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Keperawatan UNEJ
1. Key aspects of GU trauma in an
anatomical approach:
• External Genitalia
• Urethral Injury
• Bladder Injury
• Ureteral Injury
• Renal Injury
 80% of GU trauma is BLUNT trauma
 Very rarely is life threatening, so take a step
back and move through your systems
anatomically
 Assessing for concomitant pelvic fracture is
one of the most important points
Trauma Ginjal
 Sering
 8-10% trauma tumpul / tajam abdomen
 Separuh dari kejadian trauma urogenital
 Di proteksi :
* Otot-otot lumbal
* Iga
* Vertebrae
◦ Derajat trauma
◦ Keterlibatan trauma organ lain
◦ Fasilitas penanggulangan trauma
 Buli buli normal dapat menampung 350 – 450
mL urine
 Drainase kendung kemih bermuara ke vena
iliaca interna
 Tabung yang menyalurkan urine ke luar dari
buli-buli
 Secara anatomis uretra dibagi menjadi 2
bagian :
◦ Uretra posterior dan
◦ Uretra anterior
Trauma tumpul -> penyebab trauma
Langsung, tidak langsung

Trauma tumpul langsung

 KLL
 Olah raga
 Kecelakaan kerja
 Perkelahian
Trauma tumpul tidak langsung

* Jatuh dari ketinggian

* KLL
 menyebabkan pergerakan ginjal
tiba-tiba dlm rongga retro
peritonium  Avulsi pedikel ginjal
Robekan tunika intima
Bisa juga oleh trauma iatrogenik
 Pemasangan kateter di atas ureter
 Pengambilan biopsi ginjal
 Infeksi tidak langsung

Klasifikasi
* Ada beberapa macam
* Ditentukan oleh luas dan
penatalaksanaan
Cedera Ginjal
* Minor
* Mayor
* Vaskuler

Cedera Minor
 90% trauma ginjal
 Kontusio ginjal
 Laserasi parenkim superficial
 Cedera Mayor
 Laserasi korteks, medula tanpa
ekstravasasi
 Laserasi korteks, medula dengan
ekstravasasi

Cedera Vaskuler
 Avulsi
 Trombosis
 90% blunt trauma, 10% penetrating

 Again, relax. ‘Something else will kill them’

(less than 0.1% of trauma death)
Dibagi 5 derajat
Derajat 1
 Kontusio ginjal /subkapsularhematom
 Tidak meluas
 Hematuria dengan normal imaging
Derajat 2
 Hematom perineal
 Tdk meluas ke retroperitonium
 Laserasi superficial ( < 1cm )
 Tdk melibatkan collecting systim

Derajat 3
 Renal laserasi ( > 2cm )
 Sub capsular hematom
 Perinephric hematom
 Tdk melibatkan collecting systim
Derajat 4
 Laserasi yang meluas ke collecting
systim
 Extravasasi

 Trauma vasculer  segmental infark

Derajat 5
 Shattered kidney
 Devaskularisasi / oklusi / trombosis
arteri / vena utama
 Laserasi komplit
 Extravasasi
 UPJ avulsi
 Foto polos abdomen
 IVP ( Intra Vena Pyelografi )
 USG ( Ultra Sonographi )
 CT Scan abdomen / Whole abdomen
 uretrocistografi
CT Scan
 Pemeriksaan yang sensitif dan spesifik
 Menentukan derajat trauma
 Tidak invasif
 Dpt mengevaluasi organ lain
( hepar , lien , aorta )
kontras non kontras

