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GU TraumaGU TraumaJulian Gordon, MD Julian Gordon, MD
FACSFACS
May 23, 2006May 23, 2006
PerspectivePerspectivePerspectivePerspective
Commonly covert entity, occurs in Commonly covert entity, occurs in 10% of injured patients10% of injured patients
Diagnosis usually done in Diagnosis usually done in retrograde fashion,retrograde fashion,– i.e. urethra evaluated before bladder, i.e. urethra evaluated before bladder,
etc.etc. GU trauma divided into lower tract GU trauma divided into lower tract
(bladder, urethra), upper tract (bladder, urethra), upper tract (renal, ureter) or external genitalia(renal, ureter) or external genitalia
Commonly covert entity, occurs in Commonly covert entity, occurs in 10% of injured patients10% of injured patients
Diagnosis usually done in Diagnosis usually done in retrograde fashion,retrograde fashion,– i.e. urethra evaluated before bladder, i.e. urethra evaluated before bladder,
etc.etc. GU trauma divided into lower tract GU trauma divided into lower tract
(bladder, urethra), upper tract (bladder, urethra), upper tract (renal, ureter) or external genitalia(renal, ureter) or external genitalia
Physical ExamPhysical ExamPhysical ExamPhysical Exam
Careful exam of abdomen/torso and Careful exam of abdomen/torso and compression of pelvic girdle/pubic compression of pelvic girdle/pubic symphysissymphysis
Examine genitalia, looking for Examine genitalia, looking for hematoma or blood at urethral hematoma or blood at urethral meatusmeatus
Do not insert foley if blood at Do not insert foley if blood at meatus until retrograde meatus until retrograde urethrogram doneurethrogram done
Careful exam of abdomen/torso and Careful exam of abdomen/torso and compression of pelvic girdle/pubic compression of pelvic girdle/pubic symphysissymphysis
Examine genitalia, looking for Examine genitalia, looking for hematoma or blood at urethral hematoma or blood at urethral meatusmeatus
Do not insert foley if blood at Do not insert foley if blood at meatus until retrograde meatus until retrograde urethrogram doneurethrogram done
Lower Tract InjuriesLower Tract Injuries
Women with pelvic fractures need Women with pelvic fractures need to have a vaginal exam as bone to have a vaginal exam as bone fragments may lacerate the fragments may lacerate the vaginal vaultvaginal vault
OK to pass a Foley in females with OK to pass a Foley in females with pelvic fracturespelvic fractures
Rectal exam to check for “high Rectal exam to check for “high riding” prostateriding” prostate
Women with pelvic fractures need Women with pelvic fractures need to have a vaginal exam as bone to have a vaginal exam as bone fragments may lacerate the fragments may lacerate the vaginal vaultvaginal vault
OK to pass a Foley in females with OK to pass a Foley in females with pelvic fracturespelvic fractures
Rectal exam to check for “high Rectal exam to check for “high riding” prostateriding” prostate
Physical ExamPhysical Exam
Foley should be placed in all major Foley should be placed in all major trauma patientstrauma patients
Any urine that is not clear or yellow is Any urine that is not clear or yellow is considered gross hematuriaconsidered gross hematuria
Most lower tract injuries accompanied Most lower tract injuries accompanied by pelvic fracture will have blood at by pelvic fracture will have blood at meatus or gross hematuria meatus or gross hematuria
Blunt trauma to renovascular pedicle or Blunt trauma to renovascular pedicle or penetrating uretral injury may not penetrating uretral injury may not produce hematuriaproduce hematuria
Foley should be placed in all major Foley should be placed in all major trauma patientstrauma patients
Any urine that is not clear or yellow is Any urine that is not clear or yellow is considered gross hematuriaconsidered gross hematuria
Most lower tract injuries accompanied Most lower tract injuries accompanied by pelvic fracture will have blood at by pelvic fracture will have blood at meatus or gross hematuria meatus or gross hematuria
