1. GU

2. TRAUMA

3. GU TRAUMA
FRANK SABATINO

4. 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

5. BASIC LESSON # 1

6. = CARDINAL SIN

7. 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

8. 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

9. 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

10. 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”

11. BLUNT TRAUMA
PHYSICAL EXAM
IMAGING
SPECIALS

12. 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

13. 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

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

15. 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)

16. 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)

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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. IMAGING- CYSTOGRAPHY Indications Technique-
Suspected bladder or urethral injuries
Technique-
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

24. 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

25. 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

26. 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

27. 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

28. 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

29. PENETRATING TRAUMA
General
Imaging

30. 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

31. 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

32. 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

33. SPECIFIC INJURIES
Renal
Ureter
Bladder
Urethral

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

35. RENAL INJURIES Contusion Laceration Pedicle injury Renal Rupture
Renal Pelvis Rupture

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

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

38. 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

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

40. 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

41. 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

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

43. 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

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

45. 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

46. 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

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

48. 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

49. 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

50. 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

51. 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

52. 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

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

54. 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

55. 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

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

57. QUESTIONS

58. 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

59. 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

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

61. 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. ANSWERS

68. 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

69. 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

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

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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

77. SUMMARY

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

79. 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
Wagner, M.J, Promes S. Last Minute Emergency Medicine. McGraw Hill Medical