In the ED, 10% of patients who present with abdominal trauma may have genitourinary injuries.1-3 Injuries to the urinary tract can involve (in order of frequency) the kidneys, bladder, urethra, and ureter.1,3,4 Trauma to the back, flank, lower thorax, or upper abdomen can cause renal injuries, 80% to 95% of which are due to blunt trauma.1,8-12 Rapid deceleration from motor vehicle collisions is the most common cause of blunt trauma.13 Hemodynamically stable patients with hematuria and suspected urinary tract injury are best evaluated by contrast-enhanced computed tomography (CT).
The pediatric kidney is more vulnerable to injury because of less protection from a pliable pediatric rib cage, abdominal muscles which are weaker, larger kidney size in the infant and toddler in proportion to the rest of the body, less perirenal fat, and presence of congenital abnormalities. Residual fetal lobulations of the kidneys allow for increased risk or renal parenchymal laceration after blunt trauma.
Ten percent of renal injuries are from penetrating trauma.1,8 Minor injuries account for 85% of total renal injures, lacerations in 10%, and severe renal ruptures, fractures, or pedicle injuries in 3% of cases.14 Renal trauma was associated with multiple other injuries in 51% to 80% of cases; head and skeletal injuries are the most common of the associated injuries.15-17
It is important to diagnose the extent and type of renal injury accurately to ensure adequate treatment. Computed tomography scanning with contrast enhancement is the modality of choice for renal trauma because it offers a quick and accurate way of demonstrating injury to the renal parenchyma, renal pedicles, and associated abdominal or retroperitoneal organs.18 If CT scanning is not an available mode for evaluating stable patients, an intravenous pyelogram is an alternative. Though renal ultrasound is increasing in popularity, its efficacy has not yet been proven and reliability and reproducibility depend on the operator and interpreter of the images.19
Over the years, the nonoperative management of blunt abdominal trauma in children with solid-organ injuries has evolved. There is a broad consensus in favor of less invasive procedures and more conservative management of traumatic renal injuries if the patient is stable; the exception would be cases of severe injury, such as injury to the vascular pedicle or complete laceration of the ureteropelvic junction.20-22
An 11-year-old female presents with abdominal pain, vomiting, and left arm pain after being injured by a horse. The horse was standing on the patient's right side when it was spooked and bumped into her. She fell to the ground but was not sure whether or not she had been directly kicked by the horse. Vomiting and abdominal pain developed after she was back at home, approximately 30 minutes after the incident. Upon her arrival at the triage area of the ED, the patient discovered that she had gross hematuria. Her initial vital signs on triage included a blood pressure of 106/60 mm Hg, a heart rate of 90 beats per minute, and a respiratory rate of 20 breaths per minute. Physical examination revealed pallor during retching, a chin abrasion, a horseshoe-shaped contusion over the right lateral ribs, and tenderness in the abdominal right upper quadrant and right flank. Bilateral peripheral intravenous catheters were placed, and 0.9% normal saline solution (20 mL per kg of body weight) was administered in the ED.
What are the priorities in the initial evaluation and management of this child? How would you evaluate this possible renal injury?
The patient was evaluated by the trauma team and connected to cardiac and pulmonary monitors. Her initial laboratory results showed a hemoglobin of 12.8 g/dL and a hematocrit of 38.3%. A renal function panel showed a blood urea nitrogen of 18 mg/dL and creatinine of 0.7 mg/ dL. A complete urinalysis showed too many to count rbc / hpf. Abdominal and pelvic CT with contrast revealed a grade III laceration of the right kidney that extended through the proximal collecting system and a large, perinephric fluid collection. Delayed-phase CT of the right kidney showed extravasation from the collecting system of the right upper pole moiety. Interval enlargement of the perinephric fluid collection compatible with blood and urine was also seen with mildly increased anterior displacement of the right kidney. The amount of intermediate- density ascites was slightly increased in the abdomen and pelvis, and the composition was compatible with urine. The patient was admitted to the pediatric intensive care unit for continued monitoring, and a urologist was consulted. Because of severe concurrent liver laceration, she was hospitalized for 9 days, during which she remained hemodynamically stable.
Click here to download a PDF of the Evidence-Based Practice Recommendations for this issue.
