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Urogenital Trauma

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Title: Urogenital Trauma


1
Urogenital Trauma
  • Amit Sarnaik MD
  • Scottish Rite Pediatric Emergency Department

2
Genitourinary trauma
  • In multiple trauma patients, GU trauma is second
    in frequency (1 CNS)- 10
  • MOI Blunt (90) vs. Penetrating
  • MVC most common
  • Falls, Sport related and direct blow
  • Most common Injury is to the kidney 47
  • Associated intra-peritoneal injuries
  • Penetrating 80 vs. Blunt

3
Pediatric considerations
  • Renal injury more likely in children
  • Larger proportion of kidney to abdominal size
  • Retained fetal lobulations Easier parenchymal
    disruption
  • Weaker abdominal muscles
  • Less ossified thoracic cage
  • Less developed perirenal fat and fascia

4
Renal trauma - Presentation
  • Localized signs flank tenderness, flank
    hematoma, or palpable flank mass.
  • Non specific Abdominal tenderness, rigidity,
    paralytic ileus or hypovolemic shock
  • Gross hematuria is the hallmark of severe injury
    absent in 50 of patients with vascular pedicle
    injuries and 30 penetrating injuries
  • Most common injuries
  • Parenchymal contusions and hematomas (60-90)
  • Lacerations are less common (10)

5
Classification of renal trauma
  • Grade I Contusion or subcapsular nonexpanding
    hematoma
  • Grade II Nonexpanding hematoma confined to the
    retroperitoneum or lac lt1 cm
  • Grade III Lac gt1 cm into the renal cortex
    without collecting system rupture or urinary
    extravasation
  • Grade IV Lac extending into the collecting
    system or renal vascular injuries with contained
    hemorrhage
  • Grade V Shattered kidneys or avulsions of renal
    hilum with devascularized kidneys

6
Grade 1,2 and 3 renal injuries
7
Grade 4 and 5 injuries
8
Renal Trauma Management
  • Evaluate GU system only after life threatening
    conditions have been indentified
  • A urinalysis should be obtained in all patients
    with multisystem trauma or suspected isolated
    renal injury
  • Pediatric renal trauma patient order a CXR,
    Abdominal and Pelvis X-rays

9
Renal trauma Hematuria and Kidney injury
  • Gross hematuria
  • Microscopic hematuria with major mechanisms or
    signs of renal injury
  • Hematuria of gt 20 RBC per hpf
  • Microscopic hematuria with shock ( relied upon in
    adult EM)

10
Imaging of renal trauma
  • CT with contrast is preferred study at most
    trauma centers - 98 sensitivity
  • Detection of associated injuries
  • 3-D views and no dependence on renal vascularity 
  • Ultrasound 70 sensitivity
  • Not accepted for the staging of renal trauma
  • Has been used for long term follow up
  • Alternative modality for the evaluation of the
    pregnant trauma patient

11
Imaging in renal trauma
  • IVP used only if CT is not readily available
  • Provides rapid information about the overall
    functional and anatomic integrity of both kidneys
  • It can be obtained in the ED in an unstable
    patient or in the OR prior to surgery
  • IVP will only diagnose 5 contusions, 50 lacs,
    29 pedicle injuries

12
Blunt Uro-genital trauma Diagnostic evaluation
  • Blunt and Unstable
  • Limited IVP
  • Blunt Stable, major renal injury, none lower
  • CT scan
  • Blunt and Stable, Findings of lower tract injury
  • Cystourethrogram /- upper tract evaluation
  • Blunt and Stable, Minor renal injury (Microscopic
    hematuria)
  • No CT, serial UA, delayed imaging

13
Management of blunt renal trauma
  • Grades 1,2 and 3
  • Strict bed rest, analgesia, prophylactic
    antibiotics.
  • Limited activity on resolution of gross hematuria
  • Grades 4,5 Management is controversial.
  • Depends upon hemodynamic status, degree of
    urinary extravasation, renal bleeding, associated
    injuries.
  • Many patients are being managed with serial
    hematocrit, vital signs and broad spectrum
    antibiotics

