Genitourinary (GU) injuries frequently occur in the setting of multiple trauma, so a thorough evaluation is necessary to avoid missing significant injuries.
Injuries should be suspected with any blunt or penetrating trauma near the GU tract, including any rapid deceleration, which can cause major vascular or parenchymal injury even without specific signs or symptoms. Hematuria of any amount raises the index of suspicion for GU injury, and difficulty with urination can be due to bladder or urethral injury or associated concomitant spinal cord injury. Flank contusions or hematomas, evidence of lower rib fractures, or penetrating flank injuries raise concern for renal injury. Lower abdominal pain, tenderness, ecchymosis, or evidence of a pelvic fracture as well as perineal or scrotal edema is consistent with possible bladder injury. Vaginal bleeding, high-riding prostate, perineal hematoma, and/or blood at the urethral meatus are consistent with urethral disruption.
There is no direct relationship between the degree of hematuria and the severity of renal injury. There is some evidence that gross hematuria or microscopic hematuria in patients with a blood pressure <90 mm Hg is associated with more significant injury. An IV contrast-enhanced abdominal/pelvic CT scan is the imaging “gold standard” for the stable trauma patient with suspected kidney injury (Table 167-1). A “one-shot” intraoperative IV urogram is recommended by some for the unstable patient, though this is controversial. A retrograde cystogram (plain film or CT) is the “gold standard” for demonstrating bladder injury, and a retrograde urethrogram is indicated for demonstrating urethral injury. Color Doppler ultrasonography is the preferred imaging technique for investigating closed scrotal and testicular injury.
Table 167-1 Indications for Imaging in Patients with Suspected Renal Trauma |Favorite Table|Download (.pdf)
Table 167-1 Indications for Imaging in Patients with Suspected Renal Trauma
Any degree of hematuria
Adult with blood pressure <90 mm Hg and any degree of hematuria
Child with >50 red blood cells per high power field
High index of suspicion for renal trauma
Deceleration injuries (especially vertical) even with no hematuria
Suspected other associated intraabdominal or intrapelvic injuries (multiple trauma patient)
Take a standardized approach to all multiple trauma patients to identify and treat life-threatening injuries (primary survey) and then perform a thorough secondary survey, including a GU examination, to diagnose all injuries. Obtain appropriate diagnostic imaging and laboratory testing as indicated by the initial history and examination.
Various kidney injuries include contusions, hematomas, lacerations, and completely shattered kidneys with or without vascular injury. Eighty percent of patients with kidney injury have additional visceral or skeletal injuries that complicate their management. Most renal injuries are handled nonoperatively, but indications for operative treatment include life-threatening bleeding from the kidney; expanding, pulsatile, or noncontained hematoma (thought to be from an avulsion injury); and renal avulsion injury (Fig. 167-1). There are little data to support specific treatment recommendations for patients with isolated renal trauma. Patients with microscopic hematuria and no indication for imaging can be discharged home with instructions for no strenuous activity and follow-up in 1 to 2 weeks for repeat ...