GU

TRAUMA

GU TRAUMA FRANK SABATINO

OUTLINE INTRODUCTION BLUNT TRAUMA PENETRATING TRAUMA SPECIFIC INJURIES QUESTIONS SUMMARY ABC’S OF BEING AN ITAILIAN AMERICAN BLUNT TRAUMA WITH A FOCUS ON P/E, IMAGING

BASIC LESSON # 1

= CARDINAL SIN

EPIDEMIOLOGY GU injury in 2 -5 % of adult trauma situations Vast majority from blunt trauma 80% of patients with kidney injuries have other injuries 1/3 of which are life threatening Take home is gu trauma is easily missed

CLINICAL APPROACH GU injuries usually don’t require immediate intervention (ABC’s first ) Secondary survey: Inspection of perineum for lacerations = pelvic fracture Rectal assess sphincter tone, position of prostate high riding prostate = urethral injury

CLINICAL APPROACH Scrotum/ Vagina injuries A/W pelvic fractures If you can wait evaluate urine for hematuria before placing Foley cath. If not consider suprapubic approach. Standard hematology and chemistry are useless in the acute setting

BASIC LESSON #2 YOUR NICKNAMED BY YOUR DEFORMITY Left handed = “Left handed mike” Speech impediment = “Joey two times” You have one leg – “Jimmy one leg”

BLUNT TRAUMA PHYSICAL EXAM IMAGING SPECIALS

BLUNT TRAUMA P/E MEATAL BLOOD Meatal blood = Urethral Injury = Retrograde Urethrogram seen in males (big and dumb) Posterior = Pelvic fracture Anterior = instrumentation, straddle injuries DON’T PUT A CATHETER IN WITH MEATAL BLOOD

BLUNT TRAUMA P/E Hematuria- > 5 RBC’s/ hpf (trauma) dipstick can be false positive due to myoglobin (rhabdo) IN ADULTS THE DEGREE OF HEMATURIA DOES NOT CORRESPOND TO THE DEGREE OF INJURY

BLUNT TRAUMA Hematuria Initial hematuria = distal system (urethra or prostate) Late hematuria = bladder injury Continuous = upper renal system (bladder, kidney or ureter

BLUNT TRAUMA P/E Hematuria - IF the patient has isolated microscopic hematuria no imaging is necessary. EXCEPTIONS: Rapid deceleration injuries Renal pedicle injuries Hematuria with any hypotension (transient)

BLUNT TRAUMA IMAGING (Disclaimer) IV contrast can cause false positives for blood on imaging Total quantity of contrast is limited (esp. shock) Hypotensive patients are at higher risk for contrast induced renal failure Oral contrast should not be given before an IVP or Cystogram (can obscure findings)

BLUNT TRAUMA IMAGING CHOICES Ultrasound Plain films CT abdomen/ pelvis MRI Angiography Radionuclide imaging IVP

IMAGING- CT Indications- Advantages- Gross hematuria (children) Hematuria with multiple injuries Rapid deceleration injuries Advantages- Non-invasive Superior imaging detail vs. US, IVP, Angiography Allows staging of renal injury simultaneous evaluation of other organs

IMAGING-CT Disadvantages- Other Considerations- Can only be used in a hemodynamically stable patient. Other Considerations- may need to delay oral contrast to maximize accuracy

IMAGING- ANGIOGRAPHY Indications Considerations remains gold standard for detecting renal venous injury (board questions) no renal function on ct or IVP Considerations Kidney can only tolerate 4-6 hrs of warm ischemia

IMAGING- IVP Indications Not the ideal study for trauma Stable patient when ct is unavailable Used to diagnose urethral injuries extravasation of contrast material Not the ideal study for trauma Contrast dose is 2ml/kg vs. the standard 1ml/kg (hemodilution)

IMAGING - IVP “ONE-SHOT” IVP used in unstable patients in the ER/OR Technique- 2ml/kg IV contrast 5 min before the film is taken Indications-(controversial) Can give info about status of contralateral kidney Can help to determine renal injuries that can be observed limited to flank wounds or hematuria

IMAGING- CYSTOGRAPHY Indications Technique- Suspected bladder or urethral injuries Technique- 300-500 ml of contrast material instilled retrograde into the bladder from a height of 2 ft above the patient (Fluoro guidance is ideal) Distended bladder and postdrainage view looking for extravasation Option to “wash out” with NS before post drainage view