14
Complications from non operative management of
Grade 4 and 5 renal trauma
  • Patients managed nonoperatively have a 50
    complication rate
  • Persistent/recurrent hemorrhage
  • Extravasation and urinoma formation
  • Infection
  • Infarction
  • Segmental hydronephrosis

15
Penetrating Uro-genital trauma Diagnostic
evaluation
  • Penetrating and Unstable
  • Limited IVP
  • Penetrating Stable, upper tract injury
    suspected
  • CT scan
  • Penetrating Stable, findings of lower tract
    injury
  • Cystourethrogram /- upper tract evaluation

16
Management of Penetrating renal trauma
  • Surgical
  • Vascular injury
  • Hemodynamic instability
  • Urinary extravasation
  • Non surgical
  • Hemodynamically stable Isolated Low grade
  • Delayed bleeding may occur in 24 with grade 3-4

17
Complications of renal trauma
  • Short Term
  • Delayed hemorrhage
  • Urinary extravasation
  • Abscess formation
  • Obstruction secondary to clot formation
  • Long Term
  • HTN (lt5)
  • Hydronephrosis
  • Arteriovenous fistulas
  • Renal intestinal fistula
  • Stone formation

18
Ureteral Trauma
  • Ureteral injuries are uncommon, lt1 of all
    urologic trauma
  • Blunt trauma usually involves the UPJ
  • Suspect ureter trauma if fracture of the
    transverse process of lumbar vertebra
  • Penetrating injuries along the ureter 90
    association with other intra-abdominal injuries
  • Stab wounds rarely cause ureteral injury, but 50
    of GSW to abdomen have injury to the ureter

19
Ureteral trauma Diagnosis
  • Diagnosis is difficult, gt50 not diagnosed in 1st
    24h
  • PE may be unremarkable, urinalysis is unreliable
  • Delayed diagnosis may manifest as fever, chills,
    lethargy, leukocytosis, pyuria, bacteriuria,
    flank mass/pain, fistulas, strictures

20
Ureteral Trauma
  • CT and IVP has low sensitivity (33)
  • Retrograde pyelogram may be more reliable

21
Bladder Trauma
  • Blunt trauma secondary to MVC is most common
    cause
  • 80 of injuries associated with pelvic fracture
  • Mortality rate 40 with bladder rupture (from
    assoc head injury)

22
Classification of bladder trauma
  • Extraperitoneal associated with pelvic
    fractures.
  • Intraperitoneal caused by blunt trauma to
    distended bladder.
  • Combined GSW.

23
Bladder trauma Diagnosis
  • Hematuria and dysuria typically seen at
    presentation
  • gt90 with bladder rupture have gross hematuria
  • Diagnostic evaluation is indicated
  • in patients who sustain pelvic or lower
    abdominal trauma with gross hematuria
  • inability to void
  • abnormal GU exam
  • multiple associated injuries

24
Evaluation of bladder trauma
  • Pelvic X-rays
  • Retrograde cystogram
  • High suspicion and normal X-rays
  • No catheterization if blood at the urethral
    meatus or high-riding prostate
  • CT cystography is recommended over plain
    cystogram for patients undergoing CT for
    associated injuries

25
Management of bladder injuries
  • Extra peritoneal
  • Contusion conservative management, /- catheter
  • Manage with urethral cath or suprapubic drainage
    for 7-10 days.
  • Large tear OR
  • Intraperitoneal - Go to OR.
  • Combined Go to OR

26
Urethral trauma
  • Mechanisms
  • MVC
  • straddle injuries
  • Instrumentation
  • More common in males
  • Urethral injuries
  • Anterior Pendulous and Bulbar
  • Posterior Membranous and Prostatic