Blunt trauma to renovascular pedicle or Blunt trauma to renovascular pedicle or penetrating uretral injury may not penetrating uretral injury may not produce hematuriaproduce hematuria
Foley CatheterFoley Catheter
Urethral TraumaUrethral TraumaUrethral TraumaUrethral Trauma
Anatomy:Anatomy: Divided by UG diaphragm into Divided by UG diaphragm into
anterior and posterior urethraanterior and posterior urethra Pelvic fracture may result in a Pelvic fracture may result in a
laceration of the prostatic or laceration of the prostatic or membranous urethramembranous urethra
Anatomy:Anatomy: Divided by UG diaphragm into Divided by UG diaphragm into
anterior and posterior urethraanterior and posterior urethra Pelvic fracture may result in a Pelvic fracture may result in a
laceration of the prostatic or laceration of the prostatic or membranous urethramembranous urethra
PathophysiologyPathophysiology Most posterior urethral injuries due Most posterior urethral injuries due
to pelvic fracturesto pelvic fractures Most anterior injuries due to Most anterior injuries due to
straddle injuries, GSW, self-straddle injuries, GSW, self-instrumentationinstrumentation
PathophysiologyPathophysiology Most posterior urethral injuries due Most posterior urethral injuries due
to pelvic fracturesto pelvic fractures Most anterior injuries due to Most anterior injuries due to
straddle injuries, GSW, self-straddle injuries, GSW, self-instrumentationinstrumentation
Urethral TraumaUrethral Trauma
Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features
Lack of pelvic tenderness, no Lack of pelvic tenderness, no hematomas, normal rectal exam hematomas, normal rectal exam all support an intact urethraall support an intact urethra
Pelvic crush injuryPelvic crush injury Blood at meatusBlood at meatus Distended BladderDistended Bladder Catheter-no urine outputCatheter-no urine output
Lack of pelvic tenderness, no Lack of pelvic tenderness, no hematomas, normal rectal exam hematomas, normal rectal exam all support an intact urethraall support an intact urethra
Pelvic crush injuryPelvic crush injury Blood at meatusBlood at meatus Distended BladderDistended Bladder Catheter-no urine outputCatheter-no urine output
DiagnosisDiagnosisDiagnosisDiagnosis
Ability to pass a Foley precludes Ability to pass a Foley precludes complete urethral disruption, complete urethral disruption, partial tear may existpartial tear may exist
If partial tear exists/attempt of If partial tear exists/attempt of passage of a Foley may be done, passage of a Foley may be done, consult urology if difficulty consult urology if difficulty
Consider urethral tear in any Consider urethral tear in any patient following unsuccessful cath patient following unsuccessful cath followed by bleedingfollowed by bleeding
Ability to pass a Foley precludes Ability to pass a Foley precludes complete urethral disruption, complete urethral disruption, partial tear may existpartial tear may exist
If partial tear exists/attempt of If partial tear exists/attempt of passage of a Foley may be done, passage of a Foley may be done, consult urology if difficulty consult urology if difficulty
Consider urethral tear in any Consider urethral tear in any patient following unsuccessful cath patient following unsuccessful cath followed by bleedingfollowed by bleeding
RadiologyRadiologyRadiologyRadiology
Retrograde urethrogram is procedure of Retrograde urethrogram is procedure of choice is all suspected urethral injurieschoice is all suspected urethral injuries
Perform urethrogram with patient in Perform urethrogram with patient in supine position with penis stretched supine position with penis stretched obliquely over the thigh, or in oblique obliquely over the thigh, or in oblique positionposition
First obtain KUB, and try to do with flouroFirst obtain KUB, and try to do with flouro Using a Toomey syringe, inject 60 ml of Using a Toomey syringe, inject 60 ml of
contrast into the penis over 30-60 secondscontrast into the penis over 30-60 seconds
Retrograde urethrogram is procedure of Retrograde urethrogram is procedure of choice is all suspected urethral injurieschoice is all suspected urethral injuries