AAP: American Academy of Pediatrics
CDC: Centers for Disease Control and Prevention
CT: Computed tomography
ED: Emergency department
FAST: Focused Assessment Sonography for Trauma
HPF: High-powered field
HSP: Henoch-Schoenlein purpura
HUS: Hemolytic-uremic syndrome
IV: Intravenous
IVP: Intravenous pyelography
RBC: Red blood cell
UPJ: Ureteropelvic junction
A literature review of articles published from 1979 to 2009 was launched using Ovid MEDLINE® (www.ovid.com) and PubMed (www.pubmed.gov). Keywords used in the search were genitourinary tract injuries, renal injuries, uretal injuries, bladder injuries, penile injuries, hematuria, scrotal injuries, hemolyticuremic syndrome, and henoch-schoenlein purpura.
A variety of trauma registries and databases have been developed as a means to document and follow trauma trends and outcomes. Such data can be analyzed and used to influence local prevention initiatives and legislation. Examples of national databases include the retired National Pediatric Trauma Registry and the current National Trauma Data Bank. A Web-based Injury Statistics Query and Reporting System, developed by the National Center for Injury Prevention and Control, provides customized reports of injury statistics.
Blunt genitourinary injuries most commonly occur upon rapid deceleration. The kidneys are crushed against the ribs or vertebral column from their relatively fixed position within Gerota's fascia. Contusions or parenchymal lacerations can result. The vascular pedicle can be stretched, which can injure the renal vein or artery and lead to thrombosis.
The grading system of renal injuries devised by the American Association for the Surgery of Trauma is based on the depth of injury, vascular involvement, and the presence of urine extravasation.23-25 (See Table 1.) Grade I injuries, which occur in about 80% of all injuries to the kidney, are the most common types of renal trauma.13 A grade I injury is a contusion or hematoma accompanied by microscopic or gross hematuria with normal results on urologic imaging studies. A grade II injury is a hematoma with a laceration to a depth of less than 1 cm of the parenchyma of the renal cortex without extravasation of urine. A grade III injury is a laceration to a depth of more than 1 cm of the parenchyma of the renal cortex or medulla without collecting system rupture or urine extravasation. In a grade IV injury, parenchymal lacerations extend through the renal cortex, medulla, and collecting system. A grade IV injury can also involve the main renal artery or vein, with contained hemorrhage. The hallmark of grade IV injuries is extravasation of opacified urine into the perirenal space, as visualized on CT26; this finding resolves spontaneously in about 80% of cases.27 Grade IV segmental infarctions often resolve with conservative treatment.13 In grade V injuries, the hallmark of complete avulsion of the ureteropelvic junction (UPJ) is the failure of the distal ureter to opacify on CT. Renal pedicle injuries occur in up to 5% of all cases of renal trauma.28 Hematuria may be absent. Renal artery occlusion is the most common vascular pedicle injury from blunt trauma. Traumatic renal infarction can occur at any time, even long after the initial traumatic event. Renal vein thrombosis from trauma almost always occurs with an arterial or parenchymal injury.29 A devascularized kidney will show no enhancement on CT.
Table 2 lists the possible complications of renal trauma, which occur in 3% to 33% of cases.13 The most common is urine extravasation, which is present in grade IV parenchymal injury and in grade V UPJ avulsion.18 Intraperitoneal extravasation of urine is usually due to a penetrating injury.30 Secondary hemorrhage is common in grade V injuries and in penetrating trauma that is managed conservatively.13 Post-traumatic renovascular hypertension may occur weeks to decades after injury to the kidney, the average onset being 34 months.23
Traumatic ureteral injuries are rare, occurring in less than 1% of all cases of genitourinary trauma.31 The proximal ureter is protected by the psoas muscle and the vertebrae. The distal ureter is protected by the bony pelvis. Penetrating trauma is the most common external mechanism; however, traumatic avulsion of the ureter occurs more often in children than in adults and is usually due to blunt trauma. The pediatric spine, being more mobile, allows the renal pelvis and upper ureter to be compressed against the lower ribs or lumbar transverse processes. Sudden extreme flexion of the trunk can stretch the ureter. After blunt trauma, UPJ disruption may be overlooked because patients often do not exhibit hematuria, but it should be suspected in injuries due to rapid deceleration.
