Emergency Management of Renal and Genitourinary Trauma: Best Practices Update

Table of Contents

 

For trauma patients in the ED, life- and limb-threatening injuries take priority, but renal and genitourinary injury can have long-term consequences for patients, including chronic kidney disease, erectile dysfunction, incontinence, and other serious problems. This issue offers a review of the literature regarding treatment of renal and GU injuries, from diagnosis to management to disposition.

The mechanism of the trauma can be a clue to the injury sustained:

Rapid deceleration forces can injure the kidney, from contusions to shattering

Most injuries to the ureter are a result of penetrating trauma

Bladder injuries are often seen in pelvic fractures

Injuries to the external genitalia are more likely from sports or sexual intercourse

Gross hematuria is the best indicator of injury, but its absence does not rule out injury; in penetrating trauma, there is no correlation between the amount or even presence of hematuria and the degree of injury.

The type of injury suspected will dictate the diagnostic studies needed: CT, CT cystography, intravenous pyelogram, retrograde urethrogram, or ultrasound.

With grade IV or V kidney injuries, 10-minute-delayed IV contrast CT scans should be obtained.

Do not place a urinary catheter if there is a possibility of urethral injury.

In the last 20-30 years, conservative management therapies have become standard. 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Epidemiology
6. Etiology and Pathophysiology
   1. Kidney and Ureter
   2. Bladder
   3. Male Genitalia
   4. Female Genitalia
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Ability to Void, Dysuria, and Hematuria
   3. Physical Examination
10. Diagnostic Studies
    1. Urinalysis
    2. Baseline Renal Function
    3. Computed Tomographic Imaging
    4. Computed Tomographic Cystography
    5. Computed Tomographic Angiography
    6. Retrograde Urethrogram
    7. Ultrasound
11. Treatment
    1. Catheters and Urinary Diversion
       1. Suprapubic Catheterization
       2. Alternative Methods of Urinary Diversion
    2. Surgery
    3. Interventional Radiology
    4. Admission
12. Special Populations
    1. The Pediatric Patient
    2. The Elderly
13. Controversies and Cutting Edge
    1. Magnetic Resonance Imaging
    2. Nonoperative Management
    3. Contrast-Enhanced Ultrasound
14. Disposition
    1. Consultation
    2. Urinary Catheter Care
15. Summary
16. Risk Management Pitfalls for Renal and Genitourinary Trauma
17. Time- and Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway for Evaluation of Blunt Renal Trauma in Adults
20. Tables and Figures
    1. Table 1. Potential Sequelae of Renal and Genitourinary Injuries
    2. Table 2. Expert Guidelines in Renal and Genitourinary Trauma
    3. Table 3. Renal and Genitourinary Organ Injuries
    4. Table 4. American Association for the Surgery of Trauma Kidney Injury Scoring Scale
    5. Table 5. Key Historical Questions in Renal and Genitourinary Trauma
    6. Table 6. American College of Radiology Guidelines Appropriateness Criteria® for Computed Tomographic Imaging in Renal and Genitourinary Trauma
    7. Table 7. Recommendations for Use of Computed Tomographic Cystography
    8. Table 8. Antibiotic Prophylaxis and Renal Injury
    9. Figure 1. Anatomy of the Normal Male Urethra
    10. Figure 2. Diagram of The American Association for the Surgery of Trauma Grading System for Renal Injury
    11. Figure 3. Eggplant Deformity
    12. Figure 4. Positive Computed Tomographic Cystogram in a Patient With Penetrating Trauma and Bladder Rupture
    13. Figure 5. Retrograde Urethrogram Performed in a Patient With a Penile Fracture
21. References

Abstract

In up to 10% of patients who experience abdominal trauma, renal and urogenital systems will be involved. In polytrauma patients with other potentially life-threatening injuries, renal and genitourinary trauma may be overlooked initially, but a delayed or missed diagnosis of these injuries may result in preventable complications. This review provides a best-practice approach to the diagnosis and management of renal and genitourinary injuries, with an emphasis on the systematic approach needed to identify subtle injuries and avoid long-term urinary sequelae such as hypertension, incontinence, erectile dysfunction, chronic kidney disease, and nephrectomy.

Case Presentation

You’ve just arrived for a long Saturday overnight when the EMS notification pager goes off. Your first patient is a 23-year-old man who was in an altercation outside a bar. He is intoxicated, has bruises and red marks that look like shoe prints all over his abdomen, flanks, and chest, and tells you it hurts “everywhere.” On his right flank, he has a 1- by 2-centimeter wound that he thinks was made by a screwdriver. You put out a trauma page, and in the interim, you wonder: will a urinalysis really help in working up this patient? What kind of special imaging is he going to need? Should I order pre-op labs?”

