Urogenital Trauma
Amit Sarnaik MD
Scottish Rite Pediatric Emergency
Department
Genitourinary trauma
• In multiple trauma patients, GU trauma is
second in frequency (#1 CNS)- 10%
• MOI: Blunt (90%) vs. Penetrating
– MVC: most common
– Falls, Sport related and direct blow
– Most common Injury is to the kidney – 47%
• Associated intra-peritoneal injuries
– Penetrating – 80% vs. Blunt
Pediatric considerations
• Renal injury more likely in children
– Larger proportion of kidney to abdominal size
– Retained fetal lobulations: Easier parenchymal
disruption
– Weaker abdominal muscles
– Less ossified thoracic cage
– Less developed perirenal fat and fascia
Renal trauma - Presentation
• Localized signs: flank tenderness, flank hematoma, or
palpable flank mass.
• Non specific: Abdominal tenderness, rigidity, paralytic ileus or
hypovolemic shock
• Gross hematuria is the hallmark of severe injury: absent in
50% of patients with vascular pedicle injuries and 30%
penetrating injuries
• Most common injuries
– Parenchymal contusions and hematomas (60-90%)
– Lacerations are less common (10%)
Classification of renal trauma
• Grade I : Contusion or subcapsular nonexpanding
hematoma
• Grade II : Nonexpanding hematoma confined to the
retroperitoneum or lac <1 cm
• Grade III : Lac >1 cm into the renal cortex without
collecting system rupture or urinary extravasation
• Grade IV : Lac extending into the collecting system or
renal vascular injuries with contained hemorrhage
• Grade V : Shattered kidneys or avulsions of renal
hilum with devascularized kidneys
Grade 1,2 and 3 renal injuries
Grade 4 and 5 injuries
Renal Trauma: Management
Evaluate GU system only after life threatening
conditions have been indentified
• A urinalysis should be obtained in all patients with
multisystem trauma or suspected isolated renal
injury
• Pediatric renal trauma patient – order a CXR,
Abdominal and Pelvis X-rays
Renal trauma: Hematuria and
Kidney injury
• Gross hematuria
• Microscopic hematuria with major
mechanisms or signs of renal injury
• Hematuria of > 20 RBC per hpf
• Microscopic hematuria with shock ( relied
upon in adult EM)
Imaging of renal trauma
• CT with contrast is preferred study at most
trauma centers - 98% sensitivity
– Detection of associated injuries
– 3-D views and no dependence on renal
vascularity
• Ultrasound – 70% sensitivity
– Not accepted for the staging of renal trauma
– Has been used for long term follow up
– Alternative modality for the evaluation of the
pregnant trauma patient
Imaging in renal trauma
• IVP : used only if CT is not readily available
– Provides rapid information about the overall
functional and anatomic integrity of both kidneys
– It can be obtained in the ED in an unstable patient
or in the OR prior to surgery
• IVP will only diagnose 5% contusions, 50%
lacs, 29% pedicle injuries
Blunt Uro-genital trauma: Diagnostic
evaluation
• Blunt and Unstable:
– Limited IVP
• Blunt & Stable, major renal injury, none lower
– CT scan
• Blunt and Stable, Findings of lower tract injury
– Cystourethrogram +/- upper tract evaluation
• Blunt and Stable, Minor renal injury
(Microscopic hematuria)
– No CT, serial UA, delayed imaging
Management of blunt renal trauma
Grades 1,2 and 3
• Strict bed rest, analgesia, prophylactic antibiotics.
• Limited activity on resolution of gross hematuria
Grades 4,5 – Management is controversial.
• Depends upon hemodynamic status, degree of
urinary extravasation, renal bleeding, associated
injuries.