Angiografi
 Invasif
 Delayed renal bleeding-pseudo-
aneurisma
 Poor correlation with degree of injury
 Microscopic hematuria on its own is not a
concern. Repeat urinalysis in 3 weeks
 You should image if the following:
 Microscopic hematuria with shock
 GROSS hematuria
 Rapid deceleration without hematuria or shock
(rare, but important)
 Penetrating trauma in the region
 CT with IV contrast is 90-100% SENS
 Remember, FAST ultrasound is not good for
solid organ injury, do not use it in this setting
 Formal ultrasound not as sensitive as CT
IVP normal
USG ginjal normal
CT scan ginjal normal
Gambar 1. Kidney trauma. Absent nephrogram. Abdominal radiograph after
intravenous contrast administration in a patient with hypotension after a
motor vehicle collision shows absent right nephrogram
Gambar 2. Kidney trauma. Grade 3 renal laceration on
abdominal radiograph. Abdominal radiograph after
intravenous contrast administration shows very
diminished left nephrogram and no urinary contrast
extravasation
Gambar 3. Kidney trauma. Grade 5 renal injury. Shattered kidney with renal
vein thrombosis (incomplete). Abdominal radiograph after intravenous
contrast administration shows absent right nephrogram
Gambar 4 Kidney trauma. Grade 1 renal injury, contusion. Image from a
contrast-enhanced CT scan of the abdomen in a patient with hematuria after a
motor vehicle collision shows ill-defined area of hypoenhancement in the
medial right kidney.
Gambar. 5. Kidney trauma. Grade 1 renal injury, subcapsular
hematoma. CT scan of the abdomen with intravenous contrast in a
patient after a motor vehicle collision shows crescentic high-density
fluid collection around the left kidney. Note the well-defined outer
margin
Gambar 6. Kidney trauma. Grade 1 renal injury, subcapsular hematoma. CT
scan of the abdomen with intravenous contrast in a patient after a motor
vehicle collision; shows crescentic high-density fluid collection around the
left kidney. Note the well-defined outer margin and the mild deformity of the
renal parenchyma
Derajat II dan III

Gambar 6. Kidney trauma. Grade 2 renal injury, subcapsular and

perinephric hematomas. Contrast-enhanced CT scan of the abdomen
on a patient with hematuria after a motor vehicle collision shows an
ill-defined fluid collection in the left perinephric space. There is also a
subcapsular hematoma with deformity of the renal parenchyma
Gambar 7 Kidney trauma. Grade 2 renal injury, perinephric
hematoma. Contrast-enhanced CT scan of the abdomen on a
patient with hematuria after a motor vehicle collision shows an
ill-defined fluid collection in the left perinephric space
Gambar 8. Kidney trauma. Grade 3 renal laceration with normal one-shot
intravenous pyelogram. CT scan through the kidneys after intravenous
contrast on the same patient as in Image 1 shows renal laceration and
perinephric hematoma.
Gambar 9 Kidney trauma. Grade 2 renal laceration. Contrast-enhanced CT
scan of the abdomen after a motor vehicle collision shows a superficial
(less than 1 cm deep) renal parenchymal defect with a large perinephric
hematoma
Gambar 10. Kidney trauma. Grade 2 renal laceration. Delayed image
shows no urinary contrast extravasation. Contrast-enhanced CT scan
of the abdomen after a motor vehicle collision shows a superficial (<1
cm deep) renal parenchymal defect with a large perinephric hematoma
Gambar 11. Kidney trauma. Grade 3 renal laceration. CT scan of the
abdomen after intravenous contrast administration shows irregular
nonenhancing renal parenchymal defect with extension greater than 1 cm
deep to near the renal pelvis. no urinary contrast extravasation
Gambar 12. Kidney trauma. Grade 3 renal laceration. CT scan of the
abdomen after intravenous contrast administration shows irregular
nonenhancing renal parenchymal defect with extension greater than 1 cm
deep to near the renal pelvis. This delayed image showed no urinary
contrast extravasation.
Derajat IV