Because the bladder is protected by its position within the bony pelvis, injuries to this structure are uncommon. However, in young children, the bladder is located within the abdomen and is therefore more vulnerable to rupture, especially when it is full. In the majority of children, motor vehicle collisions are responsible for injury to the bladder. About 10% of patients who sustain pelvic fractures will also have a bladder injury.32 Bladder ruptures are classified as either extraperitoneal, resulting from direct laceration (eg, from the bony spicules of a fractured pelvis), or intraperitoneal, resulting from the rapid rise in intraabdominal pressure during blunt trauma.81
Traumatic urethral injuries occur in about 10% of patients with pelvic fractures and are more common when the fractures are bilateral.33 The usual mechanism is blunt trauma, although such injuries are less common in children because of their more flexible pelvis. Urethral injuries are rare in females owing to the hypermobility of the urethra and lack of bony attachments. Bladder injuries accompany urethral injuries in 10% to 29% of cases.34 Causes of urethral injuries include pelvic fractures, straddle injuries, and urethral manipulation. The diagnosis should be suspected when there is blood at the urethral meatus, when a full bladder is palpable on abdominal examination, or when the patient is unable to urinate. Urethral injuries can result in strictures, incontinence, impotence, diverticula, fistulas, or chordee (abnormal curvature of the penis).
Complications of circumcision are the most common causes of penile injury. The penis can also incur direct crush injuries from toilet seats, falls and sports-related injuries, zipper entrapment of the foreskin, and tourniquet injuries. Serious injuries can occur with major trauma. Urethral injuries occur in up to 50% of patients with injury to the genitals.35,36 Patients with penile injuries can present with blood at the meatus, gross hematuria, or inability to void.
Penile fracture, or rupture of the corpus cavernosum, from blunt trauma to an erect penis is uncommon. This type of injury occurs most often when an erect penis is forced against a solid object, such as the pubis or perineum during sexual intercourse. A "crack" or "pop" is heard, followed by pain, swelling, ecchymosis, deformity of the penis, and occasionally a palpable corporal defect.
Tourniquet injuries in infants may occur when hair encircles the coronal groove, binding the shaft of the penis, and may present as balanitis, paraphimosis, or cellulitis of the penis.
Injuries to the external male genitalia usually occur when the testes are forcibly pressed against the pubic ramus. A common example is straddle injury. Patients with significant straddle injuries should frequentbe screened to detect possible fracture of the pubic ramus on pelvic radiography. Doppler ultrasound, if immediately available, can be used in the evaluation. A delay of 4 to 6 hours may result in the loss of the testis. Early urologic consultation is warranted.
Scrotal trauma can lead to a number of complications. (See Table 3.) Testicular or epididymal rupture results from direct trauma when the testis is forced against the pubic ramus, which causes tearing of the inelastic tunica albuginea with extrusion of seminiferous tissue. This complication is rare in children. Testicular or epipidymal rupture should be suspected when there is a recurrence of pain and the onset of scrotal swelling is delayed from hours to 3 days after the injury. Early surgical exploration is recommended if testicular or epididymal rupture is suspected. Complications include epididymo-orchitis, with localized redness, warmth, swelling, and fever.
Testicular dislocation occurs when the testis is forcibly displaced from the scrotum into the inguinal, acetabular, crural, perineal, penile, or abdominal region or is extruded through a scrotal laceration. Testicular dislocations are rare. This diagnosis should be considered when the hemiscrotum is empty after trauma. Symptoms include scrotal pain, nausea, and vomiting. A urologic consultation is necessary in testicular dislocations.
If testicular torsion, rupture, dislocation, and a large expanding hematoma are ruled out, the patient may be discharged to home with urologic follow-up. Scrotal support and cold packs may be helpful.
Vaginal lacerations may be caused by bony fragments resulting from pelvic fracture(s) or from penetrating wounds. Perineal trauma in females often results from blunt trauma, such as straddle injuries. Other mechanisms of injury include stretching of the perineum from the sudden abduction of the legs (eg, doing the splits) and penetrating injuries. Complications of perineal trauma include retention of urine, secondary infection, and urinary tract infection.
Before inserting a urinary catheter when an injury is suspected, it is important to confirm that the urethra is intact by means of retrograde urethrography. A disrupted urethra may require placement of a suprapubic tube. Significant straddle injuries are screened with pelvic radiography to detect fracture of the pelvic ramus.
Vulvar injuries are usually minor and can be treated with rest and cold packs. Large or expanding vulvar hematomas may require surgical drainage and are susceptible to secondary infection.