Into the next trauma bay arrives a 46-year-old woman, also intoxicated, who was the unrestrained and ejected passenger in a high-speed, rollover motor vehicle crash. She is hypotensive and tachycardic. She has a pelvic binder on, with a tense, swollen belly extending above it. During the resuscitation, you notice she is bleeding briskly from her vagina. Your nursing colleague asks if you want a Foley catheter. Should you place one? Do you need to page urology as well as trauma? Is it necessary to alert interventional radiology of this patient’s arrival?

Since bad news comes in threes, you are immediately called to a third trauma patient. This one is a 54-year-old man who was in a high-speed motorcycle collision. He is screaming in pain and has an obvious chest wall deformity with crepitus. What he’s screaming about, however, is his genitals, making a number of medical students and residents blush. He has a massive hematoma to his perineum and scrotum, a testicle that appears dislocated and free from the scrotal sack, and a deformity to his penile shaft. There is gross blood at the urethral meatus. Where do you begin in assessing this patient’s genitourinary trauma? Should you place a suprapubic catheter? Is an ultrasound, CT, or MRI best for fully assessing the extent of his injury and helping your urology colleagues plan for treatment?

Introduction

Worldwide, approximately 250,000 traumatic renal injuries occur annually.¹ The urological organ most commonly injured is the kidney, followed by the testicles and the bladder.² Depending on the data set used, renal and genitourinary (GU) trauma is present in 5% to 10% of all abdominal trauma patients.^3-5 Over the last 20 to 30 years, the care of renal and GU injuries has evolved, becoming more conservative and expectant. Advances in military medicine, where 5% of all combat injuries are GU-related, have accelerated the pace of this change and advances in care.⁶

The principles of effective trauma care are to prioritize life- and limb-threatening injuries.⁷ Blunt and penetrating trauma that affects the kidneys or other GU organs is rarely isolated, and nearly all patients with penetrating or high-grade blunt abdominal trauma have multiple injured organs.^8,9 As a result, renal, bladder, and other GU injuries can be missed in the rush to contend with emergent interventions.^7,10,11 Indeed, in one case series performed at a specialized trauma center, 20% to 25% of all bladder and urethral injuries associated with pelvic fracture were missed initially.¹²

Patients with GU injuries tend to be sicker than their cohorts without such injuries.^13-15 Missed renal and GU injuries are associated with increased morbidity and mortality.^14,16 Coordinated trauma care, particularly care that takes place in a designated trauma center, reduces the risk of nephrectomy and inpatient mortality in renal trauma.¹⁷ Table 1 lists potential sequelae of renal and GU injuries.^16,18-20

Long-term consequences of renal and GU injuries include hypertension, chronic kidney disease, erectile dysfunction, incontinence and voiding issues, hydronephrosis, fistula, recurrent pyelonephritis, and nephrolithiasis.^4,16,21,22 Although hypertension is relatively rare as a late consequence (approximately 5%), it is emblematic of the need to accurately and quickly diagnose these types of injuries to avoid unnecessary morbidity.²³ Recognizing and initiating treatment of these non–life-threatening GU injuries is vital in reducing the incidence of future strictures, impotence and other sexual dysfunction, and incontinence.^24-26 This issue of Emergency Medicine Practice will review common and uncommon traumatic GU emergencies and provide a best-practice framework for diagnosis and management.

Critical Appraisal of the Literature

A literature search was performed using PubMed and the services of a medical research librarian using the search terms kidney trauma, renal trauma, ureteral trauma, bladder trauma, urethral trauma, genital trauma, penile trauma, urological trauma, and genitourinary trauma. A total of 383 articles from 1968 to the present were reviewed. There are no reviews in the Cochrane Database on this topic. We searched the National Guideline Clearinghouse created by the United States Agency for Healthcare Research and Quality (www.guideline.gov). This, in addition to our literature search, yielded 5 core, evidence-based and consensus guidelines, listed in Table 2. We also reviewed guidelines by the American Association for the Surgery of Trauma (AAST) organ injury severity system.

The majority of recommendations on this topic are based on retrospective reviews, case studies, and consensus. Well-designed prospective trials are rare in GU trauma.²⁷ Most articles are case reports, expert opinion pieces, or single-institution retrospective case series. One sizable study randomized penetrating renal trauma patients to direct exploration of the kidney versus early vascular control. This study, and a limited number of large retrospective reviews, are the exception; the rest of the literature is weak.^1,28 One expert, lamenting this dearth of quality literature on GU trauma noted, “Most studies repeat the same old messages/prejudices. One could argue that there has been no major advance in the (early) treatment of urethral trauma since 1757.”²⁹ Although we disagree with that grim assessment of the recent advances in this field, expert consensus is the norm in the literature presented here.

