Urogenital InjuriesUrogenital InjuriesUrogenital injuries in trauma patientsUrogenital injuries in trauma patients Renal injuryRenal injury Ureteral injury (infrequent/iatrogenic) Ureteral injury (infrequent/iatrogenic) Bladder injuryBladder injury Urethral injuryUrethral injury Scrotal and penile injuries (infrequent) Scrotal and penile injuries (infrequent)Renal InjuryRenal InjuryRenal ProtectionRenal ProtectionWell protected but fragile Well protected but fragile Psoas major muscle Psoas major muscle VertebraVertebraRibsRibsCapsuleCapsulePerirenal fatPerirenal fatFasciaFasciaKidneys with existing pathologicKidneys with existing pathologicconditions such as hydronephrosis or conditions such as hydronephrosis or malignant tumors are more readily malignant tumors are more readily ruptured from mild trauma.ruptured from mild trauma.EtiologyEtiology1. Blunt trauma (90-95%)1. Blunt trauma (90-95%) Motor vehicle accidents Motor vehicle accidents Falls from heights Falls from heights Assaults Assaults2. Penetrating trauma ( 10%)2. Penetrating trauma ( 10%) Gunshot Gunshot Stab wounds Stab woundsGrade IGrade IContusionContusion or contained subcapsular or contained subcapsular hematoma without parenchymal lacerationhematoma without parenchymal lacerationGrade IIGrade IIConfined perirenal hematoma or cortical Confined perirenal hematoma or cortical lacerationlaceration 1 cm deep without urinary 1 cm into the cortex Laceration extending 1 cm into the cortex without urinary extravasationwithout urinary extravasationGrade IVGrade IVLaceration extending through Laceration extending through corticomedullary junction and into the corticomedullary junction and into the collecting systemcollecting systemEarly pathologyEarly pathologyGrade VGrade VMultiple major lacerations, “shattered” kidneyMultiple major lacerations, “shattered” kidneyGrade VGrade VAvulsion of main renal artery or vein or bothAvulsion of main renal artery or vein or bothLate pathologyLate pathologyUrinomaUrinomaHydronephrosisHydronephrosisArteriovenous fistulaArteriovenous fistulaRenal vascular hypertensionRenal vascular hypertensionHaematuriaHaematuriaNo correlation to extent of injuryNo correlation to extent of injuryMay not be present (30%)May not be present (30%)Clinical PresentationClinical PresentationShockShockPainPainMassMassLarge retroperitoneal hematoma or urinary Large retroperitoneal hematoma or urinary extravasationextravasationLarge loss of blood from heavy retroperitoneal Large loss of blood from heavy retroperitoneal bleeding or associated injuriesbleeding or associated injuriesFlank or upper quadrants of the abdomenFlank or upper quadrants of the abdomenDiagnosisDiagnosis1. History and physical examination1. History and physical examination2. Chemical examination2. Chemical examination3. Imaging investigation 3. Imaging investigation (1) (1) Ultrasonography Ultrasonography (Non-invasive)(Non-invasive) (2) (2) CT CT (Most valuable, even plain scan)(Most valuable, even plain scan) (3) IVU (3) IVU (4) Arteriography (DSA) (4) Arteriography (DSA)LacerationLacerationContrast-enhanced CT of the Contrast-enhanced CT of the mid-abdomen reveals mid-abdomen reveals a linear zone of low attenuation a linear zone of low attenuation through the left kidney with a through the left kidney with a deep renal laceration deep renal laceration Hematoma & urinary extravasationHematoma & urinary extravasationShattered kidneyShattered kidneyManagementManagement1. Emergency treatment1. Emergency treatment2. 2. Conservative treatmentConservative treatment (1) Absolutely bed rest (1) Absolutely bed rest (2) Serial observation(Hb,Urine) (2) Serial observation(Hb,Urine) (3) Haemostasis (3) Haemostasis (4) Antibiotics (4) Antibiotics (5) Symptomatic relief (5) Symptomatic relief3. Operative management (Renal embolization3. Operative management (Renal embolization, , Renal exploration)Renal exploration)4. Management of complications4. Management of complicationsUreteral InjuryUreteral InjuryUreteral injuryUreteral injury1. Operative injury1. Operative injury (Iatrogenic(Iatrogenic ) ) (1) Gynecological, abdominal, or pelvic surgery (1) Gynecological, abdominal, or pelvic surgery (2) Urological procedure (2) Urological procedure 2. Penetrating injury2. Penetrating injury 3. Radiotherapy3. Radiotherapy (Iatrogenic (Iatrogenic ) ) Gynecological, abdominal, or pelvic