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INTRODUCTION

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Falls, assaults, motor vehicle crashes, and sports injuries are the most common mechanisms for blunt genitourinary injuries, whereas gunshot wounds and stab wounds are the most common causes for penetrating injuries.1 The majority of ureteral injuries are caused by penetrating trauma.1,2 Bladder injuries are typically caused by pelvic fracture, with urethral injuries seen in 5% to 10% of pelvic fractures.1,3 Children are more susceptible to genitourinary injury than the general population. Children lack periadipose tissue, and kidney size is large relative to overall body size.4 Appropriate management will minimize or prevent complications such as renal function impairment, urinary incontinence, and sexual dysfunction.

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CLINICAL FEATURES

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HISTORY

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Obtain a detailed history to determine the time and mechanism of injury and the magnitude of forces involved. In motor vehicle crashes, seat location, use of restraints, vehicle speed, and crash details provide information about forces applied to the victim. Sudden deceleration can cause major vascular disruption and parenchymal damage to the kidneys and bladder, even in the absence of symptoms and physical findings. For penetrating trauma, obtain information about the caliber of weapon or type of knife, its length, any contamination, and whether removed intact.

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An inability to urinate may be due to an empty bladder or inability to void because of pain, but can also result from bladder perforation, urethral injury, or spinal cord injury.

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PHYSICAL EXAMINATION

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Inspect the perineum during the secondary survey. Blood on the underwear or pants is an important finding and may suggest genital trauma. Inspect the folds of the buttocks for ecchymoses, abrasions, or lacerations, which may be related to an open pelvic fracture. Do not deeply probe perineal injuries because probing could disrupt a clot.

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Rectal examination identifies sphincter tone, position of the prostate gland, and presence of blood. If the prostate is "missing" or riding high or feels boggy, assume disruption of the membranous urethra until proven otherwise. In males, examine the scrotum for ecchymoses, laceration, and testicular disruption. Palpate and inspect the penis for ecchymoses, deformity, and blood at the meatus. In females, examine the vaginal introitus for lacerations and hematomas. Lacerations and hematomas can accompany pelvic fracture. Perform a speculum examination when vaginal bleeding or hematoma is present to exclude vaginal laceration. Complications of missed vaginal injuries include infection, fistula formation, and hemorrhage.

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KIDNEY INJURIES

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DIAGNOSIS

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Renal injury is present in up to 10% of patients with abdominal trauma.1,3 Because of the protected position of the kidneys, most injuries are associated with other intra-abdominal injuries.5 Flank contusions or ecchymosis, palpable mass, lower rib fractures, and penetrating wounds in the flank mandate consideration of renal injury. Renal injuries consist of lacerations, avulsions, and hematomas to the kidney itself and renal ...

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