Perform urethrogram with patient in Perform urethrogram with patient in supine position with penis stretched supine position with penis stretched obliquely over the thigh, or in oblique obliquely over the thigh, or in oblique positionposition
First obtain KUB, and try to do with flouroFirst obtain KUB, and try to do with flouro Using a Toomey syringe, inject 60 ml of Using a Toomey syringe, inject 60 ml of
contrast into the penis over 30-60 secondscontrast into the penis over 30-60 seconds
Complete vs. partial tear Complete vs. partial tear distinguished by the presence of distinguished by the presence of contrast in the bladdercontrast in the bladder
Complete vs. partial tear Complete vs. partial tear distinguished by the presence of distinguished by the presence of contrast in the bladdercontrast in the bladder
RadiologyRadiology
TreatmentTreatmentTreatmentTreatment
If normal urethrogram, place a If normal urethrogram, place a Foley Foley
For a partial tear, 1 attempt at For a partial tear, 1 attempt at Foley placement may be doneFoley placement may be done
For complete tear consult urology, For complete tear consult urology, may need to place suprapubic may need to place suprapubic catheter, or attempt endoscopic catheter, or attempt endoscopic assisted cathassisted cath
If normal urethrogram, place a If normal urethrogram, place a Foley Foley
For a partial tear, 1 attempt at For a partial tear, 1 attempt at Foley placement may be doneFoley placement may be done
For complete tear consult urology, For complete tear consult urology, may need to place suprapubic may need to place suprapubic catheter, or attempt endoscopic catheter, or attempt endoscopic assisted cathassisted cath
Bladder TraumaBladder Trauma
Bladder AnatomyBladder AnatomyBladder AnatomyBladder Anatomy
Lies within pelvis when empty, can Lies within pelvis when empty, can reach umbilicus when fullreach umbilicus when full
Consists of 3 muscle layersConsists of 3 muscle layers Blood supplied from int. iliac artery, Blood supplied from int. iliac artery,
nerve supply from lumbar and sacral nerve supply from lumbar and sacral plexusplexus
Bladder trauma usually associated Bladder trauma usually associated with severe injuries, mortality 22-with severe injuries, mortality 22-44%44%
Lies within pelvis when empty, can Lies within pelvis when empty, can reach umbilicus when fullreach umbilicus when full
Consists of 3 muscle layersConsists of 3 muscle layers Blood supplied from int. iliac artery, Blood supplied from int. iliac artery,
nerve supply from lumbar and sacral nerve supply from lumbar and sacral plexusplexus
Bladder trauma usually associated Bladder trauma usually associated with severe injuries, mortality 22-with severe injuries, mortality 22-44%44%
PathophysiologyPathophysiologyPathophysiologyPathophysiology
Can rupture in or outside of Can rupture in or outside of peritoneum, or bothperitoneum, or both
Extraperitoneal rupture usually Extraperitoneal rupture usually from pelvic fracture with laceration from pelvic fracture with laceration of bladder, but may occur with of bladder, but may occur with blunt traumablunt trauma
Can rupture in or outside of Can rupture in or outside of peritoneum, or bothperitoneum, or both
Extraperitoneal rupture usually Extraperitoneal rupture usually from pelvic fracture with laceration from pelvic fracture with laceration of bladder, but may occur with of bladder, but may occur with blunt traumablunt trauma
Intraperitoneal rupture usually Intraperitoneal rupture usually from blunt trauma in patients with from blunt trauma in patients with a full bladdera full bladder
Clinically will see lower abdominal Clinically will see lower abdominal pain, inability to urinate, blood at pain, inability to urinate, blood at meatusmeatus
Intraperitoneal rupture usually Intraperitoneal rupture usually from blunt trauma in patients with from blunt trauma in patients with a full bladdera full bladder
Clinically will see lower abdominal Clinically will see lower abdominal pain, inability to urinate, blood at pain, inability to urinate, blood at meatusmeatus
PathophysiologyPathophysiology
LabLabLabLab
