   3. Make vertical incision over aorta (medial to IMV, superior to IMA) and extend to ligament of Treitz
   4. Identify the aorta, dissect upward until renal vein exposed (artery posterior)
   5. After vascular control, mobilize kidney
      
      1. Occlude renal artery if needed, ice, clamp, pressure
      2. Sparingly debride nonviable tissues
      3. Perform partial or total Nx
      4. Control bleeding vessels
      5. Close collecting system with absorbable suture
      6. Close renal parenchyma over lac
   6. Close renal parenchymal defect
      
      1. Close renal capsule over bolsters
      2. Close Gerota’s
      3. Place drain near RP, not over repair to avoid fistula

Question 54

Intraop complications of trauma exploration/renal repair/nx?

Answer 54

1. Splenic injury: minor injuries cautery, surgicel, gel-foam
2. Pancreatic injury: tail requires distal pancreatectomy, drain
3. Intractable bleeding: if attempting partial, perform simple nx
4. Bowel injury: repair with primary closure or excision and anastomosis

Question 55

How do you perform a one shot IVP for trauma?

Answer 55

2 mL/kg or 150 mL of IV contrast, wait 10 mins, KUB

Question 56

AAST Renal Trauma Rating

Answer 56

Question 57

What are next management stents for a patient with multiple GSW to abdomen, blood at meatus, stable, nonopacification of right mid and distal ureter with free air?

Answer 57

RUG

Cystogram

OR

Question 58

Patient status post MVC, pelvic fracture, urethral disruption with SPT, 2-3 days later with pelvic and perineum pain and swelling with + crepitus and erythema, next steps?

Answer 58

PE
Labs (BMP, CBC, PT/PTT, UA, UCX, BCX)

Abx (Vanco, Gent, Flagyl or very broad)
IVF
Glucose Control
OR (CT first if stable) → debridement +/- colostomy if rectal involvement

CT to evaluate pelvic/RP gas/abscess

assess for any pelvic injuries such as rectal/bladder injury, bone fragments

FOURNIER’S

Question 59

How do you manage Fournier’s debridement post op in regards to wound care? How are the testis mangaged?

Answer 59

Wound vac best choice (debride, promotes granulation, contraction, decreases edema)

Wet to dry (when they cannot hold seal)

Testis → in thigh pouch if no remaining scrotal skin

Question 60

What type of reconstruction is done for scrotum and penis for Fournier’s ?

Answer 60

split thickness skin grafts

meshed → scrotum

unmeshed → penis

Question 61

Pop during intercourse with detumesce and blood at meatus, dx? Imaging?

Answer 61

Penile fracture with urethral injury

RUG or repair and cysto/RUG at time

Question 62

Pathophysiology of penile fx?

Answer 62

when erect, corporal bodies stretch tunica albuginea to limit as well as midline septum

penis buckles during intercourse and tears tunica and possibly spongiosum

Question 63

Describe penile exploration for repair of fx and urethra:

Answer 63

1. cysto, pass wire, place foley or RUG
2. place tourniquet at base of penis
3. make circumcising and deglove or overlying incision of fx
4. evacuate hematoma
5. identify lacerated area of urethra, dissect out, excise devitalized tissue, close with water-tight 4-0 or 5-0 absorbable, close vertically to preserve length, close spongiosum
6. identify lacerated tunica albuginea, debride, close with absorbable suture
7. close skin

Question 64

How do you manage penetrating penile injuries? Amputation?

Answer 64

Penetrating:
operative exploration
like penile fx
make sure drainage established (foley/SPT)

Amputation:
clean, wrap in soaked sponge with sterile saline in ziploc bag
keep on ice
reimplantation for as long as 18 h
approximate corpora and urethra
approximate deep dorsal vein and artery
approximate nerve bundles

*microvascular repair not required

Degloving:
remove distal skin to injury
non-meshed split thickness skin graft and secure bolster dressing over

Question 65

Intraop GYN consult for vag hyst, foley balloon seen in vagina (injury), how should you assess and r/o ureteral involvement?