• Many patients are being managed with serial
hematocrit, vital signs and broad spectrum
antibiotics
Complications from non operative
management of Grade 4 and 5 renal
trauma
Patients managed nonoperatively have a 50%
complication rate
• Persistent/recurrent hemorrhage
• Extravasation and urinoma formation
• Infection
• Infarction
• Segmental hydronephrosis
Penetrating Uro-genital trauma:
Diagnostic evaluation
• Penetrating and Unstable
– Limited IVP
• Penetrating & Stable, upper tract injury
suspected
– CT scan
• Penetrating & Stable, findings of lower tract
injury
– Cystourethrogram +/- upper tract evaluation
Management of Penetrating renal
trauma
Surgical
• Vascular injury
• Hemodynamic instability
• Urinary extravasation
Non surgical
• Hemodynamically stable + Isolated Low grade
• Delayed bleeding may occur in 24% with grade 3-4
Complications of renal trauma
Short Term
• Delayed hemorrhage
• Urinary extravasation
• Abscess formation
• Obstruction secondary to clot formation
Long Term
• HTN (<5%)
• Hydronephrosis
• Arteriovenous fistulas
• Renal intestinal fistula
• Stone formation
Ureteral Trauma
• Ureteral injuries are uncommon, <1% of all urologic
trauma
• Blunt trauma usually involves the UPJ
• Suspect ureter trauma if fracture of the transverse
process of lumbar vertebra
• Penetrating injuries along the ureter – 90%
association with other intra-abdominal injuries
• Stab wounds rarely cause ureteral injury, but 50% of
GSW to abdomen have injury to the ureter
Ureteral trauma: Diagnosis
• Diagnosis is difficult, >50% not diagnosed in
1st 24h
• PE may be unremarkable, urinalysis is
unreliable
• Delayed diagnosis may manifest as fever,
chills, lethargy, leukocytosis, pyuria,
bacteriuria, flank mass/pain, fistulas,
strictures
Ureteral Trauma
• CT and IVP has low sensitivity (33%)
• Retrograde pyelogram may be more reliable
Bladder Trauma
• Blunt trauma secondary to MVC is most
common cause
• 80% of injuries associated with pelvic fracture
• Mortality rate 40% with bladder rupture (from
assoc head injury)
Classification of bladder trauma
• Extraperitoneal: associated with pelvic
fractures.
• Intraperitoneal: caused by blunt trauma to
distended bladder.
• Combined: GSW.
Bladder trauma: Diagnosis
• Hematuria and dysuria typically seen at presentation
• >90% with bladder rupture have gross hematuria
• Diagnostic evaluation is indicated
– in patients who sustain pelvic or lower abdominal
trauma with gross hematuria
– inability to void
– abnormal GU exam
– multiple associated injuries
Evaluation of bladder trauma
• Pelvic X-rays
• Retrograde cystogram
– High suspicion and normal X-rays
– No catheterization if blood at the urethral meatus
or high-riding prostate
• CT cystography is recommended over plain
cystogram for patients undergoing CT for
associated injuries
Management of bladder injuries
• Extra peritoneal
– Contusion = conservative management, +/catheter
– Manage with urethral cath or suprapubic drainage
for 7-10 days.
– Large tear = OR
• Intraperitoneal - Go to OR.
• Combined – Go to OR
Urethral trauma
• Mechanisms
– MVC
– straddle injuries
– Instrumentation
• More common in males
• Urethral injuries
– Anterior: Pendulous and Bulbar
– Posterior: Membranous and Prostatic
Blunt Anterior Urethral trauma
• Due to direct trauma, usually isolated, low mortality
• Bulbar injuries : common in straddle injury
• Blood at the urethral meatus is present in 90% of
anterior injuries
• Perineal ecchymosis (butterfly), inability/difficulty
voiding also possible
• Retrograde urethrogram is diagnostic
• Manage with 7-10 days of catheterization plus
antibiotics
Blunt Posterior urethral Trauma
• Occur with severe trauma and are associated
with other injuries (pelvic fx)
• Signs are blood at the meatus, hematuria,
perineal ecchymosis (butterfly),
inability/difficulty voiding
• Retrograde urethrogram is diagnostic
• Urology consultation
• Higher rate of complications
Female urethral trauma
• Urethral injuries in girls
Rare, due to mobile short urethra
• Associated with pelvic fractures or
instrumentation
• Managed with suprapubic drainage and
elective repair
Penile Trauma
• Blunt trauma from toilet seat is common
– Managed with warm soaks.
• Tourniquet injuries
– Exposure and removal of hair
– Urethrocutaneous fistula and penile loss
• Zipper entrapment.
Penile Trauma
• Penis fracture.
– Traumatic rupture of corpus cavernosum.
– Erect penis vs. hard surface.
– Patient may hear a cracking sound with pain and
edema.