Gross hematuria indicative of Gross hematuria indicative of urologic injuryurologic injury
Clear urine and no pelvic fracture Clear urine and no pelvic fracture virtually eliminates possibility of virtually eliminates possibility of bladder rupturebladder rupture
98% of patients with bladder 98% of patients with bladder rupture have gross hematuriarupture have gross hematuria
Gross hematuria indicative of Gross hematuria indicative of urologic injuryurologic injury
Clear urine and no pelvic fracture Clear urine and no pelvic fracture virtually eliminates possibility of virtually eliminates possibility of bladder rupturebladder rupture
98% of patients with bladder 98% of patients with bladder rupture have gross hematuriarupture have gross hematuria
RadiologyRadiologyRadiologyRadiology
Retrograde cystogram is Retrograde cystogram is diagnostic procedure of choicediagnostic procedure of choice
Retrograde cystogram is Retrograde cystogram is diagnostic procedure of choicediagnostic procedure of choice
Retrograde CystogramRetrograde CystogramRetrograde CystogramRetrograde Cystogram
Exclude urethral injury and place a FoleyExclude urethral injury and place a Foley Contrast is instilled under gravity thru a Contrast is instilled under gravity thru a
Toomey syringe without its central pistonToomey syringe without its central piston Obtain KUB firstObtain KUB first Instill contrast until 100cc with x-ray Instill contrast until 100cc with x-ray
evidence of extravasation, 300-400 cc in evidence of extravasation, 300-400 cc in patient older than 11patient older than 11
Use flouroscopic monitoringUse flouroscopic monitoring Children (age+2)x30ccChildren (age+2)x30cc
Exclude urethral injury and place a FoleyExclude urethral injury and place a Foley Contrast is instilled under gravity thru a Contrast is instilled under gravity thru a
Toomey syringe without its central pistonToomey syringe without its central piston Obtain KUB firstObtain KUB first Instill contrast until 100cc with x-ray Instill contrast until 100cc with x-ray
evidence of extravasation, 300-400 cc in evidence of extravasation, 300-400 cc in patient older than 11patient older than 11
Use flouroscopic monitoringUse flouroscopic monitoring Children (age+2)x30ccChildren (age+2)x30cc
Foley is clamped and AP film takenFoley is clamped and AP film taken Then empty bladder and take post-Then empty bladder and take post-
evacuation filmevacuation film If extraperitoneal perforation, will see If extraperitoneal perforation, will see
contrast in area of pubic contrast in area of pubic symphysis,intraperitoneal perforation symphysis,intraperitoneal perforation will outline abdominal contentswill outline abdominal contents
May see false negatives if less than 300-May see false negatives if less than 300-400cc of contrast used400cc of contrast used
Foley is clamped and AP film takenFoley is clamped and AP film taken Then empty bladder and take post-Then empty bladder and take post-
evacuation filmevacuation film If extraperitoneal perforation, will see If extraperitoneal perforation, will see
contrast in area of pubic contrast in area of pubic symphysis,intraperitoneal perforation symphysis,intraperitoneal perforation will outline abdominal contentswill outline abdominal contents
May see false negatives if less than 300-May see false negatives if less than 300-400cc of contrast used400cc of contrast used
Retrograde CystogramRetrograde Cystogram
CT SCANCT SCANCT SCANCT SCAN
Obtain same anatomic info, Obtain same anatomic info, contrast instilled in retrograde contrast instilled in retrograde fashionfashion
Obtain same anatomic info, Obtain same anatomic info, contrast instilled in retrograde contrast instilled in retrograde fashionfashion
TreatmentTreatmentTreatmentTreatment
If no extravasation treat with or If no extravasation treat with or without Foley drainagewithout Foley drainage
Extraperitoneal ruptures treated Extraperitoneal ruptures treated with Foley drainage for 7 to 15 with Foley drainage for 7 to 15 days with 20Fr. or greater sized days with 20Fr. or greater sized cathetercatheter
