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- Approximately 3-10% of all trauma patients have injuries involving the genitourinary system (GU).
Renal Injuries
- Of all GU injuries, renal injuries comprise the vast majority and are usually the result of blunt force trauma such as motor vehicle accidents.
- Renal contusions are the vast majority (90%) of renal injuries.
- Renal contusions maintain an intact renal capsule and range from sub capsular hematomas, small lacerations, to minimal parenchyma ecchymosis.
- An intravenous pyelogram would be normal in such an injury and these injuries are typically minor.
- Renal lacerations make up approximately 5% of renal injuries.
- Renal lacerations are divided into two categories: minor and major.
- Minor renal lacerations involve disruption of the renal capsule while sparing injury to the corticomedullary or collecting system.
- Major renal lacerations involve disruption of the renal capsule including injury to the corticomedullary or collecting system.
- Renal pedicle injuries account for 2% of renal injuries.
- Renal pedicle injuries involve damage to the main renal vessels or their branches.
- Renal pelvis rupture is rare and involves the collecting system resulting in urinary extravasation into the retroperitoneal space.
- Renal rupture (“shattered kidney”) accounts for 1% of renal injuries.
- These patients often become hemodynamically unstable due to uncontrolled hemorrhage, pediatric trauma.
Radiographic Studies
- The imaging modality of choice in patients with suspected renal injuries is an abdominal trauma/pelvis CT scan.
For most injuries, the CT scan has a higher sensitivity and specificity than intravenous pyelogram and carries the added benefit of being able to identify other intra-abdominal injuries.
- Common indications for scanning a patient include: penetrating injuries, gross hematuria, microscopic hematuria with hemodynamic instability, hemodynamic instability or persistent hematuria.
- Microscopic hematuria alone is not an indication for a CT scan since the study is often low yield in this setting.
- Intravenous pyelogram is still the study of choice for suspected ureteral injuries and is also useful to diagnose rupture of the renal pelvis.
Ureteral Injuries
- Ureteral injuries are uncommon and comprise approximately 6% of GU injuries. These often occur due to penetrating injuries and, in fact, are often iatrogenic, occurring
Table Management guidelines for renal injuries*
| Grade |
Criteria |
Comments |
| GRADE I |
Renal contusion
Microscopic or gross hematuria
Subcapsular hematoma
(nonexpanding)
No parenchymal laceration |
No intervention is required
Supportive care
Conservative management (bedrest,
hydration, serial hematocrits, serial
urinalyses, monitoring)
70% of renal injuries |
| Grade II |
Parenchymal laceration involving
the superficial cortex (<1 cm deep)
No expanding hematoma
No urinary extravasation |
No intervention is required
(usually have spontaneous resolution)
Supportive care
Conservative management
20% of renal injuries |
| Grade III |
Parenchymal laceration >1 cm deep
No involvement of the collecting
system
No urinary extravasation |
Require admission
+/- operative management** |
| Grade IV |
Parenchymal laceration extending
to the collecting system
Urinary extravasation present
Main renal vascular injury |
Require admission
+/- operative management** |
| Grade V |
Pedicle/hilum avulsion
Shattered kidney |
Surgical intervention often requiring
nephrectomy to control
life-threatening hemorrhage |
Bladder Injuries
- Approximately 80% of bladder injuries occur with pelvic fractures as a result of blunt trauma.
Bladder Contusions
- Nearly 100% of bladder contusions (“bladder bruise”) are associated with gross hematuria without disruption of the bladder wall or urinary extravasation.
- These lesions typically require no operative management and may include catheter drainage for 7-10 days.
Bladder Rupture
- The classic triad for bladder rupture includes: inability to void, gross hematuria and abdominal pain/tenderness.
- There are two different types of bladder rupture: intraperitoneal (IP) and extraperitoneal (EP).
- IP bladder rupture results in urinary extravasation into the peritoneal cavity after injury to the dome of the bladder; this can often lead to peritonitis.
- This type of injury often occurs in patients experiencing trauma with a full bladder.
- Surgical intervention is often required for this type of injury.
- EP bladder rupture is more common than IP and results in urinary extravasation after injury to the lateral wall or base of the bladder.
- For small lesions, no operative management is possible with 7-10 days of catheter drainage with antibiotic prophylaxis.
- Retrograde cystography or a CT cystogram is useful to evaluate bladder injuries.
Testicular Injuries
- Testicular injuries often occur as a result of penetrating trauma (gunshot or stab wound) or blunt injury (kick or direct blow).
- In injuries involving penetrating trauma, surgical exploration is often required.
- Clinical features resulting from blunt trauma include: ecchymosis, pain, testicular tenderness or a scrotal mass (hematocele).
- Testicular ultrasound is useful for identifying testicular rupture (75% specific), hematocele or other testicular lesions.
- Appropriate urologic consultation is required.
Penile Fracture
- Penile fractures are rare and often occur as a result of trauma to an erect penis.
The majority of cases occurs during sexual intercourse and are associated with urethral injuries in approximately 23% of cases.
- A retrograde urethrogram is useful for evaluating suspected urethral injury.
- Symptoms of penile fracture may include: immediate pain followed by flaccidity, swelling or angulation of the penis with deviation away from the injured side.
- The fracture occurs due to injury involving Buck’s fascia and the corpus cavernosum.
- Approximately 90% of penile fractures resolve spontaneously with conservative management (pain control and refraining from sexual activity).
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