IMAGING- CYSTOGRAPHY Urethral injuries- Technique- UN-lubricated urinary catheter is used 20-30 ml of contrast is injected followed by oblique view x-ray MAKE SURE NO PELVIC ANGIOGRAPHY OR EMBOLIZATION IS NEEDED FIRST

IMAGING- Misc. Ultrasound Plain films MRI Radionuclide Imaging focus on FAST Plain films wrong study for evaluating renal tract Consider if lower rib fractures are contributing to renal injury MRI not first line (similar accuracy of CT) Radionuclide Imaging replaced by CT

SPECIAL SITUATIONS Pediatric blunt trauma Degree of hematuria does correlate to degree of injury (opposite adults) Pediatric patients with < 50 RBC’s/ HPF do not have significant injury. Imaging studies (controversial) >50 RBC’s/hpf Unstable Can also use adult standards

SPECIAL SITUATIONS Rapid Deceleration Forces High mortality rates However frequency is <1% Problem:No hematuria present in majority of cases Therefore imaging is indicated with this mechanism

LESSON # 3 SUNDAY DINNER Starts at 2:00 pm Ends at 6:00 pm Meatball sandwiches come out at 8:00pm If your not there you better be hospitalized or dead Oldest female is in charge and the one you have to impress (forget about the males) Rule: there is enough food for 3 times the amount of people there so eat slow and steady Cardinal sin: refusing food it’s a serious insult Bonus: keep something on your plate and just stay at the table

PENETRATING TRAUMA General Imaging

PENETRATING TRAUMA All stable patients with penetrating trauma to GU tract should undergo further imaging studies Hematuria (microscopic or gross) does not correlate with the degree of injury Clinical and imaging decisions should be based on patient and weapon characteristics ureteral images from bullet wounds

IMAGING- CT with IV contrast is the study of choice No role for US Ureteral injuries- IVP or CT Bladder injuries- cystography Unstable patients can have “one shot” IVP in the OR

LESSON # 4 VOCABULARY To Kill = Whack Interest = Juice Fazool/ Fuhgazi= Fake 10 large = $10,000 100 huge= $100,000 Friend of mine = connected guy Friend of ours = made guy Fogeddabboudit = could mean anything

SPECIFIC INJURIES Renal Ureter Bladder Urethral

RENAL INJURIES Well protected requires significant force to cause injury Contusions most common 92% Lacerations 5%

RENAL INJURIES Contusion Laceration Pedicle injury Renal Rupture Renal Pelvis Rupture

RENAL CONTUSION Relatively minor injury IVP normal CT shows edema with microextravasation of contrast material

PEDICLE INJURY Injury Mechanism Laceration Thrombosis of renal vasculature Mechanism high-velocity deceleration Penetrating and blunt trauma

PEDICLE INJURY Imaging Management- Artery occlusion IVP- shows non-function Arteriogram- renal artery occlusion Ct “rim sign”- thin rim of contrast material below capsule Vein thrombosis delayed renal function no ureteral obstruction Management- A/W life threatening injuries Nephrectomy

RENAL RUPTURE Large expanding peri-renal hematoma Patient becomes unstable Imaging- multiple deep lacerations devitalized kidney fragments extravasation of contrast

RENAL PELVIS RUPTURE Extravasation of urine into perirenal space along the psoas muscle Rare A/W congenital defects Imaging functioning kidneys extravasation of contrast w/o visualization of ureter Delayed dx. results in fever, abd pain, sepsis Confirm w/ retrograde pyelogram

RENAL INJURY GRADING GRADE INJURY MANAGEMENT 1 2 3 4 5 Contusion w/ normal imaging Observation 2 Lac. < 1 cm only cortex Non-expanding hematoma confined to retroperitoneum 3 Lac. > 1cm w/ extravasation or collecting system rupture Possible surgery 4 Lac. to collecting system Pedicle injury Contained hemorrhage Surgery 5 Shattered kidney (devascularized) Kids will be managed conservatively Conservative management includes bed rest hydration serial hematocrit vitsal signs serial urine specimens Grade 3 is the point where surgery is considered

RENAL INJURIES Indications for operative management # Uncontrolled renal hemorrhage Penetrating injuries Multiple kidney lacs Shattered Kidney Avulsed Major Vessel Extensive extravasation QUESTION

URETERAL INJURIES Rarest of all injuries DX Management- Penetrating trauma m/c Blunt trauma causes rupture at UPJ DX CT Delayed presentations infection, sepsis, urinoma Management- Intraoperative Repair

BLADDER INJURIES 2nd mc injury after renal Mechanism Blunt trauma Pelvic fractures In children its considered an intra- abdominal organ Injury Contusion Rupture