– Most required surgical evacuation of hematoma,
ice packs, pressure dressing
• Lacerations:
– Involving the corporal bodies or the urethra
require urologic consult
– Superficial: simple repair
Perineal trauma
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•
•
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Most common is straddle injury
Vulvar hematomas = ice packs and rest
Superficial lacerations treat with sitz baths
Deep lacerations: Extension into rectum or
urethra
Straddle injury
• Injury is caused by the compression of soft
tissues against the bony margins of the pelvic
outlet
• Mechanisms:
– Bicycle riding
– Falls
– Monkey bars
Straddle injury: Appearance
• Straddle injuries typically are unilateral and
superficial
• Anterior portion of genitalia involved
• Girls:
– Mons, clitoral hood and labia minora anterior and
lateral to hymen
– Straddle injury to hymen and posterior fourchette
is rare
• Boys: Injury to penis or scrotum
Straddle injury vs Abuse
• Infant younger than nine months
• Perianal, rectal, vaginal, or hymenal injury
without history of penetrating trauma
• Extensive or severe trauma
• Presence of non-urogenital trauma
• Lack of correlation between history and
physical findings
• Abnormal genital secretions
Straddle injury: Treatment
principles
• Visibility of injury
– Physician must be assured that the injury is
properly inspected
• Ability to void
– Inability to void
• Pain
• Large hematoma
• Urethral disruption
Treatment : Girls
• Vulvar hematoma: size dependant
– Ice packs, analgesia, sitz baths
– Increasing size: Surgical drainage
• Vulvar lacerations
– Heal by secondary intention ( lateral wall of
vestibule)
– Repair of perineal lacerations under sedation
• Vaginal injury: suspect if hymenal tear
– Lacerations: superficial or deep - Repair
– Hematomas: Observation
Treatment: Boys
• Urethral injury: Anterior vs. posterior
• Testicular injury:
– Depends on severity
– Assessment with US and Urology
• Scrotal injury
– Hematoma, ecchymosis: Ice packs
– Superficial lacerations: Repair in ED
– Hematocele and scrotal swelling
– Deep ( extension through Dartos): Urology
• Penile injuries
Penile Trauma: Direct Injury
• Causes and management
– Falling toilet seat
• Significant penile edema
• Injury to corporal bodies or urethra is rare
• Treatment: warm soaks, void in bath tub, Observation
– Blunt trauma: Blood at urethral meatus
• Urethral injury
• Diagnosis: Retrograde urethrogram
– Laceration to penile shaft
• R/O urethral injury and injury to corporal bodies
• Consult urology, urethrogram, exploration in ?? Cases
• Simple laceration: Repair with chromic catgut
Penile Trauma: Zipper Injury
• Most common genital injuries in prepubertal
boys.
• Typically involve the foreskin or redundant
penile skin and may occur during the zipping
or unzipping process
– Localized edema and pain are the most common
complications
– Significant injury, including skin loss or necrosis, is
unusual.
Zipper Injury: Treatment
• Mineral oil: Allows tissue to slide freely
• Entrapment release — The procedure for
entrapment release depends upon the site of
entrapment within the zipper.
• Entrapment of penile skin between the zipper
teeth (and not the zipper mechanism)
– Release by cutting the cloth of the zipper - results
in separation of the zipper teeth
• Local anesthesia or sedation usually is not
necessary for this procedure.
Zipper Injury : Treatment
• Entrapment of penile skin in the zipper
mechanism (which consists of two faceplates
connected with a median bar)- More difficult
to release.
• Sedation may be necessary to complete
procedures
• Local anesthesia usually is adequate for older
children.
Zipper injury: Treatment
• Recommended technique:
– The median bar may be cut with wire cutters, bone
cutters, or a mini hacksaw
– Allows the mechanism to fall apart and leads to release of
the entrapped skin
• Alternate technique:
– Thin blade of a small flathead screwdriver
– Placed between the faceplates on the side of the
mechanism in which the penile skin is not entrapped.
