Genitourinary Trauma
Deepak K Thakur
MS, MCh (Urology)
Contents
• Background
• Organ Injury
Renal
Ureteral
Urinary Bladder
Urethral
Penile
Testicular
• Trauma - major worldwide public health problem
• Leading cause of death and disability in both
industrialized and developing countries
• Globally, seventh leading cause of death
• Account for 9% of global mortality, and a threat to
health in every country accounting for nearly one of
every 10 deaths globally
• ‘‘…deaths due to injury represent only the tip of
the injury iceberg’’
• Approximately 10% of injuries involve the
genitourinary tract—with the kidney being the most
commonly injured organ
Renal Injury
• Most commonly injured genitourinary organs from
external trauma
• Mechanisms :
– Blunt: Motor vehicle accidents, falls from heights, and
assaults
– Penetrating: gunshot and stab wounds
Renal Injury-Presentation
• History of Trauma
• Pain
• Hematuria
• Flank hematoma, abdominal or flank tenderness, rib
fractures
• Features of associated injuries
Renal Injury-Evaluation
• Presentations
• Urine R/E/M/E
• Hematological
• RFT
• Imaging: CECT
Indications-
All penetrating trauma with a likelihood of renal
injury (abdomen, flank, or low chest entry/exit
wound) who are hemodynamically stable enough to
have a CT
Renal Injury-Evaluation
All blunt trauma with significant
acceleration/deceleration mechanism of injury
All blunt trauma with gross hematuria
All blunt trauma with microhematuria and
hypotension (defined as a systolic pressure of less
than 90 mm Hg at any time during evaluation and
resuscitation)
All pediatric patients with greater than 5 RBCs/HPF
Renal Injury-Evaluation
• American Association for the Surgery of
Trauma Organ Injury Severity Scale for
the Kidney:
Renal Injury-Evaluation
Renal Injury-Management
• Nonoperative
• Angioembolization
• Operative
Nonoperative:
– hemodynamically stable
– well-staged patients with AAST grade I to III renal injuries
– HDCU admission
– Absolute Bed rest
– Supportive rxn
– Serial monitoring
Renal Injury-Management
Angioembolization
– Highly selected patients with active bleed
– Traumatic pseudoaneurysms and arteriovenous fistulas
Operative: Indications: Absolute
– hemodynamic instability with shock
– expanding/pulsatile renal hematoma
– suspected renal vascular pedicle avulsion (grade 5)
– ureteropelvic junction disruption
Renal Injury-Management
• Relative:
– urinary extravasation with significant renal parenchymal
devascularization
– renal injury together with colon/pancreatic injury
– a delayed diagnosis of arterial injury
• Operations: Exploratory Laparotomy
Renorrhaphy
Renal revascularization
Partial nephrectomy
Nephrectomy
Ureteral Injury
• Mechanisms :
Blunt
Penetrating
Iatrogenic
• Presentation:
– High index of suspicion
– History
– Hematuria
– Urinoma
– Urosepsis
Ureteral Injury-Evaluation
• Urine R/E/M/E
• Hematological
• RFT
• Imaging:
• CECT/Urography
• Retrograde Ureterography
Ureteral Injury-Evaluation
AAST-OIS for Ureter
Ureteral Injury-Management
• Prevention is the key step
• Minor Injuries:
Conservative: Urinary drainage -DJ Stenting/PCN
placement
• Major Injuries:
Ureteral Injury-Management
Bladder Injuries
• RTA
• Falls
• Crush injuries
• Assault
• Blows to the lower abdomen
• Iatrogenic
• Bladder injuries that occur with blunt external
trauma are rarely isolated injuries—have
significant associated nonurologic injuries
Bladder Injuries
• The most common associated injury is pelvic
fracture-85%-95% association
• Types :
• Extraperitoneal
• Intraperitoneal
Bladder Injuries-Presentation
• H/O trauma
• Suprapubic pain with inability to void
• Suprapubic tenderness,
• Lower abdominal bruising,
• Muscle guarding and rigidity, and
• Diminished bowel sounds
• Features of associated injury
Bladder Injuries-Evaluation
• Clinical
• Cystography –Antegrade/Retrograde
• Others for associated injury
Bladder Injuries-Management
• Depends on
– Extraperitoneal vs intraperitoneal
– Associated injury
– Hemodynamics of the patient
Bladder Injuries-Management
• ABCs
• Conservative:
• Extraperitoneal bladder injury
• Catheter drainage
• Operative repair : Indications
– Intraperitoneal injury from external trauma
– Penetrating or iatrogenic nonurologic injury
– Inadequate bladder drainage or clots in urine
– Bladder neck injury
– Rectal or vaginal injury
Bladder Injuries-Management
– Open pelvic fracture
– Pelvic fracture requiring open reduction and internal
fixation
– Selected stable patients undergoing laparotomy for
other reasons
– Bone fragments projecting into bladder
• All patients need antibiotics & other supportive rxn
• Retrograde cystogram done after 2 weeks and if no
contrast extravasation then catheter can be removed
Urethral Injuries
• Causes:
• RTA
• Fall from height
• Assault
• In trauma often associated with multiorgan injury
• Can involve anterior or posterior urethra
Urethral Injuries-Presentation
• Triad: blood at the meatus, inability to urinate,
and palpably full bladder
• Perineal hematoma
• High riding of prostate
• Features of associated injuries
Urethral Injuries-Evaluation
• C/F
• Urethrography
• USG
• Evaluation for associated injuries
Urethral Injuries-Management
• Initial:
– Resuscitation in polytrauma
– Immediate suprapubic tube placement remains the
standard of care
• Later: after 6 weeks to 12 weeks
– Urethral reconstruction: anastomotic urethroplasty
Penile Injury
• Traumatic injuries to the genitalia are uncommon
• Spectrum:
Fracture
Zipper injury
Amputation
Penetrating injury
Bites
Strangulation
Penile Injury-Fracture
• Penile fracture is the disruption of the tunica albuginea
with rupture of the corpus cavernosum
• Fracture typically occurs during vigorous sexual
intercourse, when the rigid penis slips out of the vagina
and strikes the perineum or pubic bone, producing a
buckling injury
• The site of rupture can occur anywhere along the
penile shaft, most fractures are distal to the suspensory
ligament
• Injuries associated with coitus are usually ventral or
lateral
Penile Injury-Presentation
• A cracking or popping sound followed by pain,
rapid detumescence, and discoloration and swelling
of the penile shaft
• If Buck fascia remains intact, the penile hematoma
remains contained between the skin and tunica,
resulting in a typical “eggplant deformity”
• If Buck fascia is disrupted, hematoma can extend to
the scrotum, perineum, and suprapubic regions
Penile Injury-Presentation
• The swollen, ecchymotic phallus often deviates to
the side opposite the tunical tear
• Incidence of urethral injury: 5%-20%
Penile Injury-Evaluation
• C/F
• USG/MRI
• Urethrography
• Cystoscopy
Penile Injury-Management
• Immediate Expoloration & Repair with absorbable
suture
• Broad spectrum antibiotics
• Abstinence for a month
Testicular Injury
• Spectrum :
Tunica albuginea tear
Contusion
Hematoma
Torsion
• Mechanisms:
– Blunt -75%
– Penetrating -25%
Testicular Injury-Presentation
• Scrotal pain
• Nausea & vomiting
• Swelling and ecchymosis
Testicular Injury-Evaluation
• C/F
• USG
Testicular Injury-Management
• Early exploration and repair
• Broad spectrum Antibiotics
• Scrotal Support