Answer 65

cysto and IV indigo carmine or methlylene blue

cysto and RGP (best option)

Question 66

Intraop GYN consult for vag hyst, cysto RGP shows bladder injury communicating with vaginal wall and left ureteral injury, next steps?

Answer 66

OR for explore and repair (consent next of kin)
Open transabdominal repair (distal ureter reimplant and bladder repair)

Midline or Pfannenstiel incision
Bivalve bladder dome
Explore ureter
Close anterior vag wall
Close bladder injury
Psoas if necessary to perform tension free anastomosis
Reimplant ureter (stent)

Close cystotomy
Drain

Foley

Question 67

Incontinence after ureteral and vaginal wall/bladder injury, ddx?

Answer 67

VVF
ureterovaginal fistula
both

UUI/SUI

Question 68

What is blood supply to Martius flap?

Answer 68

external pudendal artery to anterior flap and internal pudendal artery to posterior flap

one can be sacrificed depending of positioning needed

monitor serum Cr and US w/in 3-6 mo

Question 69

Hockey puck to scrotum, bruising, pain, very tender and swollen, ecchymosis, ddx? What do you do?

Answer 69

Scrotal bruising
testicular rupture

Scrotal US to define tunica albuginea

Question 70

Testicular rupture, next steps?

Answer 70

OR

even if equivocal

Question 71

Describe repair of testicular rupture:

Answer 71

urethral cath
midline scrotal incision
dissect through dartos
evacuate hematoma
identify ruptured tunica
trim back seminiferous tubules to allow closure
close with fine absorbable (PDS) 4-0 or 5-0
explore contralateral side
close dartos and skin in separate layers
consider leaving drain for 24-48 h

Return to clinic in 4 weeks

Question 72

Man s/p brachy/EBRT for CaP with air/stool in urine and drainage from rectum, ddx?

Answer 72

Rectourethral fistula

Question 73

Presenting sxs of rectourethral fistula:

Answer 73

pneumaturia
fecaluiria and/or urorrhea
fevers, chills, sepsis
palpation on PE
visualization on cysto

Question 74

Testing for rectourethral fistula? If found next steps?

Answer 74

Cysto
DRE
Near trigone, CTU or RGP to eval ureters
Plan film CT barium enema
RUG

Referral to colorectal for diverting colostomy
Foley
Nutritional optimization
Tx UTIs

Question 75

If patient has an injury to rectal sphincter what is management?

Answer 75

Permanent diverting colostomy

Question 76

Considerations when treating rectourethral fistula in patient s/p RT?

Answer 76

life expectancy
premorbid urinary and bowel function
continence
local anatomy
nutrition status
smoking status

Question 77

In general what surgical approches for rectourethral fistula?

Answer 77

perineal or abdominal/lap (higher)

key is to interposition health tissue: omentum, gracilis flap between rectum and urethra

consider cystoprostatectomy if urinary or bowel function adequate or buccal graft and repair

temporary diversion vs. permanent depending on severity of bowel function

Question 78

Post operative detection of ureteral injury, with urinoma, best management?

Answer 78

Foley
IR drain
Delayed ureteral repair - at least 2 mo

Question 79

After reimplant, patient complains of numbness on anterior thigh, what happened?

Answer 79

Injury to genitofemoral nerve (sensory nerve)

Question 80

Patient s/with extraperitoneal bladder injury with clots, requiring irrigation, next step?

Answer 80

Upsize foley
explore via midline incision, open dome, avoid RP hematoma, repair extraperitoneal injury

Cystogram 1-2 weeks

Question 81

13yo boy whose father pinned him with car, stable, diffuse abdominal pain, has not voided, next evaluations?

Answer 81

KUB (if fx, need more imaging)
labs: CBC, BMP
Blood at meatus? → RUG
RUG with extravasation → Cystogram
Rectal exam (if pelvic fx, bony fragments?)
CT A/P

Question 82

Pelvic fx and bladder neck extravasation on RUG/cystogram, mgmt?

