Genitourinary Trauma

GU Trauma Overview - Basics & Beyond

• Mechanisms: Blunt (MVCs, falls, assaults; ~80-85%), Penetrating (GSW, stabs).
• Initial Approach: ATLS guidelines. Suspect with pelvic fractures, flank/lower abdominal pain, hematuria.
• FAST exam: May detect free fluid (blood) suggesting intra-abdominal or retroperitoneal injury.
• Key Signs: Hematuria (gross/microscopic), flank pain/ecchymosis (Grey Turner's sign), blood at urethral meatus.

⭐ Blood at the urethral meatus is a cardinal sign of urethral injury; blind Foley catheterization is contraindicated. Perform RUG first.

Renal Trauma - Kidney Calamities

• Most common GU injury; blunt trauma predominates.
• Signs: Hematuria (gross/micro), flank pain/ecchymosis, Grey Turner's sign.
• AAST Renal Injury Scale (I-V) guides management:
  • I: Subcapsular hematoma/contusion.
  • II: Cortical laceration <1 cm, no extravasation.
  • III: Cortical laceration >1 cm, no extravasation.
  • IV: Collecting system laceration OR vascular injury (main artery/vein).
  • V: Shattered kidney OR hilar avulsion.
• Imaging: CECT (Contrast-Enhanced CT) is gold standard.
• Management:
  • Non-operative (NOM) for most hemodynamically stable Grades I-III & selected IV.
  • Surgery for: Hemodynamic instability, expanding/pulsatile hematoma, Grade V, UPJ avulsion.

⭐ UPJ disruption can occur with minimal or no hematuria, especially in pediatric deceleration injuries or penetrating trauma near hilum.

Ureter & Bladder Trauma - Leaky Pipes

• Ureteral Injury:
  • Causes: Iatrogenic (gynae/colorectal surgery) > penetrating trauma.
  • Dx: Delayed (fever, urinoma); CT urogram (gold standard), retrograde pyelography.
  • Rx: Stenting; surgical repair (uretero-ureterostomy, ureteroneocystostomy, Boari flap, psoas hitch).
• Bladder Injury:
  • Often with pelvic fractures. Gross hematuria common.
  • Dx: Retrograde cystogram / CT cystography.
    • 📌 Mnemonic: "Bladder on the floor, and 4 more" (pelvic #, gross hematuria, abd tenderness, shock, perineal/scrotal hematoma) - indications for cystography.
  • Types & Rx:
    • Contusion: Conservative.
    • Extraperitoneal: Catheter drainage (7-14 days); surgery if bladder neck injury/bone fragments.
    • Intraperitoneal: ALWAYS surgical repair (laparotomy).

      ⭐ Intraperitoneal bladder rupture requires surgical repair due to risk of chemical peritonitis. oka

Urethral Trauma - Tube Troubles

• Types & Mechanism:
  • Posterior (PUI): Pelvic # (membranous/prostatic). Associated with bladder neck injury.
  • Anterior (AUI): Straddle injury (bulbous), penetrating.
• Clinical Triad (PUI): Blood at meatus, inability to void, palpable bladder.
  • Other signs: Perineal/scrotal hematoma ("butterfly" for AUI), high-riding prostate (PUI).
• Diagnosis: Retrograde Urethrogram (RUG). ⚠️ No Foley before RUG if suspected.
• Management: Initial Suprapubic Cystostomy (SPC) for complete tears/failed Foley. Definitive: Delayed repair (3-6 months).

⭐ Blood at the meatus is the single most important sign of urethral injury.

External Genitalia Trauma - Genital Gear Gaffes

• Penile Trauma:
  • Fracture ("Eggplant Sign"): Tunica albuginea rupture (often coitus-related). Urgent surgical repair.
  • Zipper Entrapment: Common in boys. Mineral oil, gentle release. Rarely, dorsal slit.
  • Strangulation (rings/bands): Remove constricting object; may need specialized tools.
• Testicular Trauma:
  • Blunt (sports, kicks): Hematoma, contusion, rupture. Ultrasound is diagnostic.
  • Scrotal Avulsion (degloving): Requires skin grafting or thigh pouches for testicular preservation.
• Female Vulvar Trauma:
  • Straddle injuries: Most common. Results in hematomas, lacerations. Often conservative management.

  ⭐ Testicular rupture: High suspicion with direct trauma, severe pain, nausea/vomiting. Surgical exploration within 72 hours offers best salvage rates.

High‑Yield Points - ⚡ Biggest Takeaways

• Renal trauma is most common, usually blunt; hematuria is a cardinal sign, but not always present.
• CT with IV contrast is the diagnostic gold standard for renal and ureteric injuries.
• Posterior urethral injury is often linked to pelvic fractures; suspect with blood at meatus or high-riding prostate.
• Intraperitoneal bladder rupture (dome) mandates surgical repair; extraperitoneal often managed conservatively.
• Testicular rupture requires prompt surgical exploration and repair to salvage the testis.