Genitourinary Trauma Hematuria

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Genitourinary Trauma Hematuria Powered By Docstoc
					Genitourinary Trauma




    François Dufresne
 McGill Emergency Medicine
    February 13th 2002
         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
  – Kidney
  – Ureters
• Lower tract
  – Bladder
  – Urethra
• External genitalia
         Urethral Trauma
• Almost exclusively in male
• Significant morbidity
  – Stricture         Andrich DE et al. The nature of urethral
                      injury in cases of pelvic fracture
  – Incontinence      urethral trauma. Journal of Urology.
                      165(5):1492-5, 2001 May.
  – Impotence
• 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 didn’t 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: Smith’s 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
    Management…by 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/C’ed , 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%
           Kidney Injury
•   Retroperitoneal organ
•   Cushoned by perinephric fat
•   Gerota’s fascia
•   Along T10 - L4
•   Ribs 10-12
•   Fixed only through pedicle.
•   1.2L of blood / min
         Kidney Injury…
• Blunt trauma: 80-90%
• Rapid deceleration / Direct blow
• MUST be suspected if
  – Trauma to back / flank / lower thorax /
    upper abdomen
  – Flank pain / low rib #
  – Hematuria / Ecchymosis over the flanks
  – Sudden decelaration / Fall from height.
  – Lumbar transverse process #
    Lumbar Transverse Process
           Fractures
•   Prospective study (1994-1999)
•   Lumbar spine #
•   191 patients
•   Transverse # in 29%
•   Abdominal organ injuries 47% vs. 6%
                organ injuries 47% vs. 6%
•   Kidney: 1/3
                     Miller et al. Lumbar transverse process
•   Liver: 1/3       fractures: a sentinel marker of
                     abdominal organ injuries. Injury.
•   Spleen: 1/4      31:773; 2000.
   Classification of Injury
• 5 Classes of Renal Injury :

           Organ Injury Scaling
                    Committee
        Moore et al. Organ Injury Scaling: Sleen,
        Liver and Kidney, The Journal of Trauma,
        29: 1664; 1989.
Grade I
    • Contusion
      – Hematuria
      – Urologic studies N


    • Hematoma
      – Subcapsular
      – Non expanding
      – Parenchyma N
Grade II
    • Hematoma
      – Perirenal
      – Nonexpanding


    • Laceration
      – < 1.0 cm
      – Renal cortex only
      – No urinary
        extravasation
Grade III

    • Laceration
      –   > 1.0 cm
      –   Renal cortex only
      –   No urinary extravasation
      –   Intact collecting system
Grade IV
    • Laceration
      – Renal cortex
      – Renal medulla
      – Collecting system


    • Vascular
      – Main renal artery/vein
        injury with contained
        hemorrage.
                    Grade V
                                • Completely shattered
                                  kidney.

                                • Avulsion of renal
                                  hilum (pedicule)
                                  which devascularizes
                                  kidney.



Kennon et al. Radiographic assessment of renal trauma: our 15-year
experience. The Journal of Trauma, 154: 353-355; August 1995.
Pedicule Injury
 Organ Injury Severity Scale
• Validated lately: Journal of Trauma, 2001
• Predicts the need for surgery
• Need for surgery ; nephrectomy rates:
  –   Grade I: 0 ; 0%
  –   Grade II: 15 ; 0%    Santucci et al. Validation of the
                           American Association for the
  –   Grade III: 76 ; 3%   Surgery of Trauma Organ Injury
                           Severity Scale for the Kidney. J
  –   Grade IV: 78 ; 9%    Trauma; 50:195-200; 2001.

  –   Grade V: 93 ; 86%
              Investigation
• IVP
  –   Used to be intial exam of choice.
  –   Very poor sensitivity for penetrating injury
  –   Limitation in staging renal injuries
  –   Not 1st choice anymore. Only if pt unstable.
• Contrast CT
  – Study of choice if stable
  – More sensitive and specific for staging
  – Detects other abdominal injuries
          Management
• Penetrating trauma:
  – Imaging for ALL (9%: NO hematuria)
• Blunt trauma Imaging:
  – Gross hematuria
  – Microscopic hematuria (5 RBC/hpf) +
    shock (BPs90)
  – Any child with > 50 RBC / hpf
             Management…
• Absolute indication for Surgery:
   –   Uncontrollable renal hemorrage
   –   Multiply lacerated, shattered kidney
                                            Grade V
   –   Main renal vessels avulsed
   –   Penetrating injuries usually
• Grade I-II
   – conservative
• Grade III-IV
   – Conservative if stable hemodynamically vs. surgery
• Grade V
   – Surgery
        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
• Don’t 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

				
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