Genitourinary Trauma

AAST renal injury severity, from AAST + Campbell's

Renal Trauma

IF... THEN...
Diagnosis Blunt trauma + GH Obtain CTU
Blunt trauma + MH + SBP < 90
Blunt trauma concerning for renal injury but no hematuria
Penetrating trauma near kidney with(out) hematuria
Exam (rib fx, flank bruising) concerning for renal injury
Unstable patient taken to OR without imaging Obtain on table IVP
2mL/kg contrast bolus
XR 10-15min later
MH, no hypotension, no concerning injury Can observe without imaging
Management Grade I-III injury Manage conservatively
Grade IV-V injury Repeat CT within 48hrs
Fever
Worsening flank pain
Worsening anemia
Abdominal distension
Expanding urinoma with:
Fever
Increased pain
Ileus
Fistula
Infection
Provide GU drainage
Stent preferred
Can consider PCN or drain
Urinary extravasation without above signs Can manage conservatively
Hemodynamically unstable not responding to resuscitation Absolute indication for embolization/exploration
Hemodynamically unstable + perirenal hematoma > 4cm or Grade 3-5 injury with contrast extravasation
Expanding/pulsatile renal hematoma
Suspected vascular pedicle avulsion
UPJ avulsion
Urine extravasation with significant parenchymal devascularization Relative indication for embolization/exploration
Renal + colon/pancreas injuries
Arterial thrombosis
Urine extravasation from parenchymal injury

CT findings concerning for major renal injury - 9x more likely to require intervention

  1. Medial hematoma - suggests vascular injury
  2. Medial urinary extravasation - suggests renal pelvis or UPJ avulsion
  3. Global lack of parenchymal enhancement - suggests renal artery occlusion
  4. Combination of 2+: large hematoma > 3.5cm, medial renal laceration, vascular contrast extravasation

Post-renal injury hypertension mechanisms (renin production stimulated by partial ischemia)

Renal injury tips

AAST ureteral injury severity, from AAST + Campbell's

Algorithm for ureteral injury from external trauma, from Campbell's

Algorithm for iatrogenic ureteral injury discovered intraoperatively, from Campbell's

Algorithm for iatrogenic ureteral injury discovered postoperatively, from Campbell's

Ureteral Trauma

IF... THEN...
Diagnosis Ureteral injury suspected (see renal criteria) CT urography
Management Stable + contusion Place stent
Debridement not necessary
Stable + intraop laceration Place stent
repair laceration
Unstable + intraop injury Ligate + place PCN or cutaneous ureterostomy +/- stent
Delayed repair
Delayed identification Retrograde pyelogram + stent placement
If fails, place PCN
Delayed repair
Ureterovaginal fistula Stent (64-76% success)
Delayed repair (100% success)

Prophylactic stenting

Ureteral repair principles

Ureteral injury tips

Bladder Trauma

IF... THEN...
Diagnosis Pelvic fracture + gross hematuria Retrograde cystography
Penetrating injury to butt, pelvis, lower abdomen + any hematuria
Management Intraperitoneal injury Immediate surgical repair
Pelvic fracture + bone fragments in bladder
Simultaneous rectal/vaginal injury
Bladder neck injury
Laparotomy for non-bladder reasons
Inadequate drainage or clots
Extraperitoneal injury Catheter x2-3 weeks (avoid exploration if possible to prevent severe bleeding)
Prolonged catheterization required Consider suprapubic tube placement
Neurologic injuries
Orthopedic injury + immobility
Complex bladder closure

Cystography tips

Bladder injury tips

Urethral Trauma

IF... THEN...
Diagnosis Blood at meatus Immediate retrograde urethrogram
Pelvic fracture Assess for posterior urethral injury (1-10%)
Bladder rupture Assess for urethral injury (10-29%)
Management Partial urethral disruption Attempt catheter placement once
Then place SPT
Penetrating anterior injury Consider immediate repair if able
Delay if unstable, extensive tissue loss, or lack of experience
Pelvic fracture + urethral injury Primary realignment (mixed results) vs SPT (preferred)
Straddle injury Place urethral or SP catheter

Retrograde urethrogram instructions

  1. Bottom leg flexed, top leg straight, oblique angle
  2. Small catheter placed in meatus (12Fr)
  3. Gentle traction, inject 20mL undiluted contrast
  4. If catheter already placed, use 3Fr catheter next to indwelling catheter

Urethral injury tips

Penile Trauma

Fractures

Penetrating trauma

Amputation

Zipper injuries

Strangulation injuries

Scrotal/Testis Trauma

Rupture

Scrotal skin loss

Sources