27
Blunt Anterior Urethral trauma
  • Due to direct trauma, usually isolated, low
    mortality
  • Bulbar injuries common in straddle injury
  • Blood at the urethral meatus is present in 90 of
    anterior injuries
  • Perineal ecchymosis (butterfly),
    inability/difficulty voiding also possible
  • Retrograde urethrogram is diagnostic
  • Manage with 7-10 days of catheterization plus
    antibiotics

28
Blunt Posterior urethral Trauma
  • Occur with severe trauma and are associated with
    other injuries (pelvic fx)
  • Signs are blood at the meatus, hematuria,
    perineal ecchymosis (butterfly),
    inability/difficulty voiding
  • Retrograde urethrogram is diagnostic
  • Urology consultation
  • Higher rate of complications

29
Female urethral trauma
  • Urethral injuries in girls
  • Rare, due to mobile short urethra
  • Associated with pelvic fractures or
    instrumentation
  • Managed with suprapubic drainage and elective
    repair

30
Penile Trauma
  • Blunt trauma from toilet seat is common
  • Managed with warm soaks.
  • Tourniquet injuries
  • Exposure and removal of hair
  • Urethrocutaneous fistula and penile loss
  • Zipper entrapment.

31
Penile Trauma
  • Penis fracture.
  • Traumatic rupture of corpus cavernosum.
  • Erect penis vs. hard surface.
  • Patient may hear a cracking sound with pain and
    edema.
  • Most required surgical evacuation of hematoma,
    ice packs, pressure dressing
  • Lacerations
  • Involving the corporal bodies or the urethra
    require urologic consult
  • Superficial simple repair
  •  

32
Perineal trauma
  • Most common is straddle injury
  • Vulvar hematomas ice packs and rest
  • Superficial lacerations treat with sitz baths
  • Deep lacerations Extension into rectum or
    urethra

33
Straddle injury
  • Injury is caused by the compression of soft
    tissues against the bony margins of the pelvic
    outlet
  • Mechanisms
  • Bicycle riding
  • Falls
  • Monkey bars

34
Straddle injury Appearance
  • Straddle injuries typically are unilateral and
    superficial
  • Anterior portion of genitalia involved
  • Girls
  • Mons, clitoral hood and labia minora anterior and
    lateral to hymen
  • Straddle injury to hymen and posterior fourchette
    is rare
  • Boys Injury to penis or scrotum

35
Straddle injury vs Abuse
  • Infant younger than nine months
  • Perianal, rectal, vaginal, or hymenal injury
    without history of penetrating trauma
  • Extensive or severe trauma
  • Presence of non-urogenital trauma
  • Lack of correlation between history and physical
    findings
  • Abnormal genital secretions

36
Straddle injury Treatment principles
  • Visibility of injury
  • Physician must be assured that the injury is
    properly inspected
  • Ability to void
  • Inability to void
  • Pain
  • Large hematoma
  • Urethral disruption

37
Treatment Girls
  • Vulvar hematoma size dependant
  • Ice packs, analgesia, sitz baths
  • Increasing size Surgical drainage
  • Vulvar lacerations
  • Heal by secondary intention ( lateral wall of
    vestibule)
  • Repair of perineal lacerations under sedation
  • Vaginal injury suspect if hymenal tear
  • Lacerations superficial or deep - Repair
  • Hematomas Observation

38
Treatment Boys
  • Urethral injury Anterior vs. posterior
  • Testicular injury
  • Depends on severity
  • Assessment with US and Urology
  • Scrotal injury
  • Hematoma, ecchymosis Ice packs
  • Superficial lacerations Repair in ED
  • Hematocele and scrotal swelling
  • Deep ( extension through Dartos) Urology
  • Penile injuries

39
Penile Trauma Direct Injury
  • Causes and management
  • Falling toilet seat
  • Significant penile edema
  • Injury to corporal bodies or urethra is rare
  • Treatment warm soaks, void in bath tub,
    Observation
  • Blunt trauma Blood at urethral meatus
  • Urethral injury
  • Diagnosis Retrograde urethrogram
  • Laceration to penile shaft
  • R/O urethral injury and injury to corporal bodies
  • Consult urology, urethrogram, exploration in ??
    Cases
  • Simple laceration Repair with chromic catgut

40
Penile Trauma Zipper Injury
  • Most common genital injuries in prepubertal boys.
  • Typically involve the foreskin or redundant
    penile skin and may occur during the zipping or
    unzipping process
  • Localized edema and pain are the most common
    complications
  • Significant injury, including skin loss or
    necrosis, is unusual.

