1 / 72

Genitourinary Trauma

Genitourinary Trauma. François Dufresne McGill Emergency Medicine February 13 th 2002. The Case of Jeremy. 23 y.o male Driver, Seatbelted Frontal Impact, High Speed (  100Km/h) Airbag + Other driver dead Car completely destroyed Empty EtOH bottles in the OTHER car

salena
Télécharger la présentation

Genitourinary Trauma

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Genitourinary Trauma François Dufresne McGill Emergency Medicine February 13th 2002

  2. The Case of Jeremy • 23 y.o male • Driver, Seatbelted • Frontal Impact, High Speed ( 100Km/h) • Airbag + • Other driver dead • Car completely destroyed • Empty EtOH bottles in the OTHER car • Patient was conscious at the scene. • On scene: BP=85/50 HR:120 RR:22 Sat:98%

  3. Jeremy… • A: Clear. C-spine protection. Backboard+ • B: A/E symetric. O2 Sat N. No crepitus. Trachea central. • C: BP:100/60 HR:100 Mentating well. • D: GCS=15 PERL. • Pt is exposed. • O2 - iv – monitor • Temperature N Capillary Glucose N

  4. Jeremy • AMPLE • C/O abdo. Pain + “hip” pain • C/O right lower leg pain • Secondary Survey • Spleen normal. Mild suprapubic tenderness. • Pelvic instability • Probable right tibial # • No gross blood at meatus. Rectal Normal. • “Doctor, can I put a Foley?”

  5. Jeremy • What are your concerns? • Foley? • What will be the usefulness of dipstick? • Dipstick good enough? U/A? • What if he has microscopic hematuria? • What if he has a pelvic fracture? • Any different if you had blood at meatus? • Urethrogram? Cystogram? Abdominal CT? • Worried about the kidneys? Bladder? • Does the low BP changes your suspicion for a GU injury?

  6. Introduction • GU Trauma overlooked • 10-20% of all injured patients • Long term morbidity • Impotence • Incontinence • Life-threatening injuries first

  7. Plan • Urethral Injury • Bladder Injury • Hematuria in Trauma • Kidney Injury

  8. Definitions • Upper tract • Kydney • Ureters • Lower tract • Bladder • Urethra • External genitalia

  9. Urethral Trauma • Almost exclusively in male • Significant morbidity • Stricture • Incontinence • Impotence • If unrecognized: • Converting partial to complete tear • Inaccurate assessment of U/O • Foley catheter implication Andrich DE et al. The nature of urethral injury in cases of pelvic fracture urethral trauma. Journal of Urology. 165(5):1492-5, 2001 May.

  10. Anatomy Bladder Symphysis

  11. Prostatic Membranous Bulbous Pendulous

  12. Posterior Urethra • Violent external force • Pelvic # in  90% • Pelvic # : 5-25% of Posterior urethral injury

  13. Clinical Features • Gross hematuria in 98% • Inability to void • Blood at urethral meatus • Pelvic / suprapubic tenderness • Penile / scrotal / perineal hematoma • Boggy / high-riding prostate/ ill-defined mass on rectal examination.

  14. Digital Rectal Exam in Trauma • Porter et al. Am Surg, 2001. • Prospective • Level II Trauma Center. • 423 patients. • DRE on all. • 7 (1.7%) pelvic fracture. NO Urethral injury • Prostate exam didn’t change management Porter, J.M. et al. Digital rectal examination for trauma: does every patient need one? Am Surg 67(5):438, May 2001.

  15. Posterior Urethral rupture From McAnich JW. In Tanagho EA, McAninch JW, editors: Smith’s general urology, ed 14, Norwalk, Conn, 1995, Appleton & Lange.

  16. Diagnosis:Retrograde Urethrogram • Pretest KUB film • Supine position • Injection of 25ml of water-soluble contrast • Different techniques • X-ray when 10ml left and after 25ml • Post-voiding x-ray.

  17. Retrograde Urethrogram

  18. Retrograde Urethrogram:Interpretation • Contrast extravasation + Contrast in bladder • Contrast extravasation only PARTIAL Tear COMPLETE Tear

  19. Partial Tear

  20. Complete Tear

  21. Management • Partial tear • careful passage of 12-14 Fr. Foley. • If any resistance: Urology • Complete tear: • Urology + suprapubic cath. • If Foley already there and suspect tear: • LEAVE FOLEY IN PLACE • Small tube alongside the foley • Angiocath 16-gauge • Modified urethrogram

  22. Management…by Urology • Controversial • Complete VS Partial • Posterior VS Anterior • Foley X 3-14 days • Suprapubic catheters • Surgical approach / Endoscopy • Delayed repair usually

  23. Foley Catheter • NO if you suspect a urethral injury • Most of urethral injuries: Pelvic # or Gross hematuria • Initial bladder effluent MUST be looked at. • Danger to convert partial into complete • Successful passage  complete tear • NEVER REMOVE A FOLEY WHEN YOU SUSPECT A PARTIAL TEAR AFTERWARDS. • ANY colored urine other that yellow = BLOOD until proven otherwise