– The blade is then rotated toward the median bar
– This widens the gap between the faceplates, releasing the
skin
Penile Injury: Strangulation
• Constriction ring: Hair, fiber, thread
• Pitfall: Local edema may hide the ring of hair
• Treatment:
– Division of hair &release of constriction
– May require GA and urologic consultation
• Complication
– Urethrocutaneous fistula
– Penile loss: case report
• Occasional report as form of sexual abuse
Scrotal Trauma
• Mechanisms of trauma
– Direct blow
– Straddle injury: Impingement of testis against the
pubic bone
– Penetrating injuries: Rare
• Spectrum of scrotal trauma
– Minimal scrotal swelling to testicular rupture with
blood filled scrotum
• Suspicion of testicular rupture: surgical exploration
– Best salvage of ruptured testis
– Rare presentation of testicular torsion
Scrotal trauma: hematocele
• Hematocele: Blood within tunica vaginalis
– May represent severe testicular injury
– Ecchymosis of scrotal wall in setting of trauma
– Sonography:
• Identifies fluid collection in the tunica
• Blood more echogenic than hydrocele fluid
– Treatment: Surgical exploration to drain large
hematoceles as well as testicular repair if ruptured
Scrotal trauma spectrum
• Intratesticular hematoma or laceration of tunica
– Ultrasound : Assists to determine location of blood
– Intact Tunica: Surgery not necessary
– ? Testicular laceration: surgical exploration
• Traumatic epididymitis
– Results from blunt trauma
– Initial pain, then pain free, then pain returns
– Scrotal erythema, edema, epididymal tenderness
– Ultrasound: rules out severe injury
– Treatment: Supportive
• Scrotal laceration
– Evaluate testis and spermatic cord for injury
– Simple laceration: Hemostasis and chromic sutures
Scrotal injuries: Urology
intervention
• Large testicular hematoma may need drainage
– Delay in surgery may lead to ischemic necrosis,
secondary infections, disruption of testicular
function
• Testicular rupture with tear of the tunica
albuginea requires surgical exploration.
– Salvage more likely if repaired within 24h
• Laceration to scrotum through the dartos
• All penetrating testicular injuries
Testicular torsion
• Scrotal pain and swelling – common
presenting symptom in ED
• Acute scrotum
• Acute testicular torsion – rapid pickup is vital
for salvage
– Salvage rate drops when repair delayed beyond 68 hours after acute event
• Acute scrotum – Testicular torsion is the
working diagnosis until proven otherwise
Testicular torsion: Stats
• 1 out of every 4000 males before age of 25
• Peak incidence: 13 years of age
• Another peak:
– Perinatal period.
– Newborn born with hard, necrotic testis.
– Hard or discolored scrotum
– Salvage not possible
• Rare: after age of 30 yrs
Testicular torsion: Cause
• Basic mechanism – Movement of testis that is
abnormally fixed in tunica vaginalis
• Infants: Lack of fixation of tunics in the
scrotum. Extravaginal torsion
• Bell Clapper deformity: Tunica vaginalis has
abnormally high attachment to spermatic cord
– Testis not fixed. Prone to torsion
– Allows testis to lie transversely and rotate
– Found in most cases. Commonly bilateral
Bell Clapper deformity
Testicular torsion: Clinical features
• PAT:
– Appearance: Crying, irritable, uncomfortable
– WOB: Normal
– Circulation: Normal systemic
• Other findings:
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–
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–
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History of pain in past
Acute onset pain in groin or scrotum
Nausea and vomiting
High riding testis, Transverse lie of testis
Diffuse testicular pain, absent cremasteric reflex
Testicular torsion: Complications
• Delay in re-establishing blood flow – loss of
testicular function
• Delay
– Patient presentation
– Physician taking his or her time to establish
diagnosis
• Testicular salvage:
– 80-90%: within 8 hours of acute pain
– <20%: for delay up to 12 hrs
Diagnostic studies
• Lab studies: not sufficient to make definitive
diagnosis
• Ultrasound with Doppler:
– Readily available, non invasive and highly accurate
– Any uncertainty: Indicates surgical exploration
• Testicular scintigraphy:
– PPV of 95%
– Access may not be easy at all times
• High index of suspicion: Do not delay surgical
procedure to confirm suspicion with a diagnostic
study.
Testicular torsion: Differential
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•
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•
•
•
•
Torsion of appendix testis or appendix epididymis
Epididymitis
Orchitis
Incarcerated Inguinal Hernia
Scrotal trauma
Hydrocele
Varicocele
HSP/ Kawasaki disease
Scrotal cellulitis
Testicular tumors
Management
• Analgesia: IV narcotic
• Manual detorsion: Can preserve testicular
viability and provide time
– Twist affected testis outwardly
– Successful detorsion: Relief of pain and visible
lengthening of cord structures
– More than 360o detorsion may be required
• Surgery
– Non viable testis: Orchiectomy
– Viable testis: Orchiopexy
– Exploration of unaffected testis
Torsion of testicular appendage:
Appendix testis or Appendix epididymis
• Average age: 10 years
• Clinical features:
– Sudden onset pain limited to scrotum
– No abdominal or urinary symptoms
– Point tenderness at superior aspect of testis in
early stages
– Blue dot: visible tender nodule in 20% cases
Diagnosis and Management
• Testicular scan and Ultrasound
– Increased blood flow
– Inflammation at superior aspect of testis
• Treatment
– Expectant
– Analgesics
• Any doubt about diagnosis
– Urology consultation for exploration
Phimosis & Paraphimosis
• Phimosis: Tightness of distal foreskin
– Cannot withdraw to expose the glans
– Not to be confused with penile adhesions
• Paraphimosis: Foreskin is retracted behind
glans and left there – swollen, retracted
foreskin
– Venous congestion & edema: reduction to normal
position is difficult
Paraphimosis: Treatment
• Manual reduction: Application of ice and
steady local compression
– Local anesthesia: Penile block
– Pressure on glans (turning a sock inside out)
• Surgical reduction: Failure of manual
reduction (2-3 attempts)
– Surgical division of foreskin
– Circumcision: after a few weeks
• Prevention: Education of uncircumcised male
Improving success of manual
reduction
• Wrap the penis in plastic and apply ice packs
• Use compressive elastic dressings
• Apply direct circumferential manual
compression
• Granulated sugar
• Hyaluronidase therapy - directly into several
sites of the edematous prepuce.