Answer 82

Exploration and repair of bladder

DO NOT disrupt pelvic hematoma

cysto to visualize posterior urethra

Question 83

Posterior urethral injury in setting of pelvic fracture, if stricture occurs at site of injury, describe workup prior to delayed repair:

Answer 83

Cystogram via SPT
RUG
Assess stricture length and bladder neck

if contrast seen in posterior urethra and not in bladder, then VUD to assess competency of bladder neck

if not competent, may need continent stoma

Question 84

Options for repair of posterior urethral traumatic injury?

Answer 84

Graft (buccal) urethroplasty
Flap (penile fasciocutaneous) urethroplasty

EPA

Question 85

15 yo with handlebar injury, falls 5 feet, left flank pain, stable, next steps?

Answer 85

Is there microhematuria or gross hematuria?

has patient voided?

Any other ortho/thoracic injuries?

stable?

PE:
Testes
Abdomen (flank)
Meatus
Perineum
UA

Question 86

Indications for radiographic assessment in peds patient for GU trauma, non-penetrating injuries:

Answer 86

Microhematuria > 50 rbc/hpf with shock (SBP < 90 mm Hg)

Significant trauma to thoracic or intra-abdominal organs

Significant deceleration or high velocity accident, fall from > 10 feet, or strike to abdomen

Gross hematuria

Question 87

How can you minimize radiation in pediatric trauma patient in need of CT

Answer 87

Just do delayed phase after IV contrast (10-15 mins)

Question 88

What does medial extravasation of contrast and no functioning parenchyma and intravascular contrast extravasation indicate?

Answer 88

Concern for renal pedicle (hilum) injury

Question 89

What does lateral extravasation of contrast with non-visualization of distal ureter indicate?

Answer 89

UPJO
UPJ avulsion

Question 90

What does medial extravasation of contrast with functioning parenchyma but no distal ureter indicate?

Answer 90

UPJO

Question 91

What questions can be asked as a brief trauma history, pneumonic?

Answer 91

SAMPLE

signs and symptoms
allergies
past illness/LMP
last meal
events related to injury

Question 92

After ABCDE, what are the next steps before any GU injuries are evaluated? Then first steps

Answer 92

BP (serial)
Hct (current and serial)
IVF
C-spine films (r/o neck fx)
airway
pelvis stable?

Attempt foley one time vs. RUG
Can attempt OR (if going for other reasons) or bedside cysto alignment
or just SPT

Question 93

SPT for urethral injury, plan for treatment?

Answer 93

Wait 6+ weeks
RUG/VCUG

Depending on length:

2 cm or below can do EPA

vs.

Urethroplasty

Question 94

How do you evaluate/follow patient after urethroplasty?

Answer 94

symptom check
uroflow
PVR
cysto if poor uroflow, high pvr, obstructive sxs

Question 95

What is ddx of gross hematuria after blunt trauma?

Answer 95

renal injury
bladder injury (intra- or extra-)
urethral injury

Question 96

patient undergoing ex-lap and bladder repair becomes cold and coagulopathic with excessive bleeding, next steps?

Answer 96

PRBC, FFP to correct coagulopathy
Damage control, tell anesthesia
Pack pelvis and return tomorrow

Question 97

During repair of suspected penile fx, you cannot find injury in corpora, what can be done? most common site of injury?

Answer 97

artificial erection with saline or die to identify injury

most common: distal to suspensory ligament ventral or lateral

Question 98

Complications after urethral repair and repair of penile fx?

Answer 98

Urethrocorporal fistula
Penile curvature
ED
Urethral stricture

AUA guidelines say to follow of a year

Question 99

Management of linear vaginal tear in setting of extraperitoneal bladder rupture? if ortho taking patient?

Answer 99

OR to repair vaginal laceration transvaginally, can try to fix bladder through hole, but not easy

urethral catheter

Intra: repair transvesically, drain, foley, repair vagina