EMERGENCY Trauma & NON TRAUMA

IN GENITO URINARY
Kurnia Penta seputra

Department of Urology
Saiful Anwar General Hospital / Medical Faculty Brawijaya University
Malang

STANDARD KOMPETENSI DOKTER

INDONESIA (KKI 2012)
Tingkat kemampuan yang harus dicapai (standard
Kompetensi)
1.Mengenali dan menjelaskan
2.Mendiagnosis dan merujuk
3.Mendiagnosis, melakukan penatalaksanaan awal, dan
merujuk
A.Bukan gawat darurat
B.Gawat darurat

4.Mendiagnosis, melakukan penatalaksanaan secara

mandiri dan tuntas
A. Kompetensi yang dicapai pada saat lulus dokter
B. Profisiensi (kemahiran) yang dicapai setelah selesai internsip
dan/atau Pendidikan Kedokteran Berkelanjutan (PKB)

STANDARD KOMPETENSI DOKTER

INDONESIA

22 November 2008

The Current Clinical Development

of Trauma Care

Incidence of UG Trauma

KIDNEY TRAUMA

Kidney (Renal) trauma

Kidneys are retroperitonel organs those are protected
by surrounding organs
Renal trauma accounts for approximately 3% of all
trauma admissions and as many as 10% of patients
who sustain abdominal trauma.
: = 3 : 1
Majority of renal traumas are mild and can be managed
conservatively
Advanced of imaging study
more accurate staging of renal injury: decrease
surgical intervention and increase renal preservation

Epidemiology
Most of renal trauma are blunt type

Grade IV
3%
Grade III
4%
Grade II
4%

Grade V
7%

Grade I
81%

Mode of Injury
Blunt
trauma

Mechanism of
renal injury

Penetrating
trauma

Rapid
deceleration
injuries

In rural areas:
90-95 %

In urban:
up to 20 %

Stab
wounds
Gunshot
wounds

renal artery occlusion

Diagnosis
Initial Emergency Assessment
Securing of the airway
Controlling any external bleeding
Resuscitation of shock
Decide : Haemodynamic stability !

 Initial Assessment
History:
Direct, witnesses or emergency
personal
Possible indicators of renal injury :

a rapid deceleration event

high speed motor vehicle accident
direct blow to the flank
penetrating (stab/gunshot) along the line of kidneys

 Urinalysis

basic test for renal injury

Serial

Haematocrit

indicate blood loss

Creatinine

reflects renal function prior to the injury

Imaging Examination
1) Ultrasonography
2) Intravenous Pyelography (IVP)
3) Computed Tomography (CT scan)
4) MRI
5) Angiography

Indication
1) Gross haematuria
2) Microscopic haematuria and shock
3) The presence of major associated
injuries
4) Rapid deceleration injury
5) Penetrating wound suspected passing
the kidney

IVU (intravenous urography)

IVU revealed :
the presence of contra
lateral kidney
define the renal
parenchyma
out line the collecting
system

Extravasation of contrast

CT Urography

Grading and Treatment of Kidney

Trauma
Goal of management :
Minimize morbidity
Preserve renal function

The question of renal trauma

management
Explore or observe ?

Influenced by the associated abdominal injuries

Grading Renal Injury

Grade I and II are managed conservatively

Grade III and IV injuries are now managed conservatively

Operative: salvage or nephrectomy

Conservative management

Observation

T
N
Hb
Hematuria
Flank mass

Exploration

Complication
Early complication
Bleeding/delayed
bleeding
Infection
Perinephric abscess
Sepsis
Urinary fistula
Urinary extravasations
Urinoma
Hypertension

Late complication

Delayed bleeding
Hydronephrosis
Urolithiasis
Chronic
pyelonephritis
Hydronephrosis
Hypertension
AV Fistula
Pseudoaneurysms

URETERAL TRAUMA

Etiology

Ureteral
injuries
(452
cases)

Iatrogenic:
75%
(340 cases )
Blunt: 18%
(81 cases)

Gynecologic: 73% (247

cases )
General surgery: 14% (46
cases)
urological surgery: 14%
(47 cases)

Penetrating
: 7%
(31 cases)
(Dobrowolski et, BJU Int 2002, 89 : 748-751)

Location of Injury

(Dobrowolski et, BJU Int 2002, 89 : 748-751

Diagnosis
Should be suspected for ureteral trauma :

In all cases of penetrating abdominal injury

(especially gunshot wounds)
Deceleration trauma
Signs of upper tract obstruction, urinary fistula
Sepsis after trauma
Flank pain
Vaginal leakage
After gynecological pelvic
surgery
Septic

Suspected ureteral injury durante operation

inject methylene blue I.V.