tumorGynecological, abdominal, or pelvic tumorHaematuriaHaematuriaClinical PresentationClinical PresentationUrinary extravasationUrinary extravasationUrinary fistulaUrinary fistulaUpper urinary tract obstructionUpper urinary tract obstructionManagementManagement1. Stenting (Double pigtail)1. Stenting (Double pigtail)2. Surgery2. SurgeryBladder InjuryBladder Injury1. Open injury1. Open injury2. Closed injury2. Closed injury(1) Extraperitoneal(1) Extraperitoneal(2) Intraperitoneal(2) IntraperitonealPathologyPathologyDirect blow over the full bladder causesDirect blow over the full bladder causesbladder ruptures into the peritoneal cavitybladder ruptures into the peritoneal cavityPelvis fracturePelvis fractureClinical featuresClinical features1. Shock1. Shock2. Abdominal pain 2. Abdominal pain 3. Hematuria, difficulty in voiding 3. Hematuria, difficulty in voiding 4. Urinary fistula4. Urinary fistulaDiagnosisDiagnosis1. History and physical examination1. History and physical examination2. Catheterization (Bladder filling test: 300ml)2. Catheterization (Bladder filling test: 300ml)3. Cystography3. CystographyExtraperitonealIntraperitonealIntraperitonealManagementManagement1. Emergency treatment 1. Emergency treatment Drainage, antishock, antibiotic Drainage, antishock, antibiotic2. Conservative treatment2. Conservative treatment Drainage and antibioticDrainage and antibiotic3. Surgery3. Surgery IntraperitonealIntraperitoneal Extraperitoneal Extraperitoneal Severe bladder rupture,Severe bladder rupture, Associated injuries Associated injuriesUrethral InjuryUrethral InjuryInjury to posterior urethraInjury to posterior urethraWhen pelvic fractures occur from blunt trauma, the When pelvic fractures occur from blunt trauma, the membranous urethra is membranous urethra is shearedsheared from the prostatic from the prostatic apex at the prostatomembranous junction.apex at the prostatomembranous junction.The prostate has been avulsed from the membranousurethra secondary to fracture of the pelvis. Extravasationoccurs above the triangular ligament and isperiprostatic and perivesical.Injury to posterior urethraInjury to posterior urethraThe prostate has been avulsed from the The prostate has been avulsed from the membranous urethra secondary to fracture of the membranous urethra secondary to fracture of the pelvis. pelvis. Extravasation occurs above the triangular ligament Extravasation occurs above the triangular ligament and is periprostatic and perivesical.and is periprostatic and perivesical.Key Point of injuryKey Point of injuryInjury to anterior urethra (bulbous)Injury to anterior urethra (bulbous)Perineal blow or fall astride an object; crushing of Perineal blow or fall astride an object; crushing of urethra against inferior edge of pubic symphysisurethra against inferior edge of pubic symphysisExtravasation of blood and urine enclosed within Extravasation of blood and urine enclosed within Colles fasciaColles fasciaKey Point of injuryKey Point of injuryClinical manifestationClinical manifestationPain Pain Difficult in voidingDifficult in voidingUrethra bleedingUrethra bleedingHemotoma and urinary extravasationHemotoma and urinary extravasationposterial urethraposterial urethraShockShockPelvic fracturePelvic fractureDiagnosisDiagnosis1. History and physical examination1. History and physical examination2. DRE2. DRE3. Catheterazation3. Catheterazation4. Urethrography4. UrethrographyFloating prostate moving up and backwardFloating prostate moving up and backwardTreatment except for complete ruptureTreatment except for complete ruptureExtravasation & No contrastExtravasation & No contrastentering the prostatic urethraentering the prostatic urethraExtravasation from Extravasation from ruptured ruptured bulbar urethrabulbar urethraManagementManagement1.Emergency treatment1.Emergency treatment Compressing and antishock, treatment for Compressing and antishock, treatment for associated injuryassociated injury2. Contusion and laceration2. Contusion and laceration Drainage and antibiotic Drainage and antibiotic 3. Laceration3. Laceration Drainage Drainage 4. Rupture4. Rupture Operation Operation Superpubic cystostomy, Drainage of extensive Superpubic cystostomy, Drainage of extensive urinary extravasation, Primary realignment, Repair or urinary extravasation, Primary realignment, Repair or anastomosis, Urethroplastyanastomosis, Urethroplasty