Genitourinary Trauma

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%

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

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?

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?

Introduction
GU Trauma overlooked
10-20% of all injured patients
Long term morbidity
Impotence
Incontinence

Life-threatening injuries first

Plan
Urethral Injury
Bladder Injury
Hematuria in Trauma
Kidney Injury

Definitions
Upper tract
Kydney
Ureters

Lower tract
Bladder
Urethra

External genitalia

Urethral Trauma
Almost exclusively in male
Significant morbidity
Stricture
Incontinence
Impotence

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.

If unrecognized:
Converting partial to complete tear
Inaccurate assessment of U/O

Foley catheter implication

Anatomy
Bladder

Symphysis

Prostatic
Membranous
Bulbous

Pendulous

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

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.

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 didnt change management

Porter, J.M. et al. Digital rectal examination for trauma: does

every patient need one? Am Surg 67(5):438, May 2001.

Posterior Urethral rupture

From McAnich JW. In Tanagho EA, McAninch JW, editors: Smiths general
urology, ed 14, Norwalk, Conn, 1995, Appleton & Lange.

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.

Retrograde Urethrogram

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

Partial Tear

Complete Tear

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

Managementby Urology

Controversial
Complete VS Partial
Posterior VS Anterior
Foley X 3-14 days
Suprapubic catheters
Surgical approach / Endoscopy
Delayed repair usually

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

Prostatic
Membranous
Bulbous

Pendulous

Anterior Urethra

More common than posterior

Direct trauma
Usually NO pelvic #
Blood at meatus
Unable to micturate
Penile/Scrotal/Perineal
Contusion
Hematoma
Fluid collection

Sleeve Hematoma

Butterfly Hematoma

Anterior Urethral Rupture

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

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

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%)

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 #
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.

100%: Gross hematuria

85% Pelvic #

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.

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.

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.

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

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.

Hardeman et al.
365 (52 %) had microhematuria only
174 D/Ced , 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.

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.

Gross Hematuria : False +

Alphamethyldopa
Ibuprofen
Levodopa
Metronidazole
Nitrofurantoin
Phenazopyridine
Phenolphtalein-containing laxatives
Rifampin
Beets/berries

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

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

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.

Daum et al.
Dipstick (Sensitivity)
Microscopy

Trace

1+

2+

3+

5 RBC/hpf

100% 92%

84%

62%

10 RBC/hpf

100% 96%

92%

81%

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.

Chandhoke et al.
Dipstick (Sensitivity)
Microscopy

Trace

1+

2+

3+

5 RBC/hpf

98%

89%

76%

51%

10 RBC/hpf

98%

92%

82%

59%

Back to Jeremy
First urine: Dipstick +++ (15 RBC/hpf)
Pelvic x-ray: Straddle #

Kozin, Berlet. Handbook of Common Orthopaedic Fractures, 4th ed., 2000.

Jeremy
First urine: Dipstick +++ (15 RBC/hpf)
Pelvic x-ray: Straddle #
Keypoints
BP: 85/50 on scene
Microhematuria
Pelvic #

NO FOLEY

Jeremy

Urology consulted
Retrograde urethrogram: N
CT cystogram: N
Contrast CT to look for renal injury:
Grade II renal injury.

Conclusion
No Foley if you suspect urethral trauma
Gross hematuria OR microhematuria + Shock =
GU Trauma.
Pelvic # + Microhematuria GU investigation
Dont remove Foley if you suspect a partial tear
of urethra afterwards.
Microhematuria alone : No imaging but F/U.
In peds: Imaging for ALL hematuria.

The End

Trauma Ginjal

dr. Jufriady ismy Sp.U

Sub Bagian Urologi-SMF Bedah FK Unsyia

BPK RSUZA Banda aceh

Anatomi
Ginjal
Ginjal terletak dibagian belakang
abdomen atas, dibelakang peritonium
(retroperitoneal)

Ukur
an
Ginj
al

Bagian-bagian Ginjal

Nefron

Nefro
n
adalah
Unit

Tahap Pembentukan Urin

Trauma Ginjal
Trauma Ginjal :
Laporan :
1 5% dari semua trauma (EAU
Guidelines)
10 15% dari seluruh trauma
abdomen
umur : 20 40 thn
Gender : + 1 : 3
kiri : kanan : sama

Trauma Ginjal

Mekanisme injury

Trauma tumpul

Trauma tumpul yang merusak ginjal sering

menyebabkan fraktur iga bawah dan prosesus
transverses vertebra lumbal

Trauma Tembak

American Association for

the surgery of Trauma
(AAST)

Diagnosis

Pemeriksaan Fisik
Tanda vital
Pemeriksaan berurutan dan
sistematis politrauma
Indikasi kecurigaan trauma ginjal :
- Hematuria
- Abdominal
distension
- Flank pain
- Abdominal
mass
- Flank ecchymoses
Abdominal tenderness
- Ileus paralytic
- Fractured ribs

