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Flashcards in Genitourinary Trauma Deck (23)
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What is the mechanism and presentation of penile fracture?

  • Mechanism
    • tunica albuginea thins out during erection
    • Blunt trauma shears tunica
    • Sudden increase in intracavernosal pressure
  • Presentation
    • Popping sound
    • Acute penile pain and swelling
    • “Eggplant Deformity”
    • Rapid detumesence
    • +/- Hematuria (approx 10% associated urethral injury)


What is the management of penile trauma?

  • Prompt surgical exploration is indicated if penile fracture is suspected
    • Ultrasound or MRI is reserved only when the diagnosis of penile fracture is equivocal following history and physical exam
  • If a patient with a penile fracture has gross hematuria, inability to void, or blood at the meatus evaluation of the urethra with cystoscopy or retrograde urethrogram must be performed


When is penile reimplantation indicated?

  • Prompt penile replantation is indicated in patients with traumatic penile amputation
  • A microscopic reanastomosis of the paired dorsal arteries, dorsal vein, and nerves prevents postoperative complications such as penile sensation loss, urethral stricture, and skin necrosis
  • Psychiatric consultation should be strongly considered in cases of self mutilation


What is the diagnostic procedure for renal trauma?

  • Diagnostic imaging is indicated with gross hematuria or microscopic hematuria with transient hemodynamic instability
  • Intravenous contrast enhanced Ct scan of the abdomen and pelvis should be performed when there is a possible renal injury


What are the indications for radiologic assessment in the case of flank trauma?

  • Flank/abdominal penetrating trauma
  • Blunt trauma with gross hematuria
  • Blunt trauma with microhematuria and shock
  • Deceleration injuries
  • Pediatric injuries with any hematuria


Describe the grading of renal trauma.

  • Grade 1: contusion/subcapsular hematoma
  • Grade 2: < 1 cm parenchymal lesion
  • Grade 3: > 1 cm parenchymal lesion s urinary extravasation
  • Grade 4: deep laceration involving collecting system or injury to main renal vasc c contained hemorr
  • Grade 5: shattered kidney or renal hilar avulsion


What is the management of renal trauma?

  • Non-invasive management should be implemented in patient with renal injury and hemodynamic stability
  • Immediate intervention is required in patients with renal injury who are hemodynamically unstable despite appropriate resuscitation
  • Urinary extravasation and renal injury can be observed in the hemodynamically stable patient with an intact collecting system (i.e. no UPJ disruption)
  • If fever, chills, ileus, increasing urinoma, fistula, or infection develop than urinary drainage via ureteral stent or percutaneous nephrostomy tube is indicated


What are the absolute indications for renal exploration following trauma?

  • Non-viable tissue
  • Persistent renal bleeding
  • Life threatening bleeding
  • UPJ Rupture
  • Extracapsular urine extravasation
  • Incomplete staging
  • Renal pedicle avulsion
  • Expanding retroperitoneal hematoma


What is the diagnostic procedure for ureteral injury?

Intravenous contrast enhanced Ct scan of the abdomen and pelvis should be performed when there is a possible ureteral injury


What is the temporary management of ureteral injury?

Patient s with ureteral injury usually have other life- threatening injuries and temporary urinary drainage with percutaneous nephrostomy can be used with repair in delayed fashion. 


What is the management of ureteral trauma?

  • Endoscopic ureteral injuries (iatrogenic) should be managed with ureteral stent and/or percutaneous nephrostomy tube drainage
  • Ureteral injuries proximal to the iliac vessels should be repaired primarily when possible
    • If long segment injury is apparent percutaneous nephrostomy tube drainage followed by delayed repair  should be considered
    • Bowel interposition, transureteroureterostomy (TUU) or autotransplant can be considered
  • Ureteral injuries distal to the level of the vessels should repaired with reimplant of the ureter
    • Psoas hitch can be used to gain length as can a bladder flap(boari) for extended distal ureteral injures


What are the contraindications to TUU?

Contraindications to TUU include a history of stone disease or previous ureteral malignancy


What is the etiology and mechanism of scrotal trauma?

  • Etiology
    • sports injuries
    • assault
    • motor vehicle accidents
  • Mechanism
    • testis entrapped against bony structure
      • 50kg force to cause rupture


What is the surgical management of blunt scrotal trauma?