41
Zipper Injury Treatment
  • Mineral oil Allows tissue to slide freely
  • Entrapment release  The procedure for entrapment
    release depends upon the site of entrapment
    within the zipper.
  • Entrapment of penile skin between the zipper
    teeth (and not the zipper mechanism)
  • Release by cutting the cloth of the zipper -
    results in separation of the zipper teeth
  • Local anesthesia or sedation usually is not
    necessary for this procedure.

42
Zipper Injury Treatment
  • Entrapment of penile skin in the zipper mechanism
    (which consists of two faceplates connected with
    a median bar)- More difficult to release.
  • Sedation may be necessary to complete procedures
  • Local anesthesia usually is adequate for older
    children.

43
Zipper injury Treatment
  • Recommended technique
  • The median bar may be cut with wire cutters, bone
    cutters, or a mini hacksaw
  • Allows the mechanism to fall apart and leads to
    release of the entrapped skin
  • Alternate technique
  • Thin blade of a small flathead screwdriver
  • Placed between the faceplates on the side of the
    mechanism in which the penile skin is not
    entrapped.
  • The blade is then rotated toward the median bar
  • This widens the gap between the faceplates,
    releasing the skin

44
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46
Penile Injury Strangulation
  • Constriction ring Hair, fiber, thread
  • Pitfall Local edema may hide the ring of hair
  • Treatment
  • Division of hair release of constriction
  • May require GA and urologic consultation
  • Complication
  • Urethrocutaneous fistula
  • Penile loss case report
  • Occasional report as form of sexual abuse

47
Scrotal Trauma
  • Mechanisms of trauma
  • Direct blow
  • Straddle injury Impingement of testis against
    the pubic bone
  • Penetrating injuries Rare
  • Spectrum of scrotal trauma
  • Minimal scrotal swelling to testicular rupture
    with blood filled scrotum
  • Suspicion of testicular rupture surgical
    exploration
  • Best salvage of ruptured testis
  • Rare presentation of testicular torsion

48
Scrotal trauma hematocele
  • Hematocele Blood within tunica vaginalis
  • May represent severe testicular injury
  • Ecchymosis of scrotal wall in setting of trauma
  • Sonography
  • Identifies fluid collection in the tunica
  • Blood more echogenic than hydrocele fluid
  • Treatment Surgical exploration to drain large
    hematoceles as well as testicular repair if
    ruptured

49
Scrotal trauma spectrum
  • Intratesticular hematoma or laceration of tunica
  • Ultrasound Assists to determine location of
    blood
  • Intact Tunica Surgery not necessary
  • ? Testicular laceration surgical exploration
  • Traumatic epididymitis
  • Results from blunt trauma
  • Initial pain, then pain free, then pain returns
  • Scrotal erythema, edema, epididymal tenderness
  • Ultrasound rules out severe injury
  • Treatment Supportive
  • Scrotal laceration
  • Evaluate testis and spermatic cord for injury
  • Simple laceration Hemostasis and chromic sutures

50
Scrotal injuries Urology intervention
  • Large testicular hematoma may need drainage
  • Delay in surgery may lead to ischemic necrosis,
    secondary infections, disruption of testicular
    function
  • Testicular rupture with tear of the tunica
    albuginea requires surgical exploration.
  • Salvage more likely if repaired within 24h
  • Laceration to scrotum through the dartos
  • All penetrating testicular injuries

