Urinary System Trauma

Urologic injuries, although only accounting for a small percentage of all injuries,are responsible for both mortality and long term morbidity.

The initial evaluation and resuscitation of the injured patient is done by the emergency department physician and the trauma surgeon

RENAL INJURIES

Of all injuries to the genitourinary system, injuries to the kidney from external trauma are the most common..

Blunt renal injuries are most often caused by motor vehicle accidents, falls from heights Rapid deceleration can cause vascular damage to the renal vessels Penetrating renal injuries most often come from gunshot and stab wounds.

Clinical manifestation 1.shock 2.hematuria, is the best indicator of traumatic urinary system injury.However, the degree of hematuria and the severity of the renal injury do not correlate consistently 3.pain 4.mass

Staging

Imaging – who’s getting CT? 1.Blunt trauma patients with gross hematuria 2.Children with micro/gross hematuria 3.Microhematuria with shock (BP <90) 4.Al penetrating injuries with any degree of hematuria 5.Other organs trauma considered

Other imaging U|S IVP Artriography

Nonoperative Management Operative Management Absolute indications: –Persistent renal bleeding –Expanding perirenal hematoma –Pulsatile perirenal hematoma Relative indications: urinary extravasation, nonviable tissue, delayed diagnosis of arterial injury, incomplete staging.

Complications

URETERAL INJURIES Etiology Ureteral injuries after external violence are rare, occurring in less than 4% and 1% of penetrating and blunt traumas, respectively. Open Surgical Injury Ureteroscopic Injury

Diagnosis –Fever –Flank pain and low abdominal pain –Peritoneal inflammation signs –Hematuria –Often paralytic ileus

Methylene Blue Excretory Urography Computed Tomography Retrograde Ureterography Antegrade Ureterography

Management Upper Ureteral Injuries The principles of repair include spatulation, lack of tension, stenting, postoperative drainage, and a watertight anastomosis with fine nonreactive absorbable suture

Midureteral Injuries Lower Ureteral Injuries Ureteroneocystostomy Psoas bladder hitch Boari flap Ligation of the ureter

BLADDER INJURIES Blunt Injury Penetrating Injury Iatrogenic Injury

Diagnosis hematuria lower abdominal pain tenderness Bruising Imaging Retrograde cystography Computed Tomography Cystography

Classification and Management Contusions Extraperitoneal Injuries Indication of surgery open pelvic fracture and rectal perforation clots obstruct the urinary catheter within 48 hours of injury Intraperitoneal ruptures

Injury of urethra Anatomy : anterior urethra 1. Pendulous 2. Bulbous posterior urethra 1.membranous 2.prostatic

Injury of anterior urethra Etiology and pathology Straddle injury,penetrating injury or direct blow 1. Contusion 2. Laceration 3. Rupture Clinical manifestation 1.blood dripping from urethral meatus 2.pain 3.difficult in voiding 4. Perineal bruising,Butterfly bruise 5.Scrotal Hematoma

Treatment 1.Emergency treatment:compressing and antishock measures. 2. Contusion : increase water intake and antibiotic 3. Laceration :drainage(suprapubic cystostomy) 4. Rupture :operation (repair)

Injury of posterial urethra Etiology and pathology Bone fracture : prostate move up and backward bleeding urinary extravasation Clinical manifestation 1. Shock 2. Pain 3. Difficult in voiding 4. Urethra bleeding 5. Hemotoma and urinary extravasation Diagnosis 1. History and examination 2. X-ray( retrograde urethrography )

Treatment: 1. Emergency management :prohibit moving antishock aspiration of urine 2. Operative treatment Delayed treatment: Suprapubic cystotomy If incomplete laceration – spontaneous healing in 2-3 weeks Complete laceration – reconstruction after 3 months Primary repair – railroading of urethra- it is not recommended. Surgery is difficult because of hematomas and impotence rates about 50%