Trauma of Urinary Tract

Dr.M.Galuh Richata,SpU

Trauma of Urinary Tract

Trauma of the:
Kidney Ureter Bladder Urethra

Basic Principle of Trauma Life Support

Primary Survey
A = Airway Control and C-Spine Control B = Breathing Control and Adequate Oxygenization C = Circulation Control and Bleeding Control D = Disability

Secondary Survey:
E = Exposure and Environment Control

Trauma of the Kidney

Blunt Trauma (most common mechanism, 80-85% of all renal injuries, cause: vehicle accidents, falls, fights, contact sports)

Penetrating Trauma (gunshot, knife)

Rapid Deceleration Trauma (vehicle collisions, falls)

Kidney Trauma
Signs & Symptoms Pain (localized to flank, or over abdomen) Hematuria Retroperitoneal bleeding abdominal distention, ileus, nausea & vomiting Shock (large loss of blood) Ecchymosis in the flank or UQ abdomen Palpable mass Blood into the peritoneal cavity acute abdomen diffuse abdominal tenderness, bowel sounds absent.

Kidney Trauma
Laboratory Findings Urine : Hematuria (gross/microscopic) Blood: serial hematocrit shows a decline Imaging CT Scan with IV contrast IVU with double dose IV contrast Arteriography Ultrasound (not sensitive)

Kidney Trauma
Classification of Renal Injuries Grade I: - Contusion - Subcapsular Hematoma

Kidney Trauma
Grade II : - Confined perirenal hematoma - Cortical laceration < 1 cm - No urine extravasation

Kidney Trauma
Grade III : - Laceration > 1 cm (into the cortex) - No urine extravasation

Kidney Trauma
Grade IV : - Laceration into corticomedullary junction and into the collecting system (urine extravasation) - Laceration to segmental vessel may present

Kidney Trauma
Grade V : - Multiple major lacerations (shattered kidney) - Avulsion of the main renal vessel

Kidney Trauma
Management Minor Renal Trauma (grade I-III) - Mostly do not need exploration - Bed rest, hydration, monitoring Major Renal Trauma (grade IV-V) - Exploration through Laparatomy Most penetrating injuries needs exploration

Trauma of the Ureter

Quite rare Mostly due to:
Instrumental trauma during pelvic surgery Penetrating injuries (knife or gunshot) Rapid deceleration accidents.

Trauma of the Bladder

Mostly from external force (often associated with pelvic trauma/fractures) Other cause: Instrumental trauma during pelvic/gynaecologic surgery

Trauma of the Bladder

Types of Bladder Ruptures Extraperitoneal Rupture - Most common - Associated in pelvic fractures Intraperitoneal Rupture - Extravasation urine in the peritoneum cavity - Sudden force to a full bladder

Trauma of the Urethra

Occur most in men Associated with: - Pelvic fractures Posterior Urethra - Straddle injury Anterior Urethra

Trauma of the Urethra

Trauma of Posterior Urethra

Commonly occur from blunt trauma and pelvic fractures. Urethra rupture at the proximal of urogenital diaphragm

Trauma of Posterior Urethra

Signs & Symptoms - Inability to urinate/void (retentio urine) - Lower abdominal pain, suprapubic tenderness - History and presence of crushing injury to the pelvis - Meatal bleeding (most important sign!) - DRE: Large pelvic hematoma with prostate displaced superiorly (floating prostate/high riding prostate)

Trauma of Anterior Urethra

Commonly caused by Straddle Injury Mechanism: A blow to perineal region or fall astride an object, with the perineal region hit the object. The urethra is crushed between the object and the inferior edge of the symphysis.

Other cause: instrumentation such as catheterization.

Trauma of Anterior Urethra

Signs & Symptoms - Mostly same with Posterior Trauma - Swelling & hematoma of the scrotum - Hematoma of the perineal region (butterfly hematoma)

Trauma of the Urethra

Imaging Retrograde Urethrography

Retrograde Urethrography
If there is contrast extravasation with contrast in the bladder Partial rupture If there is only contrast extravasation (no contrast in the bladder) Complete Rupture

Retrograde Urethrography
Partial Rupture

Retrograde Urethrography
Complete Rupture

Trauma of the Urethra

Management Absolute contraindication for catheterization Indication for Cystostomy or Bladder Puncture.