51
Testicular torsion
  • Scrotal pain and swelling common presenting
    symptom in ED
  • Acute scrotum
  • Acute testicular torsion rapid pickup is vital
    for salvage
  • Salvage rate drops when repair delayed beyond 6-8
    hours after acute event
  • Acute scrotum Testicular torsion is the working
    diagnosis until proven otherwise

52
Testicular torsion Stats
  • 1 out of every 4000 males before age of 25
  • Peak incidence 13 years of age
  • Another peak
  • Perinatal period.
  • Newborn born with hard, necrotic testis.
  • Hard or discolored scrotum
  • Salvage not possible
  • Rare after age of 30 yrs

53
Testicular torsion Cause
  • Basic mechanism Movement of testis that is
    abnormally fixed in tunica vaginalis
  • Infants Lack of fixation of tunics in the
    scrotum. Extravaginal torsion
  • Bell Clapper deformity Tunica vaginalis has
    abnormally high attachment to spermatic cord
  • Testis not fixed. Prone to torsion
  • Allows testis to lie transversely and rotate
  • Found in most cases. Commonly bilateral

54
Bell Clapper deformity

55
Testicular torsion Clinical features
  • PAT
  • Appearance Crying, irritable, uncomfortable
  • WOB Normal
  • Circulation Normal systemic
  • Other findings
  • History of pain in past
  • Acute onset pain in groin or scrotum
  • Nausea and vomiting
  • High riding testis, Transverse lie of testis
  • Diffuse testicular pain, absent cremasteric reflex

56
Testicular torsion Complications
  • Delay in re-establishing blood flow loss of
    testicular function
  • Delay
  • Patient presentation
  • Physician taking his or her time to establish
    diagnosis
  • Testicular salvage
  • 80-90 within 8 hours of acute pain
  • lt20 for delay up to 12 hrs

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59
Diagnostic studies
  • Lab studies not sufficient to make definitive
    diagnosis
  • Ultrasound with Doppler
  • Readily available, non invasive and highly
    accurate
  • Any uncertainty Indicates surgical exploration
  • Testicular scintigraphy
  • PPV of 95
  • Access may not be easy at all times
  • High index of suspicion Do not delay surgical
    procedure to confirm suspicion with a diagnostic
    study.

60
Testicular torsion Differential
  • Torsion of appendix testis or appendix epididymis
  • Epididymitis
  • Orchitis
  • Incarcerated Inguinal Hernia
  • Scrotal trauma
  • Hydrocele
  • Varicocele
  • HSP/ Kawasaki disease
  • Scrotal cellulitis
  • Testicular tumors

61
Management
  • Analgesia IV narcotic
  • Manual detorsion Can preserve testicular
    viability and provide time
  • Twist affected testis outwardly
  • Successful detorsion Relief of pain and visible
    lengthening of cord structures
  • More than 360o detorsion may be required
  • Surgery
  • Non viable testis Orchiectomy
  • Viable testis Orchiopexy
  • Exploration of unaffected testis

62
Torsion of testicular appendageAppendix testis
or Appendix epididymis
  • Average age 10 years
  • Clinical features
  • Sudden onset pain limited to scrotum
  • No abdominal or urinary symptoms
  • Point tenderness at superior aspect of testis in
    early stages
  • Blue dot visible tender nodule in 20 cases

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64
Diagnosis and Management
  • Testicular scan and Ultrasound
  • Increased blood flow
  • Inflammation at superior aspect of testis
  • Treatment
  • Expectant
  • Analgesics
  • Any doubt about diagnosis
  • Urology consultation for exploration

65
Phimosis Paraphimosis
  • Phimosis Tightness of distal foreskin
  • Cannot withdraw to expose the glans
  • Not to be confused with penile adhesions
  • Paraphimosis Foreskin is retracted behind glans
    and left there swollen, retracted foreskin
  • Venous congestion edema reduction to normal
    position is difficult

66
Paraphimosis Treatment
  • Manual reduction Application of ice and steady
    local compression
  • Local anesthesia Penile block
  • Pressure on glans (turning a sock inside out)
  • Surgical reduction Failure of manual reduction
    (2-3 attempts)
  • Surgical division of foreskin
  • Circumcision after a few weeks
  • Prevention Education of uncircumcised male