Child sexual abuse is a common problem. Healthcare providers must evaluate the possibility of child sexual abuse in all cases of genital trauma. The American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect has published recommendations for evaluating such cases in which they review the definition and presentation of sexual abuse, provide an outline for history taking, offer suggestions on how to perform the physical examination, discuss which laboratory specimens are indicated, present guidelines for reporting suspected cases, cover treatment and follow-up procedures, and address legal issues.37
Child abuse should be considered when the history or reported mechanism of injury does not match the injuries identified. In the majority of cases, patients who have disclosed sexual assault have a normal examination38; however, the absence of genital findings does not exclude sexual abuse. The Centers for Disease Control and Prevention (CDC) and the AAP have published guidelines for evaluating sexually transmitted infections in sexually abused children.39,40 When there is specific concern about sexual abuse based on caretaker history or disclosure by the patient, Child Protective Services should be involved. Each state has its own standards for collecting forensic evidence, and the AAP recommends that this step be considered when the victim presents within 72 hours of the assault.41 Accidental genital trauma may be confused with injuries due to sexual abuse. In most cases, accidental genital trauma is the result of straddle injuries,42,43 which typically include lysis of labial adhesions, lacerations in the gutter between the labia minora and the labia majora, labial contusions or hematomas, and injuries to the skin overlying the perineal body. Lysis of adhesions and small abrasions may also result from sexual abuse.44 Injuries to the hymen or vagina are unusual in accidental genital trauma.45
Hemolytic-uremic syndrome is a multisystem disorder with a diverse etiology, variable presentations, and multiple pathophysiologies. It affects both sexes equally, and sporadic and epidemic outbreaks most commonly occur with the ingestion of food contaminated by a cytotoxin (also known as a verotoxin) produced by Escherichia coli. The organism most frequently found in association with typical cases of HUS is E coli 0157:H7, which is spread by person-to-person contact and in contaminated food (eg, beef or unpasteurized milk). In underdeveloped countries, Shigella and Salmonella have been associated with HUS.
Prodromal symptoms may include severe cramping, abdominal pain, emesis, watery diarrhea followed by grossly bloody diarrhea, and occasionally upper respiratory symptoms. This is followed by acute renal failure, pallor, low-grade fever, hematuria, oliguria, petechiae, prostration, gastrointestinal bleeding, and central nervous system symptoms, including irritability, lethargy, gait disorder, personality disorder, seizures, hemiparesis, cortical blindness, and coma. If diarrhea is present, serologic testing for antibodies to the lipopolysaccharide of E coli 0157:H7 will provide evidence of this organism when fecal bacteria or verotoxin cannot be detected.46
Other clinical features include thrombocytopenia, acute nephropathy, arteriolar and capillary microthrombolic lesions, and hemolytic anemia. In microangiopathic hemolytic anemia, the red blood cells (RBCs) are damaged by fibrin strands as they pass through vessels that have become narrowed as a result of endothelial cell injury. The damaged RBCs are sequestered by the reticuloendothelial system, thus reducing the RBC count and, in turn, hemoglobin levels.47 Platelets, fibrin, and complement are deposited in the lumina of glomeruli, resulting in a decrease in the glomerular filtration rate and ultimately renal failure.48
Supportive therapy for patients with mild features of HUS but without anuria has improved survival. In severely affected patients with anuria, rehydration should be initiated promptly, and patients should be admitted for treatment. Early peritoneal dialysis is usually indicated and has improved outcomes. Packed RBCs are recommended if the hematocrit drops below 15% to 20% or if hemoglobin is less than 5 to 6 g/mL and the hemolytic process has not ceased or the patient's hemodynamic status is not stable. Platelet replacement is indicated when there is active bleeding along with a platelet count that is consistently below 20,000/ mm3.49,50 Decreases in morbidity and mortality are attributable to better management of fluid and electrolyte balance and better control of hypertension, seizures, anemia, and active bleeding secondary to thrombocytopenia. Hemolytic-uremic syndrome usually resolves from 1 to 3 months after presentation.