If no extravasation treat with or If no extravasation treat with or without Foley drainagewithout Foley drainage
Extraperitoneal ruptures treated Extraperitoneal ruptures treated with Foley drainage for 7 to 15 with Foley drainage for 7 to 15 days with 20Fr. or greater sized days with 20Fr. or greater sized cathetercatheter
Surgical repair if rupture involves Surgical repair if rupture involves bladder neck or proximal urethrabladder neck or proximal urethra
Intraperitoneal ruptures always Intraperitoneal ruptures always require surgical repairrequire surgical repair– Children 77%Children 77%– Increased Bun/CrIncreased Bun/Cr– Potentially lethalPotentially lethal
Surgical repair if rupture involves Surgical repair if rupture involves bladder neck or proximal urethrabladder neck or proximal urethra
Intraperitoneal ruptures always Intraperitoneal ruptures always require surgical repairrequire surgical repair– Children 77%Children 77%– Increased Bun/CrIncreased Bun/Cr– Potentially lethalPotentially lethal
TreatmentTreatment
Upper Tract TraumaUpper Tract Trauma
Renal InjuryRenal Injury
ComplicationsComplicationsComplicationsComplications
Renovascular HTN in 1% Renovascular HTN in 1% associated with pedicle injuries associated with pedicle injuries and failed arterial repairsand failed arterial repairs
Renovascular HTN in 1% Renovascular HTN in 1% associated with pedicle injuries associated with pedicle injuries and failed arterial repairsand failed arterial repairs
EpidemiologyEpidemiologyEpidemiologyEpidemiology
Blunt trauma accounts for 80-85% of all Blunt trauma accounts for 80-85% of all renal injuriesrenal injuries– MVAMVA– SportsSports– Domestic violenceDomestic violence
Intraperitoneal injury found in 20% of Intraperitoneal injury found in 20% of blunt trauma and 80% of penetrating blunt trauma and 80% of penetrating traumatrauma
Pedicle injuries due to Pedicle injuries due to acceleration/decelerationacceleration/decelerationor penetrating injuryor penetrating injury
Blunt trauma accounts for 80-85% of all Blunt trauma accounts for 80-85% of all renal injuriesrenal injuries– MVAMVA– SportsSports– Domestic violenceDomestic violence
Intraperitoneal injury found in 20% of Intraperitoneal injury found in 20% of blunt trauma and 80% of penetrating blunt trauma and 80% of penetrating traumatrauma
Pedicle injuries due to Pedicle injuries due to acceleration/decelerationacceleration/decelerationor penetrating injuryor penetrating injury
LabsLabsLabsLabs
Degree of hematuria not indicative Degree of hematuria not indicative of severity of severity
1998 guidelines state major renal 1998 guidelines state major renal lacerations may be repaired, adults lacerations may be repaired, adults at risk for major lacerations have at risk for major lacerations have gross or microscopic hematuria and gross or microscopic hematuria and shock shock
CT is procedure of choice for CT is procedure of choice for imagingimaging
Degree of hematuria not indicative Degree of hematuria not indicative of severity of severity
1998 guidelines state major renal 1998 guidelines state major renal lacerations may be repaired, adults lacerations may be repaired, adults at risk for major lacerations have at risk for major lacerations have gross or microscopic hematuria and gross or microscopic hematuria and shock shock
CT is procedure of choice for CT is procedure of choice for imagingimaging
PedsPedsPedsPeds
Kidney most frequently injured Kidney most frequently injured organ in blunt traumaorgan in blunt trauma
Major injuries may have Major injuries may have microscopic hematuria without microscopic hematuria without shockshock
If less than 50RBC/hpf, imaging If less than 50RBC/hpf, imaging can be deletedcan be deleted
Kidney most frequently injured Kidney most frequently injured organ in blunt traumaorgan in blunt trauma
Major injuries may have Major injuries may have microscopic hematuria without microscopic hematuria without shockshock
If less than 50RBC/hpf, imaging If less than 50RBC/hpf, imaging can be deletedcan be deleted
When is Imaging Indicated When is Imaging Indicated ??
When is Imaging Indicated When is Imaging Indicated ??