Risk Management Pitfalls for Renal and Genitourinary Trauma

1. “I ruled out kidney damage with a normal urinalysis and sent her home. She came back with renal necrosis.”

While a urinalysis can help risk stratify and identify the severity of some types of renal trauma, a normal urinalysis is not sufficient to rule out the diagnosis. There are many case reports of patients with severe injuries and normal urinalyses, especially in vascular injury and penetrating trauma.

2. “He only had a little blood at the meatus on examination, so I went ahead and tried to place a Foley.”

In any patient for whom you have a concern for possible urethral injury, based on history, physical examination, presence of significant pelvic fractures on x-ray, or suspicious findings on initial CT scan, you should perform a RUG prior to attempting placement of a Foley catheter. Without this test, you risk turning a minor urethral injury into a major one.

3. “Radiology hedged their read on our CT because we did the RUG before he went to CT.”

The contrast from a RUG can make accurately reading a subsequent CT of the abdomen with IV contrast or a CT cystogram very difficult. Since the placement of a Foley catheter is not emergent, the CT imaging should be performed first before performing a urethrogram to rule out urethral injury.

4. “I diagnosed her posterior rib fractures with an x-ray after she was hit on the flank. Her belly examination and blood pressure were normal, so I sent her home. She came back with a grade IV renal laceration.”

Patients presenting with blunt or penetrating trauma to the lower thorax, upper abdomen, or flank should raise your suspicion for underlying renal trauma. Depending on history, mechanism of injury, adjacent injuries (such as vertebral fractures) and presence and degree of hematuria, such presentations may require additional imaging for possible renal injury.

5. “When we found his pelvic fracture, I called orthopedics and trauma, but I didn’t think about a urethral injury.”

Pelvic fractures (apart from acetabular fractures), are highly correlated to urethral injury. In patients who have difficulty or pain with voiding, or hematuria with a pelvic fracture or trauma to the genitals or pelvis, a urethral injury must be on your differential, even if the patient is admitted and cannot have the definitive test before going upstairs. Depending on the institution, this can mean a RUG performed downstairs, a discussion with trauma surgery/ admitting service, or a urology consult.

6. “I just assumed he couldn’t urinate because he was anxious after his car crash and because we gave him fentanyl.”

Inability to void is common in the setting or lower urinary tract injury. In a setting of abdominal or pelvic trauma, this complaint must be investigated with bladder ultrasound to look for retention and appropriate additional imaging (CT cystogram, RUG, etc) to ensure the inability to void is not masking serious injury. Missed bladder and urethral injury can cause significant lifelong morbidity.

7. “His scrotum was so swollen and he had so many other injuries from his motorcycle crash, I couldn’t have possibly caught his traumatic testicular torsion.”

Renal and GU trauma is rarely the “main event” in the sick polytrauma patient. ATLS guidelines, with good reason, mandate dealing with the life-threatening injuries first. However, genital trauma with marked physical examination abnormalities can and should be addressed on secondary or tertiary examination, with a plan in place for additional imaging, such as ultrasound, and appropriate subspecialty consultation. The time-sensitive nature of some genital trauma makes this especially important.

8. “I assumed he had a penile fracture, but he was able to void, so I sent him home with pain medicine and a plan to see urology in the clinic in 1 to 2 days.”

Penile fracture, most commonly caused by trauma sustained during sexual intercourse, is a surgical emergency no matter how severe it appears on physical examination or the patient’s ability to void. Although urethral injury is a concern, repairing the underlying defect in the tunica albuginea is also essential for future sexual function and cosmesis.

9. “We got a stat CT of the abdomen and pelvis when we saw the flank bullet exit wound, but we missed the ureteral injury because of how we ordered it.”

Ureteral injuries are uncommon in general, but they are most commonly seen in penetrating trauma. A regular CT of the abdomen with IV contrast is not timed to catch most ureteral injuries. When the path of the projectile or stabbing implement, based on history or physical examination, is near a ureter or the kidney, delayed excretory images performed roughly 10 minutes after contrast administration are required.

10. “We called trauma when we saw the shattered kidney. When her FAST was positive and her pressure dropped, she went straight upstairs. Urology complained the next day.”

Although in most institutions the management of critically ill trauma patients is primarily dictated by the ED and their trauma surgery consultants, any high-grade renal or GU injury benefits from early involvement of a urologist. Ideally, they are involved in the initial operative intervention to help with urinary diversion and lend their expertise in renal salvage.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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