Henoch-schoenlein purpura is a vasculitis of undefined etiology, since it has been associated with certain infectious agents (group A streptococci, mycoplasma, varicella, and Epstein-Barr virus), drugs (penicillin, tetracycline, aspirin, sulfonamides, and erythromycin), and various exposures (insect bites, chocolate, milk, and wheat). It most commonly occurs during the winter months and predominantly in males.51
Patients present with abdominal pain, arthritis, and purpura. The skin lesions are pathognomonic and most commonly begin on the dependent areas of the legs, the buttocks, and the extensor surfaces of the arms. The rash initially takes the form of erythematous, maculopapular lesions that blanch on pressure and become petechial and palpable purpura. The entire body may be involved, with the rash being distributed most extensively on the lower extremities. Colicky abdominal pain with bloody diarrhea is common, and intussusception can occur. Nephritis may develop, associated with hematuria, proteinuria, and other nephrosis. Transient migratory polyarthritis may be present, with the ankles, knees, or wrists being the most tender. Other findings include soft tissue edema of the scalp, ears, face, and dorsum of the hands and feet; testicular pain; and parotitis. Multisystem involvement occurs primarily in children 2 to 11 years of age. Note that scrotal involvement with purpura and edema along with hematuria can be confused with a traumatic cause.
Supportive care is warranted, with fluid resuscitation if there is evidence of gastrointestinal hemorrhage or hypovolemia. Underlying renal disease requires consultation with a nephrologist. Patients should be hospitalized unless skin manifestations are the only problem and good follow-up can be assured.
Acute glomerulonephritis may follow infections due to strains of group A beta-hemolytic streptococci, either from pharyngeal or cutaneous infection or from exposure to this organism 1 to 2 weeks before the onset of glomerulonephritis. The disease most commonly occurs in children between 3 and 7 years of age. The pathogenesis may include deposition of circulating immune complexes in the kidney. Signs and symptoms can vary and include fluid retention and edema, hypertension, fever, malaise, and abdominal pain. Oliguria of sudden onset may be evident as dark-brown urine or hematuria. Laboratory findings can include an abnormal urinalysis with a large amount of blood and protein as well as red cell casts on microscopic examination but normal urineconcentrating ability. Leukocyturia and hyaline and granular casts are commonly noted. The level of C3 complement is usually depressed during the first 2 weeks of the illness, and the antistreptolysin titer is elevated. Blood urea nitrogen is disproportionately elevated relative to serum creatinine.
The initial focus in management must be on fluid and salt restriction to maintain a normal intravascular volume, and a nephrologist should be consulted. In mild cases, blood pressure, weight, and urinalysis should be followed closely on an outpatient basis. Patients with uncontrolled hypertension, congestive heart failure, or azotemia should be hospitalized. In children, the prognosis for complete recovery from acute poststreptococcal glomerulonephritis is excellent.
There remains a paucity of data regarding the management of GU conditions in the prehospital setting. With this in mind, it appears plausible to focus on symptom relief, typically with narcotic analgesics and antiemetic agents. In addition, administration of intravenous fluids (as well as maintenance of "NPO" status) is prudent for any condition that may require procedural sedation or surgical intervention following ED arrival.
Once any genitourinary injuries have been assessed, patients who have penetrating injuries of the torso or pelvic fractures should be taken to the nearest trauma center.52-55 When in doubt, take the patient to a trauma center.
There remains a paucity of data regarding the management of GU conditions in the prehospital setting. With this in mind, it appears plausible to focus on symptom relief, typically with narcotic analgesics and antiemetic agents. In addition, administration of intravenous fluids (as well as maintenance of "NPO" status) is prudent for any condition that may require procedural sedation or surgical intervention following ED arrival.
Once any genitourinary injuries have been assessed, patients who have penetrating injuries of the torso or pelvic fractures should be taken to the nearest trauma center.52-55 When in doubt, take the patient to a trauma center. Initial Assessment and Management
If the patient has suffered major trauma, management should begin with the basics of advanced trauma life support. Once the patient has been stabilized, specific organ systems can be evaluated, including the genitourinary system. The initial assessment of genitourinary trauma involves (1) inspecting the patient's back for signs of injury and internal bleeding; (2) inspecting the perineum for contusions or hematomas, lacerations, and urethral bleeding, as well as performing a rectal examination in male patients before placing a urinary catheter; and (3) in female patients, inspecting the vagina for lacerations and the presence of blood in the vaginal vault. In patients with hypovolemic shock, the major source of bleeding may be the kidneys; shock from an isolated renal fracture is uncommon. Since the tight fascia surrounding the kidneys limits parenchymal bleeding to 25% or less of the total blood volume, the vast majority of traumatic urologic injuries are not life-threatening; however, failure to diagnose the injuries and a delay in treatment can lead to significant morbidity.