Penetrating traumaPenetrating trauma Pediatric traumaPediatric trauma
– Blunt > 50 rbc’sBlunt > 50 rbc’s Deceleration injuryDeceleration injury Adult blunt traumaAdult blunt trauma
– Gross hematuriaGross hematuria– Microhematuria & shock (sbp<90)Microhematuria & shock (sbp<90)
Penetrating traumaPenetrating trauma Pediatric traumaPediatric trauma
– Blunt > 50 rbc’sBlunt > 50 rbc’s Deceleration injuryDeceleration injury Adult blunt traumaAdult blunt trauma
– Gross hematuriaGross hematuria– Microhematuria & shock (sbp<90)Microhematuria & shock (sbp<90)
RadiologyRadiologyRadiologyRadiology
IVP: 1.5 – 2ml/kg bolus IVP IVP: 1.5 – 2ml/kg bolus IVP preferredpreferred– This study is adequate 60-85% of the This study is adequate 60-85% of the
timetime– Abnormal findings often require Abnormal findings often require
further imagingfurther imaging– ““single shot” IVP is discouragedsingle shot” IVP is discouraged
CT with IV contrast is procedure of CT with IV contrast is procedure of choicechoice
IVP: 1.5 – 2ml/kg bolus IVP IVP: 1.5 – 2ml/kg bolus IVP preferredpreferred– This study is adequate 60-85% of the This study is adequate 60-85% of the
timetime– Abnormal findings often require Abnormal findings often require
further imagingfurther imaging– ““single shot” IVP is discouragedsingle shot” IVP is discouraged
CT with IV contrast is procedure of CT with IV contrast is procedure of choicechoice
What is the Best Imaging What is the Best Imaging Study ?Study ?
What is the Best Imaging What is the Best Imaging Study ?Study ?
Computed TomographyComputed Tomography– Accurate stagingAccurate staging– Non-invasiveNon-invasive– Detects associated injuriesDetects associated injuries– RapidRapid– Need contrastNeed contrast
Computed TomographyComputed Tomography– Accurate stagingAccurate staging– Non-invasiveNon-invasive– Detects associated injuriesDetects associated injuries– RapidRapid– Need contrastNeed contrast
RENAL INJURY SCALERENAL INJURY SCALERENAL INJURY SCALERENAL INJURY SCALE
II Contusion Contusion hematuria with hematuria with normal studies normal studies
IIII Hematoma Hematoma subcapsular or subcapsular or perirenalperirenal
IIIIII Laceration Laceration <1cm renal cortex<1cm renal cortex IVIV Laceration Laceration >1cm w/o extrav or >1cm w/o extrav or
into collecting systeminto collecting system VV Vascular Vascular Renal artery or Renal artery or
vein, vein, or or shattered kidneyshattered kidney
II Contusion Contusion hematuria with hematuria with normal studies normal studies
IIII Hematoma Hematoma subcapsular or subcapsular or perirenalperirenal
IIIIII Laceration Laceration <1cm renal cortex<1cm renal cortex IVIV Laceration Laceration >1cm w/o extrav or >1cm w/o extrav or
into collecting systeminto collecting system VV Vascular Vascular Renal artery or Renal artery or
vein, vein, or or shattered kidneyshattered kidney
TreatmentTreatment
Blunt InjuryBlunt InjuryBlunt InjuryBlunt Injury
Adults with less than 3-5 RBC/hpf or Adults with less than 3-5 RBC/hpf or children with less than 50 RBC/hpf children with less than 50 RBC/hpf can be discharged from ED with can be discharged from ED with close follow upclose follow up
Only 1-2% of injuries involve the Only 1-2% of injuries involve the pedicle, but salvage rate is only 15-pedicle, but salvage rate is only 15-20%20%
Renal injuries are more common, Renal injuries are more common, result from deceleration tend to be result from deceleration tend to be partial tearspartial tears
Adults with less than 3-5 RBC/hpf or Adults with less than 3-5 RBC/hpf or children with less than 50 RBC/hpf children with less than 50 RBC/hpf can be discharged from ED with can be discharged from ED with close follow upclose follow up
Only 1-2% of injuries involve the Only 1-2% of injuries involve the pedicle, but salvage rate is only 15-pedicle, but salvage rate is only 15-20%20%
Renal injuries are more common, Renal injuries are more common, result from deceleration tend to be result from deceleration tend to be partial tearspartial tears
