Initial management of genitourinary trauma at the triage

S. Sasikumar

Consultant Urologist, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

Epidemiology

A 3 to 10% of patients with multiple trauma have GU involvement. 10 to 15% of trauma patients with abdominal injuries have GU involvement. Most common in young males. The renal injuries constitute 45% of all GU injuries followed by ureteral injuries constitute 5%, bladder injuries constitute 40% and urethral injuries constitute 10% to the GU tract.

Classification

  • Blunt Injury
  • Penetrating Injury
Initial AssessmentResuscitation
ATLS ProtocolsOxygen
Primary Survey and stabilizationIV Fluids
ABCDE Blood Transfusion
Blunt InjuryPenetrating Injury
RTAStab Injury
FallGunshot Injury
Sports InjuryBull Gore Injury
Assault

Secondary Survey: Detailed head to Toe examination after primary survey and resuscitation

Detailed History

  • Mode of Injury
  • Pain and other symptoms
  • Voiding history
  • Color of The Urine

Past History

  • Any previous Urological Surgery /Disease
  • Any Congenital Anomalies
  • CKD

Approach toward of genitourinary trauma

Catheterization

  • Gentle with adequate lubrication
  • Preferably 18/16Fr Foley

Outside Catheterization

  • Colour of The Urine
  • Ascertain about the position of the catheter

Investigation

  • CECT Abdomen with CT Cystogram

Renal Injuries

  • The most commonly injured genitourinary organs from external trauma
  • Blunt and Penetrating injuries
  • Motor vehicle accidents
  • Falls from heights
  • Assaults

Physical Examination

Indications of possible renal injury:

  • Flank hematoma
  • Abdominal or flank tenderness
  • Rib fractures flank
  • Ipsilateral rib fracture can increase the incidence of significant renal trauma threefold

Hematuria

  • The degree of hematuria and the severity of the renal injury do not consistently correlate
  • Although critical to the initial evaluation of traumatic urinary tract injury, the presence or absence of hematuria should not be the sole determinant

Renal Imaging

  • Contrast-enhanced CT is the gold standard for genitourinary imaging in renal trauma.

CT Imaging

Management

  • Non-operative management in grade I to III renal injuries, regardless of mechanism
  • Surgical Exploration in Grade IV and V renal injuries

Bladder Injuries

  • Rarely isolated injuries—80–94% of patients have significant associated non urologic injurie
  • The most common associated injury is pelvic fracture – 83% to 95% of bladder injuries
  • Bladder injury in only 5–10% of pelvic fracture

Clinical Signs

  • Gross Hematuria
  • Suprapubic pain and tenderness
  • Low urine output
  • Clots in bladder
  • Free fluid in peritoneum
  • Abdomen distension and ileus

Imaging

  • CECT Abdomen with Cystogram

Types of Bladder Injuries

  • Extra peritoneal Bladder Injury
  • Intraperitoneal Bladder Injury

Extra peritoneal Bladder Injury

Extra peritoneal Bladder Injury

Intraperitoneal Bladder Injury

Intraperitoneal Bladder Injury

Management

  • Conservative management for uncomplicated extraperitonel bladder injuries
  • All penetrating or intraperitoneal injuries should be managed by immediate operative repair

Urethral Injuries

Posterior Urethral Injuries

  • Urethral disruption injuries typically occur in multisystem trauma
  • Fracture of the anterior pelvic ring or pubic diastasis are almost always present when urethral disruption is encountered

Diagnosis

  • Triad of blood at the meatus, inability to urinate, and palpably full bladder.
  • Classic findings, such as a “highriding” prostate or a “butterfly” perineal hematoma, may frequently be absent.

SPC

  • Immediate suprapubic tube placement remains the standard of care in men with posterior urethral injuries

Anterior Urethral Injuries

  • Anterior injuries are most often isolated
  • Most occur after straddle injury and involve the bulbar urethra

Clinical Signs

  • Blood at the meatus, perineal hematoma, gross hematuria, and urinary retention.
  • In severe trauma, Buck fascia may be disrupted, resulting in blood and urinary extravasation into the scrotum.

Initial Management

  • Initial suprapubic cystostomy is the standard of care for major straddle injuries involving the urethra.
Genital InjuriesPenile InjuryScrotal Injury
Young MalesLacerationLaceration
RTAContusionContusion
Work Spot InjuryAvulsionAvulsion
Sports InjuryCrush InjuryTesticular Rupture

Penile Injury

Initial Management

  • Control Bleeding
  • Catheterize and rule out Urethral Injury

Initial Management

  • Control Bleeding
  • Catheterize and rule out Urethral injury
  • USG Scrotum for Testis viability

Take Home Message

  • Always follow ATLS protocols
  • Local examination (Abdomen and Ext Genitalia)
  • Catheterization
  • Hematuria – Suspect Renal/Bladder Injury
  • The degree of hematuria and the severity of the renal injury do not consistently correlate.

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