An initial screening test for hematuria is the urine dipstick. If the dipstick is positive for blood, a microscopic urinalysis should be performed. Remember that hematuria may be absent in some cases of genitourinary injury.
An anteroposterior pelvic plain film obtained to evaluate major trauma to the abdomen may also show genitourinary trauma. Signs of injury to the genitourinary system as seen on plain film include (1) loss of the psoas shadow in the presence of retroperitoneal blood; (2) scoliosis with concavity toward the side of the injury; and (3) fracture of a lower rib or transverse process.
Urethral injuries usually accompany anterior pelvic fractures. Straddle injuries can penetrate the urethra and perineum and may be an isolated injury. In patients with blunt trauma, a rectal examination can reveal a high-riding prostate, which indicates urethral disruption. Children are susceptible to bladder rupture owing to their shallow pelvis. Rupture of a hollow viscus requires early operative intervention. Appropriate urinary output is age-dependent. See Table 4 for normal values by age.
Hematuria is present in at least 75% to 95% of cases of renal trauma,9 but the degree of hematuria does not always correlate with the risk of injury.56,57 Renal vessels or the ureter may be severed in penetrating trauma without causing hematuria.58 Ureteropelvic junction injuries or renal pedicle injuries occur without hematuria in 25% to 50% of patients.59 Mild renal contusions can present with gross hematuria.60,61 Gross hematuria, shock, or significant deceleration injury are indications of renal injuries.62 Contusions, hematomas, or ecchymoses of the back or flank should raise suspicion of renal injury that requires CT or intravenous pyelography of the urinary tract. Patients who are hemodynamically unstable may require immediate surgery. Indications for evaluating the urinary tract are shown in Table 5.
A diagnosis of microscopic or occult hematuria requires the detection of 3 to 5 RBC per high-power field (HPF) or more than 5 RBC per 0.9 mm3 of urine.63,64 Renal injury increased to 8% when microscopic hematuria was greater than 50 RBC/HPF and to 32% in those with gross hematuria.65 Based on a retrospective study of 180 pediatric patients, imaging was not recommended for the initial evaluation of patients with insignificant microscopic hematuria (less than 50 RBC/HPF) without associated organ injury; however, imaging was recommended if microscopic hematuria persisted.66
CT has become the gold standard and the best initial imaging study for patients suspected of having renal injury. An abdominal CT scan with IV contrast describes the extent of damaged parenchymal tissue and perirenal hemorrhage or hematomas, extravasation of urine, renal pedicle or vascular injuries, and injuries to other intra-abdominal structures.
The focused abdominal sonogram, or Focused Assessment Sonography for Trauma (FAST) scan, has been popularized as a means of evaluating blunt abdominal trauma. However, the FAST scan cannot differentiate between blood, extravasated urine, and other types of free fluid in genitourinary trauma. Compared with CT, ultrasonography is less sensitive for identifying renal injuries.67,68
Blunt renal injuries can be treated nonoperatively in 95% of cases.55 Most children who are hemodynamically unstable after blunt renal trauma respond to rapid crystalloid fluid resuscitation. These children require admission to the intensive care unit for continuous monitoring. Major penetrating injuries to the kidneys with extravasation and hemodynamic instability usually require surgery.
About 56% of patients with ureteral injuries are hypotensive.31 Gross or microscopic hematuria is present in about 75% to 85% of these patients.31,69 If there is complete ureteral transection or an adynamic segment of ureter, hematuria may not be present.
Computed tomography with contrast is the best initial imaging study and is highly sensitive for detecting urine extravasation. After the initial scanning of the abdomen and pelvis, it is important to obtain a second scan, about 10 minutes after the injection of contrast, to fully evaluate the collecting system and to assess urinary extravasation.70 Ureteral transection is treated with ureteropyelostomy.