Venous injuries tend to bleed moreVenous injuries tend to bleed more CT scan will diagnosis most arterial CT scan will diagnosis most arterial
injuries, venous injuries diagnosed injuries, venous injuries diagnosed indirectly due to large hematomaindirectly due to large hematoma
Renal lacerations account for 2-4% Renal lacerations account for 2-4% of all renal injuries, diagnosed by of all renal injuries, diagnosed by CTCT
Venous injuries tend to bleed moreVenous injuries tend to bleed more CT scan will diagnosis most arterial CT scan will diagnosis most arterial
injuries, venous injuries diagnosed injuries, venous injuries diagnosed indirectly due to large hematomaindirectly due to large hematoma
Renal lacerations account for 2-4% Renal lacerations account for 2-4% of all renal injuries, diagnosed by of all renal injuries, diagnosed by CTCT
Blunt InjuryBlunt Injury
Surgical repair controversialSurgical repair controversial Minor renal lacerations/contusions Minor renal lacerations/contusions
managed expectantlymanaged expectantly
Surgical repair controversialSurgical repair controversial Minor renal lacerations/contusions Minor renal lacerations/contusions
managed expectantlymanaged expectantly
Blunt InjuryBlunt Injury
Penetrating InjuriesPenetrating InjuriesPenetrating InjuriesPenetrating Injuries
Hematuria is of no consequence as Hematuria is of no consequence as all patients need CT, most will all patients need CT, most will need surgeryneed surgery
Hematuria is of no consequence as Hematuria is of no consequence as all patients need CT, most will all patients need CT, most will need surgeryneed surgery
Ureteral TraumaUreteral Trauma
PathophysiologyPathophysiologyPathophysiologyPathophysiology
Rare, most due to penetrating Rare, most due to penetrating injury or iatrogenicinjury or iatrogenic
Most in upper 1/3 of ureter, Most in upper 1/3 of ureter, consider in patient with recent consider in patient with recent penetrating injury and palpable penetrating injury and palpable flank massflank mass
Blunt injuries often associated with Blunt injuries often associated with other injuriesother injuries
Rare, most due to penetrating Rare, most due to penetrating injury or iatrogenicinjury or iatrogenic
Most in upper 1/3 of ureter, Most in upper 1/3 of ureter, consider in patient with recent consider in patient with recent penetrating injury and palpable penetrating injury and palpable flank massflank mass
Blunt injuries often associated with Blunt injuries often associated with other injuriesother injuries
Diagnosis/TreatmentDiagnosis/TreatmentDiagnosis/TreatmentDiagnosis/Treatment
Usually made by finding urine in Usually made by finding urine in surgical wounds/dressings or the surgical wounds/dressings or the development of a urinomadevelopment of a urinoma
Contrast CT or bolus IVP will Contrast CT or bolus IVP will delineate the injurydelineate the injury
Retrograde pyelography will aid in Retrograde pyelography will aid in diagnosisdiagnosis
All injuries need surgical repairAll injuries need surgical repair
Usually made by finding urine in Usually made by finding urine in surgical wounds/dressings or the surgical wounds/dressings or the development of a urinomadevelopment of a urinoma
Contrast CT or bolus IVP will Contrast CT or bolus IVP will delineate the injurydelineate the injury
Retrograde pyelography will aid in Retrograde pyelography will aid in diagnosisdiagnosis
All injuries need surgical repairAll injuries need surgical repair
External Genital TraumaExternal Genital TraumaPenile TraumaPenile Trauma
Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features
Strangulation with string or hair Strangulation with string or hair seen in kidsseen in kids
Adolescents /adults may have Adolescents /adults may have incarceration injuries with metal incarceration injuries with metal rings, bottles, etcrings, bottles, etc
Consider abuse in childrenConsider abuse in children
