EM@3AM: Genitourinary Trauma

Question: What is the diagnosis?

Answer: Genitourinary Trauma

Introduction

• Genitourinary (GU) trauma is rarely life threatening.¹ It has a low mortality but is associated with high morbidity (especially if missed).
• Helpful to conceptualize GU trauma injury into upper and lower GU injury:
• Upper:
  • Renal
  • Ureter
• Lower:
  • Bladder
  • Urethra
  • Genitals

Epidemiology

• Urologic organs are involved in about 10% of abdominal traumas.^2,3
• Kidneys
  • Most commonly injured GU organ.⁴
  • ~5% of trauma victims, predominantly blunt trauma.
  • Accounts for 24% of traumatic abdominal solid organ injuries.
• Ureter
  • Injuries are rare, about 1% of urologic injuries.
• Bladder
  • Injuries occur in 1.6% of blunt abdominal trauma victims.
  • Extraperitoneal in approximately 60%, Intraperitoneal in approximately 30%.
• Urethra
  • Posterior urethral injuries are almost exclusively associated with pelvic fractures.
• Genitals
  • Little data on epidemiology.
  • Most common is penile fracture, usually secondary to intercourse.

Approach

• Follow ATLS Trauma assessment algorithm for all patients presenting with concerning traumatic mechanism of injuries.
• Primary Survey: perform all aspects of the primary survey (ABCDEs).
  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure
• Always address life threatening injuries first.
  • Remember: GU injuries are rarely life threatening.
• Secondary Survey:
  • Undress and thoroughly examine all patients.
  • Any lower abdominal trauma/tenderness and/or pelvic instability or suspected fractures should raise suspicion for bladder injuries.^3,5.
  • Flank hematoma may suggest renal injury.³
  • Blood found at urethral meatus is considered a urethral injury until proven otherwise.
    • Do not place foley catheter until urethral injury is ruled out.
  • Inability to urinate should raise suspicion for GU injury.⁶

Upper GU Trauma

Renal

• Most common injuries are lacerations and contusions.
• Urine studies may reveal microscopic or gross hematuria.
• Renal injuries are graded on severity (Table 1).
• Hemodynamically stable patients of all grades may be treated nonoperatively.
  • Still warrant urology consult.
  • Likely admission for observation and serial hemoglobin/hematocrit blood draws.
  • Any injury higher than Grade 1 requires admission.
• Hemodynamically unstable patients require operative exploration (laparotomy) with urology.³
• Renal Artery Embolization (RAE) with Interventional Radiology is a consideration for stable renal trauma patients and in select cases of patients who are hemodynamically unstable or in cases of renal injury secondary to penetrating trauma.^7,8
  • Grade I-II injuries are usually self-limited.
  • Grade III-V injuries are most likely to benefit from RAE with the goal of preserving renal function and avoiding surgery.
  • RAE is considered first line treatment in hemodynamically stable patients achieving an overall 90% success rate.
• For stable patients, multi-phase CT is the diagnostic modality of choice.⁹
  • CT is highly sensitive and specific for diagnosing blunt traumatic injury, including renal injuries.
  • Ideally, CT should be a 3-phase study:⁹
    • Arterial phase to assess for vascular injury.
    • Nephrographic phase to assess for contusions or lacerations to the kidney.
    • Delayed phase to assess for collecting system and ureteric injury.
  • Ultrasound is not sensitive or specific.
    • Although a FAST exam identifies hemoperitoneum, not all GU injuries will cause hemoperitoneum.
    • The kidneys are retroperitoneal which may result in a negative FAST even if they are bleeding.