BLADDER CONTUSION Bruising of the bladder with hematuria Imaging Cytstogram Pelvic fractures cause displacement of bladder superior and lateral from hematoma “pear shaped bladder” Hematomas – CT study of choice Management- Observation

BLADDER RUPTURE Intraperitoneal Burst injury on a full bladder 1in laceration at the dome posteriorly (only part of the bladder covered by peritoneum) Urine spilled into peritoneal cavity Peritonitis Kehr sign (look smart)- radiation to the shoulder from diaphragm irritation

BLADDER RUPTURE Intraperitoneal Imaging – Cystogram extravasation of contrast posterior to bladder btwn loops of intestine above bladder Management- operative repair

BLADDER RUPTURE Extraperitoneal More common Located at bladder neck A/W pelvic ring fractures Triad: 1. Abdominal pain 2. Hematuria (gross) 3. Inability to void

BLADDER RUPTURE Extraperitoneal Imaging- Cystogram flame like extravasation of contrast material into the perivesical tissues Management- indwelling urethral catheter 10 – 14 days Repeat Cystogram before removal

URETHRAL INJURIES Anterior (males) Includes bulbous and penile urethra P/E- “butterfly” hematoma Mechanism- Direct trauma, Instrumentation Degree- Contusion- blood at meatus normal retrograde urethrogram Management – spontaneous healing

URETHRAL INJURIES Anterior (males) Partial ant. lac. extravasation at site of injury + contrast proximal to site of injury Management- indwelling urethral catheter (floro guidance) Complete ant. Lac. extravasation at the site of injury without contrast proximal to the site of injury Management- Surgical repair

URETHRAL INJURIES Posterior (males) Prostatomembranous urethra A/W pelvic fractures P/E Rectal Perineal hematoma High riding detached prostate = Complete posterior urethral disruption Management- urethral catheter suprapubic cystostomy

TESTICULAR AND SCROTAL INJURIES M/C blunt leads to rupture or contusion Penetrating trauma can cause bilateral injury Imaging- testicular ultrasound Management – conservative

PENILE INJURIES Self inflicted Zipper injury – self explanatory Foreign bodies (the pen guy) Vacuum cleaner- glans injury with loss of urethra Management- removal, debridement and reconstruction Zipper injury – self explanatory Management- Lidocaine and wire cutters

PENILE INJURIES Traumatic rupture of corpus cavernosa Intercourse, direct blow, Excessive bending ? P/E- Cracking sound penile pain detumesecence rapid swelling Management- immediate surgical evacuation of blood clots and repair of the torn tunica albuginea

BASIC LESSON #5 If your running out of stuff to talk about: Frank Sinatra The Pope Godfathers I, II (but not III)

QUESTIONS

Retrograde cystography Regtrograde urethrogram 1. After a high speed MVC a 29 y/o presents with a displaced pubic rami and gross hematuria what is the most common test to diagnose a bladder injury ? Abdominal ct IVP Peritoneal lavage Retrograde cystography Regtrograde urethrogram

IVP Abdominal US DPL CT with IV contrast 2. 35 yo presents with a stab wound to right flank. Hemoglobin/hematocrit stable. U/A negative for blood. What is the next step in management of this patient? IVP Abdominal US DPL CT with IV contrast

3. Which of the following is the most common urologic injury? Urethral transection Intraperitoneal bladder perforation Renal trauma Extraperitoneal bladder perforation

4. 28 y.o. presents w/ testicular pain after being kicked in the groin at soccer practice. His testicles are painful and swollen. What is the next step in management? Doppler ultrasound Discharge with RICE and Motrin Retrograde urethrogram D/C with oral antibiotics

Retrograde cystourethrogram IVP Antegrade cystourethrogram 5. 25 yo male presents s/p fall from unknown height. C/o pelvic pain but no blood at his meatus. KUB shows pelvic fracture. What is the next step in management (urology perspective)? Retrograde cystourethrogram IVP Antegrade cystourethrogram Kidney ultrasound Foley Catheter

Foley Catheter insertion Ultrasound of the Kidneys 6. 25 y.o. M presents after fall from unknown height has blood at meatus and a high riding prostate. What is the next step in the patients management (urologic perspective)? Foley Catheter insertion Ultrasound of the Kidneys Retrograde cystourethrogram Anterograde Cystourethrogram IVP