Laboratoriu
m

Pemeriksaan
Penunjang

Radiologi

USG
Keuntungan
(1) non-invasif,
(2) Tidak ada paparan radiasi
(3) dapat membantu
mengetahui keadaan
anatomi setelah trauma

USG
Kekurangan:
memerlukan pengalaman
sonografer yang terlatih,
Tidak dapat secara pasti
menentukan luas dan
kedalaman laserasi ginjal

IVP
TUJUAN :
untuk mendapatkan perkiraan
fungsional dan anatomi kedua ginjal
dan ureter,
sangat dibutuhkan pada bagian
emergensi atau ruangan operasi
YANG DIPERHATIKAN PADA I.V.P :
Bentuk dan kontur
Ekspresi kontras
Bentuk dan distribusi kontras
Ekstravasasi kontras

Informasi I.V.P yang

signifikan
1. NON-FUNCTION/ NON VISUALISASI
- trauma pedikel
avulsi vaskuler
trombosis
- ruptur ginjal yang hebat
2. EXTRAVASASI
- trauma yang mengenai kapsul,
parenkhim, kolekting sistem.
3. TANDA LAIN
- Eskresi yang terlambat
- Pengisian kaliks yang tidak komplit
- Distorsi kaliks
- Kaburnya bayangan ginjal

PENYEBAB UMUM NONVISUALIZATION

ONE SHOT I.V.P

Pasien yang tidak stabil perlu
tindakan operasi segera
Tidak dimungkinkan pemeriksaan
CT-Scan
harus dilakukan One Shot IVP
Tehnik : bolus injeksi IV 2cc/KgBB
pengambilan film setelah 10
menit
Safe, efisient, mempunyai kualitas

Pemeriksaan terbaik untuk trauma ginjal

adalah CT-Scan
CT-Scan lebih sensitif dan lebih spesifik
daripada :
- I.V.P
- USG
- Angiografi
Penelitian retrospektif oleh Qin,dkk pada
trauma ginjal dengan 298 penderita,
akurasinya :
- CT-Scan 95,6%
- Double dose IVP 90,9%
- USG 78,8%

Keuntungan:
Dapat menemukan hematoma
perirenal,
menilai kelangsungan hidup
fragmen ginjal,
mendeteksi kelainan ginjal yang
sudah ada
Kekurangan:
Sulit didapat
memerlukan waktu yang lama,
Biaya mahal,

Penatalaksanaan
PRINSIP
Menyelamatkan / mempertahankan
fungsi ginjal
Mengurangi morbiditas ginjal

KONSERVATIF

Ditujukan untuk trauma minor

Bedrest total
Antibiotika Broad spectrum
Penggantian cairan / darah
Observasi ketat :
- tanda vital
- status lokalis
Serial urine
Mobilisasi, bila :
- keluhan (-)
- gross hematuri (-)

Indikasi Eksplorasi
Absolut
Adanya perdarahan ginjal
yang persisten, yang ditandai
oleh:
1. hematom retroperitoneal
yang meluas dan berdenyut
2. Adanya avulsi vasa renalis
utama pada ct-scan ataupun
arteriografi

Indikasi Eksplorasi
Relatif
Jaringan nonviable
Ekstravasasi urin
Incomplete staging
Trombosis arteri
Trauma tembus

Indikasi untuk
manajemen operasi
1. Ketidakstabilan hemodinamik
2. Eksplorasi untuk cedera terkait
3. Hematoma perirenal yang meluas
dan berdenyut
4. Cedera ginjal grade 5
5. Insidental ditemukannya patologi
ginjal yang sudah ada sebelumnya
yang memerlukan terapi bedah

TRAUMA TUMPUL
ABILITAS HEMODINA
STABIL
TIDAK
STAB
LAPAROTOMI
EK
SIKROS.HEMATURI
HEMATURI
- ONE SHOT
NAL IMAGING
RADE
5 3-4 1-2
GRADE
GRADE
OBSERVASI
TRAUMA DESELERASI CEPAT /
TRAUMA BERAT

IVP NORMAL

IVP
ABNORMAL

RETROPERITONEAL
HEMATOMA
PULSATIF (-)

TRAUMA PENYERTA (+)

DIBUTUHKAN
LAPAROTOMI

PULSATIF (+)

TRAUMA PENYERTA (-)

OBSERVASI :
BEDREST
SERIAL Hct
ANTIBIOTIKA

92

TRAUMA TEMBUS
ABILITAS HEMODINAM
TIDAK STAB
STABIL
- LAPAROTOMI
EK
NAL IMAGING
- ONE SHOT
RADE
GRADE
GRADE
3 4-5 1-2
STABIL
PULSATIF
OBSERVASI
IVP NORMAL

IVP
ABNORMAL

RETROPERITONEAL
HEMATOMA

TRAUMA
PENYERTA (+)
DIBUTUHKAN
LAPAROTOMI

TRAUMA PENYERTA (-)

OBSERVASI :
BEDREST
SERIAL Hct
ANTIBIOTIKA

93

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