  24. Prostatic Membranous Bulbous Pendulous

  25. Anterior Urethra • More common than posterior • Direct trauma • Usually NO pelvic # • Blood at meatus • Unable to micturate • Penile/Scrotal/Perineal • Contusion • Hematoma • Fluid collection

  26. Sleeve Hematoma

  27. Butterfly Hematoma

  28. Anterior Urethral Rupture

  29. Anterior Urethra:Management • NO Foley if injury suspected • Retrograde Urethrogram • Urology: • Surgical Treatment

  30. Bladder Trauma • Adult: Extraperitoneal organ • Bladder dome = weakest point • Blunt: 60-85% • MVA: #1 cause • Important to recognize • Pelvic/abdominal wall abscess/necrosis • Peritonitis • Intra-abdominal abscess • Sepsis / Death

  31. Types of rupture • Extraperitoneal • Most common • Pelvic # in 89-100% • Bladder rupture in 5-10% of all pelvic # • Intraperitoneal • Extravasation of urine in abdomen • Sudden force to full bladder • Associated injuries +++ Mortality (20%)

  32. Clinical Presentation • McConnel et al. Rupture of the bladder. Urol Clin North Am. 1982. • Carroll et al. Major bladder trauma: Mechanisms of injury and a unified method of diagnosis and repair. Journal of Urology. 1984. • 98% : Gross hematuria • 2%: Microscopic hematuria + Pelvic # • 100%: Gross hematuria • 85% Pelvic # • Morey AF et al. Bladder rupture after blunt trauma : guidelines for diagnostic imaging. Journal of Trauma-Injury Infections & Critical Care. 51(4): 683-6, 2001 Oct.

  33. Investigation • Cystography: Gold standard • CT Cystography : New trend • Peng et al. AJR 1999. • Prospective study • 55 patients. 5 bladder rupture • Cystography VS. CT cystography • Ruptures confirmed by Surgery • 100% sensitive and specific Peng et al. CT cystography versus conventional cystography in evaluation of bladder injury. AJR 1999; 173:1269-1272.

  34. Investigation… Deck et al. Journal of Urology, 2000. • Retrospective study • 316 patients with CT Cystography • Sensitivity/Specificity = 95% and 100% • But 78% and 99% for intraperitoneal rupture • Comparable to Cystography alone • Identifies other injuries Deck AJ et al. CT Cystography for the diagnosis of traumatic bladder rupture. J Urol, Jul. 2000; 164(1); 43-6.

  35. Standard Helical CT • Pao et al. Acad Radiol 2000. • With IV contrast • Misses bladder rupture • 100% sensitive if “free fluid” criteria used. • Can R/O bladder injury if NO free fluid. • Not specific. • Not accepted as diagnostic tool. Pao et al. Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 2000; 7:317-324.

  36. Treatment • Penetrating injuries: OR • Blunt • Intraperitoneal: Almost all OR • Extraperitoneal: Urethral cath. drainage x 7-10 days.

  37. Hematuria • Hardeman and al. Journal Urol, 1987. • Prospective study • 506 patients • IVP in all. CT/arteriography/O.R. PRN • Shock: BPs<90 at any time • 25 Injuries • ALL had either • Gross hematuria • Shock + microhematuria Hardeman et al. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. The Journal of Urology. 38:99-101, 1987.

  38. Hardeman et al. … • 365 (52 %) had microhematuria only • 174 D/C’ed , F/U and no problem • 191 admitted • 1 renal contusion (Grade I) • 2 minor lacerations (Grade II) • No complication Hardeman et al. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. The Journal of Urology. 38:99-101, 1987.

  39. Mee et al. Journal Urol, 1989 • Prospective • 1146 patients • IVP = Gold standard • ALL significant renal injuries had either: • Gross hematuria • Microscopic hematuria + shock • Intensity of hematuria  Severity of injury Mee et al. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. Journal of Urology. 141(5):1095-8, 1989 May.

  40. Gross « Hematuria »: False + • Alphamethyldopa • Ibuprofen • Levodopa • Metronidazole • Nitrofurantoin • Phenazopyridine • Phenolphtalein-containing laxatives • Rifampin • Beets/berries

  41. Microscopic hematuria… • 8 major studies • 3406 adult blunt trauma with microscopic hematuria and NO shock. • 0.23% major renal injuries (gradeII) • No imaging necessary for that group • F/U 3-4 weeks to R/O underlying pathology. • BUT…

  42. Microscopic hematuria… • Patients with pelvic # often excluded from studies. • Penetrating trauma excluded. • Pediatric population excluded • « Rapid Deceleration injuries » • Urinalysis on FIRST urine.

  43. Dipstick vs. U/A • Daum et al. AM J Clin Pathol, 1988. • Prospective • 178 patients • Abdominal Trauma • Dipstick AND Microscopic examination Daum et al. Dipstick evaluation of hematuria in abdominal trauma. Am J Clin Pathol, 1988; 89:538-542.

  44. Daum et al.

  45. Dipstick vs. U/A • Chandhoke et al. J Urol, 1988. • Prospective study • 339 patients • Suspected blunt renal trauma • Dipstick AND microscopic examination Chandhoke et al. Detection and significance of microscopic hematuria in patients with blunt renal trauma. J.Urol. 140: 16-18, 1988.

More Related