7. Which of the following correctly describes a Malgaigne fracture of the pelvis? Fracture from forces which cause bony injury to both the right and left hemipelvis Fracture which causes the involved lower extremity to appear externally rotated without shortening A fracture which results from significant lateral forces Fracture with high incidence of urinary tract injury as its major complication A vertical shear fracture involving disruption of the anterior and posterior elements of a single hemi-pelvis

8. Regarding extraperitoneal bladder rupture all are true except? Most will heal spontaneously If a patient had a known UTI prior to injury, Foley catheter drainage and antibiotics are adequate treatment Surgical repair of these injuries should be considered if the injury involves the bladder neck Elective repair may be considered in any patient already undergoing laparotomy

Cystogram IVP CT Pelvic X-ray 9. WHAT IS THE BEST INITIAL TEST ON A PATIENT WITH SUSPECTED BLADDER INJURY ? Cystogram IVP CT Pelvic X-ray

ANSWERS

Retrograde cystography Regtrograde urethrogram 1. After a high speed MVC a 29 y/o presents with a displaced pubic rami and gross hematuria what is the most common test to diagnose a bladder injury ? Abdominal ct IVP Peritoneal lavage Retrograde cystography Regtrograde urethrogram Retrograde cystography is the usual means for dx bladder injury with blunt abdominal trauma IVP before instilling conrst die

IVP Abdominal US DPL CT with IV contrast 2. 35 yo presents with a stab wound to right flank. Hemoglobin/hematocrit stable. U/A negative for blood. What is the next step in management of this patient? IVP Abdominal US DPL CT with IV contrast

3. Which of the following is the most common urologic injury? Urethral transection Intraperitoneal bladder perforation Renal trauma Extraperitoneal bladder perforation

4. 28 y.o. presents w/ testicular pain after being kicked in the groin at soccer practice. His testicles are painful and swollen. What is the next step in management? Doppler ultrasound Discharge with RICE and Motrin Retrograde urethrogram D/C with oral antibiotics

Retrograde cystourethrogram IVP Antegrade cystourethrogram 5. 25 yo male presents s/p fall from unknown height. C/o pelvic pain but no blood at his meatus. KUB shows pelvic fracture. What is the next step in management (urology perspective)? Retrograde cystourethrogram IVP Antegrade cystourethrogram Kidney ultrasound Foley Catheter A pelvic fracture in a male is an indication for retrograde urethography and cystography

Foley Catheter insertion Ultrasound of the Kidneys 6. 25 y.o. M presents after fall from unknown height has blood at meatus and a high riding prostate. What is the next step in the patients management (urologic perspective)? Foley Catheter insertion Ultrasound of the Kidneys Retrograde cystourethrogram Anterograde Cystourethrogram IVP Blood at meatus and a high riding prostate indicates urethral disruption and is a C/I to blind foley insertion

7. Which of the following correctly describes a Malgaigne fracture of the pelvis? Fracture from forces which cause bony injury to both the right and left hemipelvis Fracture which causes the involved lower extremity to appear externally rotated without shortening A fracture which results from significant lateral forces Fracture with high incidence of urinary tract injury as its major complication A vertical shear fracture involving disruption of the anterior and posterior elements of a single hemi-pelvis Complication is retroperitoneal hemorrhage Straddle injuries cause pubic rami fractures on both sides of the sympysis pubis or in one side. All are likely to cause lower gu injury

8. Regarding extraperitoneal bladder rupture all are true except? Most will heal spontaneously If a patient had a known UTI prior to injury, Foley catheter drainage and antibiotics are adequate treatment Surgical repair of these injuries should be considered if the injury involves the bladder neck Elective repair may be considered in any patient already undergoing laparotomy Know until prior to injury perivesicular drains should be placed to prevent abscess formation

Cystogram IVP CT Pelvic X-ray 9. WHAT IS THE BEST INITIAL TEST ON A PATIENT WITH SUSPECTED BLADDER INJURY ? Cystogram IVP CT Pelvic X-ray

SUMMARY

ANATOMIC INJURY RENAL URETERAL BLADDER URETHRAL IMAGING STUDY ABDOMINAL CT SCAN URETERAL BLADDER CT CYSTOGRAM URETHRAL RETROGRADE URETHROGRAM

REFERENCES Tintinalli, J.E. et al. Emergency Medicine: A Comprehensive Study Guide. 6th Edition. ACEP. 2004 Rosen, P. et al. Emergency Medicine: Concepts and Clinical Practice. 4th Edition. Mosby. 1998. http://www.emedicine.com/renal.pdf Wagner, M.J, Promes S. Last Minute Emergency Medicine. McGraw Hill Medical. 2007.