Genitourinary tract injury
| Genitourinary tract injury | |
|---|---|
| Specialty | Urology |
The kidney is the most commonly injured urinary tract organ.[1] Injuries occur commonly after automobile- or sports-related accidents.[1] A blunt force is involved in 80-85% of injuries to the kidney.[1] Major decelerations can result in major vascular injuries near the kidney's hilum.[1] Gunshots and knife wounds commonly are the cause of penetrating injuries.[1] Fractured ribs can result in penetrating injuries to the kidney.[1]
Injuries to the urethra occur most commonly in men after pelvic fractures or straddle-type falls.[1]
Presentation
Comorbidity
In 90% of bladder injuries there is a concurrent pelvic fractures.[1] Pelvic bone fragments penetrate and perforate the bladder.[1] Perforations can be either extraperitoneal or intraperitoneal.[1] Intraperitoneal perforations allow for urine to enter the peritoneal cavity. Symptoms typically develop immediately if the urine is infected.[1] Otherwise sterile urine may take days to cause symptoms.[1]
Diagnosis
Hematuria in Patients Presenting After Trauma
Blood in the urine after abdominal trauma suggests a urinary tract injury.[1] Renal injuries are suggested by lower rib fractures.[1] Bladder and urethral injuries are suggested by pelvic fractures.[1]
Foley Catheter
The urethral meatus should be examined after trauma.[1] Blood at the urethral meatus precludes insertion of a foley catheter into the bladder.[1] Erroneously placing a foley in this situation can result in infections of periprostatic and perivesical hematomas or conversion of a partial transection to a complete urethral transections.[1] Blood at the urethral meatus suggests an injury to the urethra.[1] Otherwise a foley catheter can be placed into the bladder and hematuria can be assessed for.[1]
Abdominal Imaging
Hemodynamically stable individuals should undergo further radiographic assessment.[1] Abdominal computed tomography (CT) with contrast can detect retroperitoneal hematomas, renal lacerations, urinary extravasation, and renal arterial and venous injuries.[1] A repeat scan ten minutes after the first is recommended.[1]
Retrograde Urethrography (RUG)
The purpose of this study is to identify and characterize injuries to the urethra.[1] The tip of a small (12F) foley catheter is placed in the urethral meatus.[1] The catheter remains fixed after 3 mL of water are instilled into the foley catheter's balloon.[1] Radiographic films are taken as 20 mL of water-soluble contrast material are injected[1] This outlines the urethra from the urethral meatus to the bladder neck.[1] If injuries exist, the location can be determined.[1]
Retrograde Cystography
The purpose of this study is to identify bladder perforations.[1] The bladder needs to be adequately distended with contrast medium.[1] 300 mL or more are generally recommended.[1] The study has two films. One film is taken when the bladder is adequately distended and filled with contrast.[1] The next film is taken after the bladder is emptied without the assistance of a foley catheter.[1]
Angiography
Helpful in identifying injuries to the kidney's parenchyma and vasculature.[1]
Management
Genitourinary Trauma
Urethral Injuries
Management depends on what part of the urethra was injured and to what extent.[1] The two broad anatomical separations are the posterior and anterior urethra.[1] The posterior urethra includes the prostatic and membranous urethra.[1] The anterior urethra includes the bulbous and pendulous portion.[1]
Posterior Urethra Injuries
The membranous urethra can be separated from the prostate's apex after blunt trauma.[1] The urethra should not be catheterized.[1] Initial management should be the creation of a suprapubic cystostomy for urine drainage.[1] The bladder should be opened in the midline so to facilitate inspection of bladder lacerations.[1] Perforations can be closed with absorbable sutures.[1] The suprapubic cystostomy remains in place for three months.[1] Incomplete urethral disruptions heal spontaneously and the suprapubic cystostomy can be removed after three weeks for these injuries.[1] Before removing a cystostomy, a voiding cystourethrography should demonstrate no urine extravasation.[1] Delayed urethral reconstruction may be performed within 3 months.[1] This typically entails a direct excision of the now strictured area and anastomosis of the bulbous urethra to the prostate's apex.[1] A urethral catheter and suprapubic cystostomy should be left in place.[1] These are removed within a month.[1]