Gambar13 Kidney trauma. Grade 4-5 renal injury. Lacerations

extending to the collecting system. Contrast-enhanced CT scan of
the abdomen in a patient with hematuria after a motor vehicle
collision shows deep lacerations extending into the collecting
system of the right kidney. Extension into the collecting system is
confirmed by urinary contrast extravasation on delayed image
through the kidney in excretory phase
Gamba14. Kidney trauma. Grade 4-5 renal injury. Lacerations extending to the
collecting system. Contrast-enhanced CT scan of the abdomen in a patient with
hematuria after a motor vehicle collision shows deep lacerations extending into the
collecting system of the right kidney (Image 22). Extension into the collecting
system is confirmed by urinary contrast extravasation on this delayed image
through the kidney in excretory phase
Gambar 15. Kidney trauma. Grade 4 renal injury segmental infarction.
Contrast-enhanced CT scan of the upper abdomen shows a segmental area
of nonenhancement in the upper medial left kidney without associated renal
laceration
Gambar 16. Kidney trauma. Grade 4 renal injury segmental infarction.
Contrast-enhanced CT scan of the upper abdomen in another patient after a
motor vehicle collision shows a segmental area of nonenhancement in the
upper medial left kidney without associated renal laceration
Derajat V

Gambar 17. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-
enhanced CT scan of the abdomen in a patient with hematuria and hypotension
after a motor vehicle collision shows transection of the right kidney with a large
hematoma around and between the 2 halves of the kidney. The 2 halves are both
perfused because there were 2 renal arteries Delayed images show urinary
contrast extravasation
Gambar 18. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-
enhanced CT scan of the abdomen in a patient with hematuria and hypotension
after a motor vehicle collision shows transection of the right kidney with a large
hematoma around and between the 2 halves of the kidney. The 2 halves are both
perfused because there were 2 renal arteries. Delayed images show urinary
contrast extravasation
Gambar 19 Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-enhanced
CT scan of the abdomen in a patient with hematuria and hypotension after a motor
vehicle collision shows transection of the right kidney with a large hematoma around
and between the 2 halves of the kidney. The 2 halves are both perfused because there
were 2 renal arteries Delayed images show urinary contrast extravasation
Gambar 20. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-
enhanced CT scan of the abdomen in a patient with hematuria and
hypotension after a motor vehicle collision shows transection of the right
kidney with a large hematoma around and between the 2 halves of the
kidney. The 2 halves are both perfused because there were 2 renal arteries.
Delayed images show urinary contrast extravasation
Gambar 21. Kidney trauma. Grade 5 renal injury. Shattered kidney with renal vein
thrombosis (incomplete). CT scan of the abdomen with intravenous contrast
administration shattered right kidney and renal vein thrombus extending slightly
into the inferior vena cava
Gambar 22. Kidney trauma. Normal ultrasound with grade 5 renal injury.
Ultrasound gray-scale image of a patient involved in a motor vehicle
collision shows what appears to be a normal right kidney
Gambar 23 Kidney trauma. Grade 5 renal injury. Color Doppler ultrasound of
same motor vehicle collision patient as in Image 4 shows no blood flow within
the right kidney.
 4.Arteriografy

Gambar 24. Kidney trauma. Active vascular contrast extravasation.

Catheter angiography during arterial phase on the same patient as in Image
40 shows a small pseudoaneurysm at the lower pole
gambar 25. Kidney trauma. Active vascular contrast
extravasation. Catheter angiography during nephrographic
phase in the same patient as in Image 41 shows a small
pseudoaneurysm at the lower pole
gambar 26. Kidney trauma. Active vascular contrast extravasation.
Pseudoaneurysm at the lower pole in the same patient as in Image 42
was embolized by using a coil.
 If no ‘rapid’ deceleration mechanism (how
rapid?) and no gross hematuria, can d/c
home with f/u urinalysis
 Grade I and II injuries  non-operative. ‘Bed
rest’ until gross hematuria clears.
 Grade III and up  decision point for urology
Ureter  jalur transportasi dari ginjal ke buli-
buli
Trauma ureter  mengganggu fungsi ginjal

Trauma mengenai pinggang, punggung 

resiko mengenai ureter
ok * Lokasi terlindungi
* Ukuran kecil
* Mobilitas / fleksibel
 trauma ureter  jarang
Etiologi

 Trauma Luar
a. Tajam
b. Tumpul
 Iatrogenik 
a. Ginekologis
b. Pembedahan rektum
c. Endoskopi
 IVP ( Intra Vena Pyelografi )
 RPG ( Retro Grade Pyelografi )
 USG ( Ultra Sono Grafi )
 CT Scan Abdomen
Disebabkan : Trauma
- Tumpul
- Tajam
- Iatrogenik
 Didaerah pelvis / abdomen bawah/
perineum
60-85 %  trauma tumpul
15-40 %  trauma tajam
Ruptur vesika urinaria : ke
 Ekstra peritoneum
 Intra peritoneum
 Keduanya