IVP
Retrograde pyelography

Management
1. Partial injuries (grade 1 and 2)
Ureteral stenting antegrade or retrograde ( 3
weeks)
Nephrostomy to divert urine
Both need fluoroscopic guidance

Grade 2 and 3 detected at surgery

(iatrogenic)
Primary closure and stent
Placement a non suction drain peri ureteral

Indwelling catheter for 2-3 days to avoid

reflux during voiding

2. Complete Tears :
Principles of repair for grade 3-5 :

Debridement of ureteral ends to fresh

tissue
Spatulation of ureteral ends
Placement of internal stent
Watertight closure of reconstructed
ureter with
absorbable suture
Placement of external, non-suction drain
Isolation of injury with peritoneum or

Prevention ureteral injury before

operation
IVP, before :

Gynecological malignancy operation

Advanced endometriosis
Pelvic inflammatory disease
Introducing
Careful dissection, identified ureter
No panic in case of arterial bleeding during
dissection
Use a traumatic vascular clamp

Bladder Trauma

ETIOLOGY
Full bladder is vulnerable for trauma
Trauma patients 10% involving genitourinary
tract
2% of abdominal injury requiring surgical
repair involve bladder
Blunt trauma accounts for 67-86%
Penetrating trauma accounts for 14-33%
In 70-97% of bladder injuries: (pelvic
fracture +)
In pelvic fracture:
(30% bladder injury +)

CLASSIFICATION OF BLADDER
INJURY
BASED ON THE TYPE OF TRAUMA
CLASSIFICATIO
N OF INJURY

Blunt
trauma

MECHANISM OF INJURY
Extra
peritoneal
(80-90%)

Intraperiton
eal (1020%)

Penetrating
trauma

Blunt pelvic trauma with

laceration by bone
fragments(s)
Shearing at ligamentous
attachment(S)
High velocity blunt lower
abdominal trauma
High intravesical pressure with
rupture at dome
Direct injury to the bladder
wall

ASSOCIATED
INJURIES
Pelvic fractures
Other long bone
fractures
High rate of
associated intraabdominal injuries
High mortality
Associated injury
to ohter organs is
common

DIAAGNOSIS
Gross haematuria 82%
Abdominal tenderness 62%
Inability to avoid
Bruises over the suprapubic region
Swelling in the perineum, scrotum
and thighs, as well as a long the
anterior abdominal wall due to urine
extravasations
An urethral catheter does not return
urine

Cystography
Is considered as standard
diagnostic procedure?
Accuracy rate 85100%
Injected contrast
identified outside the
bladder
Instillation of 350 ml
contrast media with
gravity
Exposing film :
Plain film
Filled film
Post drainage film
Intraperitoneal bladder rupture

Treatment
. Blunt trauma with extraperitoneal rupture :
Catheter drainage
- 86% ruptured bladder healed in 10 days
- 100% healed in 3 weeks

Surgical intervention
- debridemant and closure
- healed faster

2. Blunt trauma intraperitoneal rupture :

Always manage by surgical exploration
Abdominal organ should be inspected and urinoma
must be drained

3. Penetrating injuries :
Should undergo emergency exploration and repair

URETHRAL TRAUMA

Etiology :
Pelvic fracture
Male : 3,5 19%
Female : 0 6%
In 10 17% associated with bladder rupture
In 8% associated with rectal fistula

Modus of pelvic fracture :

Blunt trauma : 90 %
Traffic accidents (70%)
Fall from a leight (25%)

In 27% as associated with multi organ

injuries

DIAGNOSIS
Triad signs of urethral disruption :
Blood at the urethral meatus (positive in 37-93%
cases)
Inability to urinate
Palpably full bladder

The signs of pelvic fracture clinically and

radiographically
High riding prostate (complete urethral
disruption)
only in 34% pelvic haematoma obscures the prostatic
contour

POSTERIOR URETHRAL INJURY

Management
Initial management :
Resuscitation of the patient for
associated possibly life threatening
injuries

Definitive treatment of posterior

urethral injuries is remains
controversial due to :
Variety of injury patterns
Associated injuries
Treatment potions availability