  • Surgical Management
    • Salvage rate highest with timely exploration
    • 25/30 (83%) salvaged
    • 4/5 not salvaged > 48 hours after injury  (Buckley 2006)
    • < 72 hours 80 - 90% salvage rate
    • > 9 days salvage rate < 33%   (Gross et al, Lupetin et al) 
  • Spermatic cord injuries
    • Vas deferens repair
    • Delayed if multiple injuries
    • Ligation of injured vessels
  • Hematocele
    • > 5cm in size


What is the surgical management of penetrating scrotal trauma?


  • Surgical exploration (debridement and tunical closure) should be performed in patients with suspected tunical rupture following blunt trauma
  • Scrotal ultrasound is reserved for cases where the diagnosis of tunical rupture is equivocal from the history and physical exam
  • Surgical exploration should be performed in all patients with penetrating scrotal trauma
  • Gunshot wounds
  • Stab wounds
  • Exploration
    • Hematoma evacuation, debridement, primary closure of tunica albuginea
    • Corporal injuries
    • Spermatic cord evaluation
  • Higher rate of testis salvage for GSW as compared to stab wounds (75% to 23%)


What is the epidemiology of bladder injury?

  • National Trauma Database (2002 – 2006)
    • 75% of reported bladder injury involves men
    • •57% of injuries are in patients < 40 years old (Diebert 2011)
  • Blunt trauma accounts for 51-86% of cases
    • MVC (50.5%), pedestrian versus automobile (29.1%), falls (14.5%)
  • Penetrating bladder trauma 
    • GSW (88%)
    • 4% of all abdominal GSW involve bladder


What are the most common causes of bladder trauma?

  • Obstretric / gynecologic most common cause during open surgery
  • Pelvic fracture
  • 3.6% of pelvic fractures have associated bladder injury
  • 90% of  blunt bladder injury associated with pelvic fracture
    • Men with higher incidence of pelvic fracture
  • Extraperitoneal injury (55-78%) more common than intraperitoneal injury (17-39%)


What are the diagnostic procedures for bladder trauma?

  • Gross hematuria in the hemodynamically stable patient following pelvic trauma requires a retrograde cystogram
  • Gravity cystogram
    • 350 - 400cc contrast
    • Pre and post drainage films
      • fluoroscopy
    • CT cystogram in retrograde fashion


What is the surgical management of bladder trauma?

  • With gross hematuria in the hemodynamically stable patient following trauma a retrograde cystogram should be performed
  • Intraperitoneal bladder injuries should be surgically repaired in the setting of blunt or penetrating trauma
  • Uncomplicated extraperitoneal bladder injury can be managed with catheter drainage
  • Complicated extraperitoneal bladder injury (concomitant bladder neck injury, rectal injury, vaginal injury, bony spicules on bladder wall) should be surgically repaired


Why are men more likely to get urethral trauma?

  • Urethral injuries
    • 4% of all GU trauma (Carter 1983, Lowe 1988)
    • Men are 5X more likely than women to sustain urethral injury
      • Longer length of urethra, reduced mobility of urethra
      • Bladder neck injury is most common in prepubescent boys
    • Retrograde urethrography should be performed in patients with blood at the urethral meatus after pelvic trauma


How does a pelvic fracture lead to urethral trauma?

  • Pelvic fracture related urethral injury (PFUI)
    • 10% of males with pelvic fracture
      • 6% of females
    • Etiology
      • Fractured pubic bone and anchored prostate tear away from membranous urethra 


What are some of the complications of urethral trauma?

  • Complications of urethral injury can be devastating to men
    • urethral stenosis
    • incontinence
    • sexual dysfunction
    • infertility
    • and psychological


What is the management of urethral trauma?

  • Retrograde urethrography should be performed in patients with blood at the urethral meatus after pelvic trauma
  • Urinary drainage is necessary after pelvic fracture related urethral injury (PFUI)
    • An attempt may be made to perform endoscopic primary realignment in PFUI however placement of a suprapubic catheter and delayed urethral repair is the standard of care
  • Prompt repair of penetrating trauma to the anterior urethra should be performed
    • Stage repair with suprapubic tube secondary to blast effect or large defects
  • Prompt urinary drainage is necessary for patients with straddle injury (blunt trauma) to the anterior urethra
  • Posterior urethral injury
    • Blunt trauma
      • Endoscopic realignment attempt
    • Gold standard is suprapubic tube and staged repair in 4-6 months