Hematuria is an indication for cystography, since 95% to 100% of patients with bladder injuries have gross hematuria; the remaining patients have microscopic hematuria.71,72 Another indication for cystography is no return of urine at catheterization, since bladder injuries are associated with urethral disruption in about 10% to 29% of cases.71 These patients have blood at the urethral meatus, are unable to urinate, or have perineal ecchymosis. A retrograde urethrogram should be obtained to evaluate the urethra before attempting catheterization and cystography. Bladder rupture requires surgical consultation for possible exploration, repair, debridement, and drainage. Contusions of the bladder are self-limited.
Table 6 lists the indications for retrograde urethrography before inserting a urinary catheter. Urethral disruption may require insertion of a suprapubic tube.
Urinalysis is recommended in cases of significant penile injury. Indications for retrograde urethrography in penile fractures include gross hematuria, blood at the meatus, or the inability to void. Consider a scrotal ultrasound or cavernosography as an adjunct to the physical examination in cases of penile fractures.73,74
Most penile injuries are minor and can be treated conservatively. Superficial lacerations of the penis can be repaired as in any other laceration. Treatment of zipper injuries to the foreskin includes using cutters to break the bridge of the sliding piece of the zipper.
Scrotal exploration is recommended with the presence of a large hematocele or rupture of the tunica albuginea.75 Urologic consultation is recommended in corpus cavernosal ruptures.
Penile fractures can be treated conservatively except when there is penile deformity or urethral involvement. Urethral injuries occur in about onethird of patients with penile fractures.76
Tourniquet injuries usually involve removal of the band of hair and the treatment of any infection. If deeper injury is suspected, follow-up with a urologist is recommended.
Renal ultrasound has been recommended as a way to screen for renal injuries, but its efficacy has not been proven.19 The CT scan is the study of choice for renal trauma, since it can determine degree of renal parenchymal injury, evaluate nonviable tissue, detect urine extravasation and perirenal fluid collections, and diagnose pedicle injuries. Intravenous pyelography has traditionally been the imaging study of choice for suspected renal trauma77; however, when compared with CT scanning, the sensitivity of IVP may be as low as 50%.66
The management of suspected pediatric renal trauma remains controversial.17 Nonoperative, conservative management is successful in up to 95% of children.78 Older studies have shown a nonoperative success rate of 84% to 89%,17,79-81 and 5% require surgical repair or nephrectomy, but the overall renal salvage rate is 98.8%.78
From 3% to 10% of trauma patients will have genitourinary tract injuries.2,3 Hematuria is the hallmark of genitourinary trauma. A urinalysis should be performed in all patients with major trauma and in those with minor genitourinary injury. Renal and urinary tract imaging is indicated in patients who present with penetrating trauma, gross hematuria, blunt trauma with shock or microscopic hematuria, clinical signs indicating abdominal-organ injury, and significant deceleration injury, as shown in Figures 1 to 3. Computed tomography with contrast is the best initial imaging study to demonstrate the depth of injury and involvement of vessels or the collecting system and thereby accurately grade the injury according to the system proposed by the American Association for the Surgery of Trauma. Patients with pelvic injuries and gross hematuria should undergo cystography.
The genitourinary tract has an amazing ability to heal itself if the flow of urine can be maintained without obstruction. The majority of renal injuries can be managed conservatively.
Children often present to the emergency department with injuries that suggest sexual abuse, yet in most cases the findings on genital examination are normal. For patients who have had sexual contact within 72 hours of presentation, the collection of forensic evidence may be required.
The patient was evaluated by the trauma team and connected to cardiac and pulmonary monitors. Her initial laboratory results showed a hemoglobin of 12.8 g/dL and a hematocrit of 38.3%. A renal function panel showed a blood urea nitrogen of 18 mg/dL and creatinine of 0.7 mg/ dL. A complete urinalysis showed too many to count rbc / hpf. Abdominal and pelvic CT with contrast revealed a grade III laceration of the right kidney that extended through the proximal collecting system and a large, perinephric fluid collection. Delayed-phase CT of the right kidney showed extravasation from the collecting system of the right upper pole moiety. Interval enlargement of the perinephric fluid collection compatible with blood and urine was also seen with mildly increased anterior displacement of the right kidney. The amount of intermediate- density ascites was slightly increased in the abdomen and pelvis, and the composition was compatible with urine. The patient was admitted to the pediatric intensive care unit for continued monitoring, and a urologist was consulted. Because of severe concurrent liver laceration, she was hospitalized for 9 days, during which she remained hemodynamically stable.
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, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Joyce C. Arpilleda
May 1, 2010
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