Ureter

• Rarely injured in isolation; usually found in multisystem trauma.
• Surgical management of urethral injuries is dependent on grade, location and patient stability.
• More common in penetrating injuries.
• Urethral injuries are often missed unless specifically evaluated for.
• CT Urography is the diagnostic modality of choice
  • Sensitivity and Specificity data is limited due to the lower incidences of these injuries.
• Symptoms are usually nonspecific:
  • Hematuria present in ~70%.¹⁰
• Delayed signs of occult injury include:³
  • Fever / sepsis
  • Flank pain
  • Ileus
• Complications of missed ureter injury:
  • Peritoneal or retroperitoneal urinary leakage
  • Perinephric abscess
  • Fistula formation
  • Ureteral stricture or obstruction

Bladder

• Presenting symptoms of bladder injury include:
  • Suprapubic pain
  • Blood at meatus
  • Urinary retention
  • Gross hematuria
    • Present in 95% of significant bladder injuries.¹¹
•  Bladder injury must be considered present until proven otherwise in the setting of:
  • Pelvic fracture with gross hematuria.
  • Penetrating injuries of the buttocks, pelvis, or lower abdomen with any hematuria.¹²
• When concern for bladder injury is high a retrograde cystogram (CT or plain film X-ray) is indicated.
• Management is dependent on type of injury: extraperitoneal or intraperitoneal.

Extraperitoneal Bladder Rupture

• Associated with pelvic fracture and laceration by bony fragments.
• Leakage of urine into the perivascular space; “Tear Drop” pattern on CT imaging.
•  Management:
  • Non-operative – suprapubic vs urethral (Foley) catheter drainage.
  • Consider broad-spectrum antibiotics.¹³

Intraperitoneal Bladder Rupture

• Associated with compressive force in presence of full bladder.
• Injury to the dome of the bladder results in leakage of urine into the peritoneal space.
  • Contrast will outline loops of small bowel within the peritoneum.
• Management
  • Operative – OR for laparotomy.
  • Consider broad-spectrum antibiotics.¹³

Lower GU Trauma

Urethra

• Anterior Injury:
  • Located Anterior to the membranous urethra.
  • Common in straddle injuries, self-instrumentation (Foley) injuries.
  • Management:
    • Surgical exploration (urology) for repair.
•  Posterior Injury:
  • Located in the membranous and prostatic urethra.
  • Common in blunt trauma from massive deceleration.
  • Associated with pelvic fractures.
  • Management:
    • Suprapubic catheter placement.
    • Do NOT place a urethral catheter.
    • Surgery days/weeks later.

• Blood at urethral meatus in the setting of trauma is a urethral injury until proven otherwise.
• May also present as:
  • Vaginal bleeding
  • Perineal or scrotal hematoma
  • High-riding or detached prostate
• DO NOT PASS URETHRAL FOLEY UNTIL URETHRAL INJURY IS EXCLUDED
  • Can cause iatrogenic “false track.³
• Retrograde urethrogram (RUG) is diagnostic for urethral injury.
  • Standard CT abdomen/pelvis with IV contrast is likely to miss a urethral injury.
  • Procedure:³
    • Insert a small caliber (12-14 Fr) Foley or catheter trip 2-4 cm beyond the urethra.
    • Inflate balloon with 2-3cm saline to reduce displacement.
    • While holding penis upright (perpendicular to the patient) slowly inject water-soluble contrast (Iohexol) 20-60mL.
    • Obtain serial anterior/lateral images (X-ray/fluoroscopy) to evaluate for extravasation.
    • Continue to slowly inject contrast until contrast fills bladder (or extravasation is detected).

Genitals – Male

• Penile or Testicular Amputation
  • Often associated with decompensated psychiatric illness (self-inflicted).
  • Urology / Surgical Consult
  • Amputation Care:¹⁴
    • Wrap in Saline Soaked Gauze and place in sterile plastic bag (Bag #1).
    • In separate sterile bag place ice and water (Bag #2).
    • Place Bag #1 into Bag #2.
•  Penile Contusion
  • Can’t miss a urethral injury!: (see above)
    • Assess for urethral injury:
      • Hematuria?
      • Can the patient void?
        • If no – patient will require foley placement.¹⁵
      • Most can be managed outpatient with RICE therapy:
        • Rest-Ice-Compression-Elevation.
• Penile Fracture
  • Tunica albuginea of one or both corpora cavernosa ruptures due to trauma to erect penis.
  • Typically occurs with an erect penis during intercourse.
  • Patient will often report a “cracking sound” followed by pain, immediate detumescence, swelling, dislocation and obvious deformity.
  • Can be associated with urethral rupture and deep dorsal vein injury.
  • Can’t miss a urethral injury!
    • Urethral injury present in 38% of penile fractures.¹²
    • Evaluate for other trauma.
  • MRI or Ultrasound can assist with diagnosis.
  • Penile laceration with no fracture can be closed with 4-0 or 5-0 absorbable sutures.
  • Surgical exploration is required for most injuries in setting of fracture.
• Traumatic Epididymitis
  • Trauma to testicle without evidence of testicular rupture.
  • Ultrasound to diagnose.
  • Scrotal Support /NSAIDS +/- Antibiotics are the mainstay of therapy.
• Zipper Injury
  • Young children
  • How to Manage Zipper Injury in ED:¹⁶
    • Cut clothing around zipper.
    • Pain control.
    • Consider: Mineral Oil + Lidocaine anesthetic to free penile skin.
    • Shears to cut through zipper (horizontally across plane of zipper).
  • Avulsed penile skin should not be reapplied (will become necrotic and infected).