67
Improving success of manual reduction
  • Wrap the penis in plastic and apply ice packs
  • Use compressive elastic dressings
  • Apply direct circumferential manual compression
  • Granulated sugar
  • Hyaluronidase therapy - directly into several
    sites of the edematous prepuce.
  • Puncture of the edematous site

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69
An 8 yo boy is brought to the ED after getting
hit by a car while riding his bicycle. On exam,
he has stable vital signs, GCS of 15, and his
abdomen is soft without tenderness. Blood is
noted at the urethral meatus and he is unable to
void. Which of the following is the most
appropriate for management? a. Retrograde
urethrogram b. Foley catheter placement c.
Abdominal ultrasound d. Intravenous pyelogram
(IVP) e. Ice packs and ibuprofen
70
A 13 yo boy comes to the ED with back pain after
playing ice hockey. He was checked and hit his
back onto the boards. He noted gross hematuria a
few hours afterwards. On exam, he has normal
vital signs. His right flank shows a small
ecchymosis on inspection. His abdomen is soft
without tenderness. His urinalysis shows numerous
RBCs per high power field. Which of the following
tests is most appropriate in this patient? a.
Intravenous pyelogram (IVP) b. Ultrasonography c.
Cystourethrogram d. Abdominal CT e. Serial
urinalyses
71
A 6 yo girl comes to the ED after sustaining an
injury to the perineum. The patient was climbing
on a tree when she fell approximately 4 feet
landing on a large rock. She complains of pain
and bleeding from vaginal area. She has been
refusing to urinate due to pain. A 1-cm
superficial vulvar laceration is noted at 3
oclock with small amount of oozing blood. The
hymen appears intact. The most appropriate
management is a. Surgical exploration under
general anesthesia b. Laceration repair under
local anesthesia c. Consultation with the child
protection team d. Supportive care and sitz
baths e. Placing a Foley catheter and
hospitalization
72
A 13 yo boy comes to the ED after sustaining a
straddle injury to his scrotum while riding his
bicycle. He is able to urinate without difficulty
and has no gross hematuria. There is no trauma to
the abdomen. On exam, he has normal vital
signs. His right hemi-scrotum is swollen and
ecchymotic. There is marked tenderness on
palpation. There is no ecchymosis or swelling of
the penis, and no blood per meatus.
The management includes a. Pelvic x-ray b.
Needle aspiration c. Retrograde urethrogram d.
Scrotal ultrasound e. No intervention is needed
73
An 8 yo boy presents to the ED after his penile
skin got caught in the zipper of his pants. On
exam, his foreskin is caught in the zipper
mechanism. Management includes a. Cutting the
median bar of the zipper b. Dissecting the skin
free c. Applying ice before unzipping over the
entrapped skin d. Moving the zipper back and
forth after local anesthesia e. Performing a
dorsal slit procedure
74
A 16 yo boy comes to the ED with left-sided groin
pain and scrotal swelling that began 4 hours
prior to arrival. He also reports mild lower
abdominal pain and nausea. On exam, his
left scrotum is erythematous, moderately swollen
and diffusely tender on palpation. A cremasteric
reflex cannot be elicited. There is mild
tenderness on palpation of lower abdomen.
The most appropriate management of this patient
is a. Scrotal ultrasound b. Immediate surgical
exploration c. Ceftriaxone and doxycycline d.
Trimethoprim/sulfamethoxazole e. Incision and
drainage
75
A 3 yo uncircumcised boy presents to the ED with
swelling and penis pain since the morning of
presentation. There is no history of trauma. He
is able to void without difficulty. On exam, his
foreskin is retracted and swollen, and the
glans appears swollen. Which of the following
would be the most appropriate initial
treatment? a.Oral antibiotics b. Manual
reduction c. Topical antibiotic d.
Circumcision e. Warm sitz baths
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