• Puncture of the edematous site
An 8 yo boy is brought to the ED after getting hit by a car
while riding his bicycle. On exam, he has stable vital signs,
GCS of 15, and his abdomen is soft without tenderness. Blood
is noted at the urethral meatus and he is unable to void. Which
of the following is the most appropriate for management?
a. Retrograde urethrogram
b. Foley catheter placement
c. Abdominal ultrasound
d. Intravenous pyelogram (IVP)
e. Ice packs and ibuprofen
A 13 yo boy comes to the ED with back pain after playing ice
hockey. He was checked and hit his back onto the boards. He
noted gross hematuria a few hours afterwards. On exam, he has
normal vital signs. His right flank shows a small ecchymosis on
inspection. His abdomen is soft without tenderness. His
urinalysis shows numerous RBCs per high power field. Which
of the following tests is most appropriate in this patient?
a. Intravenous pyelogram (IVP)
b. Ultrasonography
c. Cystourethrogram
d. Abdominal CT
e. Serial urinalyses
A 6 yo girl comes to the ED after sustaining an injury to the
perineum. The patient was climbing on a tree when she fell
approximately 4 feet landing on a large rock. She complains of
pain and bleeding from vaginal area. She has been refusing to
urinate due to pain. A 1-cm superficial vulvar laceration is noted
at 3 o’clock with small amount of oozing blood. The hymen
appears intact. The most appropriate management is:
a. Surgical exploration under general anesthesia
b. Laceration repair under local anesthesia
c. Consultation with the child protection team
d. Supportive care and sitz baths
e. Placing a Foley catheter and hospitalization
A 13 yo boy comes to the ED after sustaining a straddle
injury to his scrotum while riding his bicycle. He is able to
urinate without difficulty and has no gross hematuria. There is
no trauma to the abdomen. On exam, he has normal vital signs.
His right hemi-scrotum is swollen and ecchymotic. There is
marked tenderness on palpation. There is no ecchymosis or
swelling of the penis, and no blood per meatus. The
management includes:
a. Pelvic x-ray
b. Needle aspiration
c. Retrograde urethrogram
d. Scrotal ultrasound
e. No intervention is needed
An 8 yo boy presents to the ED after his penile skin got
caught in the zipper of his pants. On exam, his foreskin is
caught in the zipper mechanism. Management includes:
a. Cutting the median bar of the zipper
b. Dissecting the skin free
c. Applying ice before unzipping over the entrapped skin
d. Moving the zipper back and forth after local anesthesia
e. Performing a dorsal slit procedure
A 16 yo boy comes to the ED with left-sided groin pain and
scrotal swelling that began 4 hours prior to arrival. He also
reports mild lower abdominal pain and nausea. On exam, his left
scrotum is erythematous, moderately swollen and diffusely
tender on palpation. A cremasteric reflex cannot be elicited.
There is mild tenderness on palpation of lower abdomen. The
most appropriate management of this patient is:
a. Scrotal ultrasound
b. Immediate surgical exploration
c. Ceftriaxone and doxycycline
d. Trimethoprim/sulfamethoxazole
e. Incision and drainage
A 3 yo uncircumcised boy presents to the ED with swelling
and penis pain since the morning of presentation. There is no
history of trauma. He is able to void without difficulty. On
exam, his foreskin is retracted and swollen, and the glans
appears swollen. Which of the following would be the most
appropriate initial treatment?
a.Oral antibiotics
b. Manual reduction
c. Topical antibiotic
d. Circumcision
e. Warm sitz baths