Strangulation with string or hair Strangulation with string or hair seen in kidsseen in kids
Adolescents /adults may have Adolescents /adults may have incarceration injuries with metal incarceration injuries with metal rings, bottles, etcrings, bottles, etc
Consider abuse in childrenConsider abuse in children
Penile FracturePenile FracturePenile FracturePenile Fracture
During an erectionDuring an erection Loud crack and detumescenceLoud crack and detumescence Penile hematomaPenile hematoma Urethral injury in 20%(blood at Urethral injury in 20%(blood at
meatus)meatus) R/O dorsal vein or artery lacerationR/O dorsal vein or artery laceration ? Cavernosogram, MRI, exploration? Cavernosogram, MRI, exploration
During an erectionDuring an erection Loud crack and detumescenceLoud crack and detumescence Penile hematomaPenile hematoma Urethral injury in 20%(blood at Urethral injury in 20%(blood at
meatus)meatus) R/O dorsal vein or artery lacerationR/O dorsal vein or artery laceration ? Cavernosogram, MRI, exploration? Cavernosogram, MRI, exploration
Penile Trauma TreatmentPenile Trauma TreatmentPenile Trauma TreatmentPenile Trauma Treatment
Superficial lacerations repaired with 4.0 Superficial lacerations repaired with 4.0 absorbable sutureabsorbable suture
Degloving injuries need to go to the ORDegloving injuries need to go to the OR Penile amputation may be reattached Penile amputation may be reattached
within 6 hours (preserve in saline & pack in within 6 hours (preserve in saline & pack in ice)ice)
Most penile fractures need operative repairMost penile fractures need operative repair Human bites to penis treated same as Human bites to penis treated same as
other body areasother body areas
Superficial lacerations repaired with 4.0 Superficial lacerations repaired with 4.0 absorbable sutureabsorbable suture
Degloving injuries need to go to the ORDegloving injuries need to go to the OR Penile amputation may be reattached Penile amputation may be reattached
within 6 hours (preserve in saline & pack in within 6 hours (preserve in saline & pack in ice)ice)
Most penile fractures need operative repairMost penile fractures need operative repair Human bites to penis treated same as Human bites to penis treated same as
other body areasother body areas
Testicular TraumaTesticular Trauma
Testicular TraumaTesticular TraumaTesticular TraumaTesticular Trauma
Usually caused by a fall or kickUsually caused by a fall or kick Will see pain, n/v, occasional Will see pain, n/v, occasional
urinary retentionurinary retention Testicle may be swollen, or small Testicle may be swollen, or small
hematoma felthematoma felt All patients need color doppler All patients need color doppler
ultrasoundultrasound
Usually caused by a fall or kickUsually caused by a fall or kick Will see pain, n/v, occasional Will see pain, n/v, occasional
urinary retentionurinary retention Testicle may be swollen, or small Testicle may be swollen, or small
hematoma felthematoma felt All patients need color doppler All patients need color doppler
ultrasoundultrasound
TreatmentTreatmentTreatmentTreatment
ContusionContusion– IceIce– RestRest– NSAIDsNSAIDs
Dislocations, lacerations, Dislocations, lacerations, disruptiondisruption– SurgerySurgery
ContusionContusion– IceIce– RestRest– NSAIDsNSAIDs
Dislocations, lacerations, Dislocations, lacerations, disruptiondisruption– SurgerySurgery
Necrotizing Skin InfectionsNecrotizing Skin InfectionsNecrotizing Skin InfectionsNecrotizing Skin Infections
Predisposing factorsPredisposing factors– ETOH abuseETOH abuse– Diabetes mellitusDiabetes mellitus– Prolonged bed restProlonged bed rest
– EtiologyEtiology: perirectal, periurethral, : perirectal, periurethral, cutaneous abcessescutaneous abcesses
Predisposing factorsPredisposing factors– ETOH abuseETOH abuse– Diabetes mellitusDiabetes mellitus– Prolonged bed restProlonged bed rest
– EtiologyEtiology: perirectal, periurethral, : perirectal, periurethral, cutaneous abcessescutaneous abcesses