Penile Nerve Block Procedure:¹⁷

• Useful for pain control and local anesthetic during procedures such as suturing.
• Procedure:
  • Identify dorsal penile base, dorsal nerves run at about the 2 and 10 o’clock positions.
  • Clean area with antiseptic solution, apply small wheal of local anesthetic at the 2 and 10 o’clock positions.
  • Insert needle just lateral to the midline at 2 and 10 o’ clock positions.
  • Advance needle just below Buck’s fascia (a loss of resistance or ‘pop’ may be felt once deep to Buck’s Fascia), avoid deep insertion (target depth ~0.5cm), and aspirate to ensure no vascular injury.
  • Inject 2-5 mL of anesthetic agent.

Scrotal Injuries

• Testicular
  • Blunt trauma usually due to impingement against symphysis pubis.
  • Testicular contusion or rupture is largely dependent on whether tunica albuginea is disrupted.
  • Will present as a large, blue, tender scrotal mass (hematocele).
  • Ultrasound is diagnostic.¹⁸
  • Patients with disruption to tunica albuginea should be evaluated by urology/surgery for operative exploration/repair.³
  • Penetrating imaging should be evaluated promptly by urology or surgery.³
• Scrotal Skin Lacerations
  • Simple Lacerations involving only the skin.
    • Can be repaired in the ED with local anesthetic.¹⁹
    • Close in layers using absorbable for subcutaneous tissue.
    • Non absorbable for skin.
  • Complex Lacerations involving deeper structures:
    • Explore wound to assess for testicular rupture of tunica albuginea injury (or other structures, dartos fascia, tunica albuginea or testicles).
    • Urology/Surgery consult for all lacerations involving deeper structures (or equivocal exams).

Genitals – Female

• Perineal Tears:
  • 1st Degree: Injury to vaginal mucosa and perineal skin only.
  • 2nd Degree: Extends into perineal muscle but not anal sphincter.
  • 3rd Degree: Involves anal sphincter.
  • 4th Degree: Extends through anal sphincter and rectal mucosa.
• Management:²⁰
  • 1st & 2nd Degree: Conservative management.
    • Cleanse wound, repair in layers with absorbable sutures, or skin glue.
  • 3rd & 4th Degree:
    • May require complex, multilayer repair in OR.
    • Recommend OB/GYN or colorectal surgical consult.

Pearls

• GU trauma is rarely fatal, but can easily be overlooked and lead to high morbidity.
• Blood at the urethral meatus is a urethral injury until proven otherwise.
  • Do not pass a foley catheter until injury is excluded via retrograde urethrogram.
• CT is imaging of choice for renal injuries
  • Multiphase CT abdomen and pelvis (arterial and venous phase) has sensitivities and specificities of >95%.^{9, 21}
  • Ultrasound is neither sensitive nor specific in this setting.
• If a patient has a pelvic fracture, consider:
  • Concomitant bladder injury; intraperitoneal vs extraperitoneal.
  • Urethral Injury.
• Genital Trauma is rare, but often signals something deeper.
  • Penile fracture: consider urethral injury.
  • Testicular Trauma: US to evaluate for contusion versus rupture.
  • Female perineal trauma: always perform a thorough exam, consider OB/GYN or colorectal consult evaluations as indicated.
    • Always consider abuse!