Urethral catheterization is contraindicated

Urethrography
Technique :
A 14-Fr foley catheter is
placed 1-2 cm into the
fossa navicularis
inflate the balloon with
1-2 ml water

Introduce 10 ml 30% /
anna contrast solution
with catheter tip syringe
Films taken in the lateral
decubitus position
Study under fluoroscopy
when available
Contrast extravasation on urethrography

Complication of Posterior Urethral

Injury
Erectile dysfunction :
13 30% (catheter only)
48 78% (open repair)

Incontinence
Stricture

Anterior Urethral Injury

Rare:
10% of lower urinary tract
injuries (Mitchell, BJU: 40, 648, 1968)
Mostly isolated injury
Etiology :
Straddle injury
Penetrating/gunshot
Intercourse related injury

Anterior urethral Injury

Iatrogenic
Straddle Injury
Bulbous Urethral
crushed (pressed)
between pubic bone
and hard object
Butterfly hematoma

Positive causative factor

Blood in the meatus

Large haematoma or swelling
in the perineum / scrotum

Urethrography

Management Anterior Urethral

Injury
Blunt Trauma :

Suprapubic catheter: 4 weeks

urethrography

Urethral catheterization
Large haematoma/swelling
multiple incisions

Open / penetrating injury :

Immediate exploration
Urethral suturing

Perioperative antibiotic
Cystourethrography after 2 weeks

Acute scrotum

ANATOMY

Tingkat kemampuan SKDI 2012

Learning Objective
At the end of medical school, the student
should be able to
Describe 6 conditions that may produce acute scrotal
pain or swelling.
Distinguish, through the history, physical examination
and laboratory testing, testicular torsion, torsion of
testicular appendices, epididymitis, testicular tumor,
scrotal trauma and hernia.
Appropriately order imaging studies to make the
diagnosis of the acute scrotum.
Determine which acute scrotal conditions require
emergent surgery and which may be handled less
emergently or electively.

Intrascrotal
Acute scrotum
(emergency
case)

Potential for
testicular loss
&
Infertility

Pain
Swelling
Acute onset

Acute scrotum Acute abdomen

Both conditions are guided by similar
management principles:
The patient history and physical examination are
key to the diagnosis and often guide decision
making regarding whether or not surgical
intervention is appropriate.
Imaging studies should complement, but not
replace.
When making a decision for conservative (nonsurgical) the provider must balance the potential
morbidity of surgical exploration against the
potential cost of missing a surgical diagnosis.
A negative exploration rate is acceptable to
minimize the risk of missing a critical surgical
diagnosis.

Causes of Acute Scrotal Pain and Swelling

Ischemia:

Torsion of the testis

Appendiceal torsion
Testicular infarction due to other vascular insult (cord injury,
thrombosis)

Trauma:

Testicular rupture
Intratesticular hematoma, testicular contusion
Hematocele

Infectious Acute epididymitis, Acute orchitis, Acute epididymoorchitis

conditions: Abscess (intratesticular, intravaginal, scrotal cutaneous
cysts)
Gangrenous infections (Fourniers gangrene)
Inflammat Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall
ory
Fat necrosis, scrotal wall
conditions:
Hernia:

Incarcerated, strangulated inguinal hernia, with or without

associated testicular ischemia

Acute on
chronic
events:

Spermatocele: rupture or hemorrhage

Hydrocele: rupture, hemorrhage or infection
Testicular tumor with rupture, hemorrhage, infarction
Varicocele: infection

PAINLESS SWELLING

Hernias
Hydrocele
Testicular masses
Lymphedema
Post-surgical scrotal wall edema
Testicular tumors

AGE FACTOR
Can occur in any age
group !
Neonates: extravaginal
torsion
Childhood and preadolescene:
intravaginal testicular torsion,
appendiceal testis torsion
Epididymitis in the sexually
active patient

TESTICULAR TORSION

Acute scrotal swelling in

children indicates torsion
of the testes until proven
otherwise.

Predisposition
The bell clapper
deformity, results
in a transverse as
opposed to
longitudinal lie of
the affected
testes.
This congenital
abnormality is
present in
approximately
12% of human
male

Bell clapper deformity and testicular

torsion

Extravaginal torsion
In neonates, the testicle frequently has not yet
descended into the scrotum, after which it
becomes attached within the tunica vaginalis.

This increased mobility of the testicle

predisposes it to torsion (extravaginal testicular
torsion).