Kontusio Vesika Urinaria

 Sobekan sebagian mkosa vesika urinaria
 Dinding  memar  hematom

Pemeriksaan :
 Sistografi
 CT scan abdomen - pelvis
Kontusio Vesika Urinaria
 Normal
 Tear Drop
 Mudah sembuh

Ruptur Vesika Urinaria

Terlihat ekstravasasi kontras
- ekstra peritonial
- intra peritonial
Dengan CT Scan  dpt juga mengevaluasi
organ lain
 Contusions – conservative
 Intra-peritoneal – operative repair
 Extra-peritoneal – many are now managed
non-operatively with an indwelling foley
catheter, will usually heal spontaneously.
 Trauma here is rare in females
 In males, injury is often obvious
 Look for swelling, ecchymoses, deformity
 Testicular torsion can occur with trauma
 Testicular rupture occurs in 50% of patients
with a direct blow to a testicle, have a low
threshold to ultrasound
 Penile Fracture
◦ Usually a ‘sexual accident’
◦ Immediate pain, often hear
a ‘popping sound’, early
swelling
◦ Is a rupture of the tunica
albuginea surrounding the
corpora cavernosa
◦ 20% association with
urethral injury
◦ Requires operative repair
 ‘Eggplant Deformity’
 Uretra laki-laki lebih panjang dari wanita
 Dihubungkan dgn trauma daerah pelvis yg
cukup berat

Etiologi
 Trauma tumpul
 Trauma tembus
 Iatrogenik
Anatomi
 Uretra posterior 
* uretra prostatika
* uretra membranosa
 Uretra anterior 
3 segmen : * pars bulosa
* pars pendulans
* pars glanularis
sampai ke meatus uretra externa
 Again, rare in females
 In males, divided into ‘anterior’ and
‘posterior’ urethra, divided by urogenital
diaphragm
 In males, 25% of all pelvic fractures have
urethral injury (vs only 5% in females), more
commonly the posterior division
 Gross hematuria and pelvic fracture =
posterior urethral injury until proven
otherwise
 The big 4 clues to urethral injury:
◦ Blood at meatus
◦ Gross hematuria
◦ Inability to void
◦ Ecchymoses, swelling of penis
Diagnosa

 Berdasarkan gejala klinik

 Pemeriksaan penunjang  radiologi
RUG ( Retrograde Uretrografi )

Klasifikasi trauma uretra  Hasil RUG

Klasifikasi  Gold Man yaitu :
“Berdasarkan Kerusakan Anatomi “
Ada 5 tipe

Tipe 1

. Ruptur ligamentum puboprostatika

. Prostate bergeser ke posterior
. Uretra tetap intak
. Tdk ada extra vasasi zat kontras
 Tipe 2

 Trauma uretra posterior & diafragma

urogenital
 Terlihat extravasasi kontras dlm pelvis
extra peritoneal
 Zat kontras tdk ada dalam perineum
 Tipe 3

 Tipe yang sering

 Kerusakan meluas
 Terlihat extravasasi kontras pada rongga
pelvis extra peritoneal dan perineum
 Tipe 4

 Terjadi dekat buli-buli meluas ke uretra

proximal
 Extravasasi kontras pada pelvis extra
peritoneal & sekitar proximal uretra
 Dapat merusak sfingter uretra interna
 Tipe 5

 Terjadi di uretra anterior

 Terlihat extravasasi kontras
bagian inferior diafragma
urogenital
 If no concern for injury, or retrograde
urethrogram normal, put a foley in.

 If a partial urethral tear, textbooks say

one careful attempt to pass a 12- or 14-
Fr Foley can be undertaken. Most
urologists disagree with this, and wish to
be consulted.

 If a complete tear – suprapubic catheter,

urology consult for operative repair.
95