Genitourinary Trauma - Diagnosis and Treatment

Introduction:

Even though the vast genitourinary (GU) tract injuries do not threaten an immediate threat to life, the inability to adequately diagnose these injuries may result in considerable long-term patient morbidity. GU injuries typically occur due to multiple organ system trauma; other potentially fatal injuries must be treated first. GU injuries usually occur in the context of multiple organ system trauma, and other potentially fatal injuries must be handled first. Indications of potentially major genitourinary injuries, such as lower rib or lumbar vertebral fractures, flank hematoma, pelvic fracture, abnormal prostate examination, excessive hematuria (blood in the urine), or blood at the urethral meatus, necessitate additional diagnosis and treatment.

Urologic injuries affect ten to 20 percent of severe trauma patients and can be caused by blunt or penetrating trauma. Upper urinary system injuries (kidneys and ureters) typically require high force, while lower tract trauma may occur from a more limited, less powerful damage. Injuries to the bladder and upper urethra seldom produce substantial shock independently but are associated with significant hemodynamically pelvic fractures. Additionally, injuries to the lower urethra or external genitalia are frequently the consequence of localized trauma. In these circumstances, the genitourinary system is frequently injured. Diagnosing urologic injuries involves a comprehensive examination of the urinary system in the presence of other injuries.

What Is the Anatomy of the Genitourinary Tract?

• The GU system is classified into three areas, each with its unique injury pattern.

  • The upper tract consists of the renal arteries, kidneys, and ureters.

  • The bladder and the posterior section of the urethra comprise the lower tract.

  • The anterior urethra, penis, scrotum, and testicles in males comprise the male external portion, whereas the labia, clitoris, hymen, and urethral meatus comprise the female external part.

• The renal artery arises from the aorta and enters the kidney at the hilum on the medial side of the kidney. The renal vein runs from the hilum to the vena cava and is anteriorly below the renal artery. The hilum is also the location of the renal pelvis, which collects urine from the kidney and distributes it to the ureter.

• The kidney is located retroperitoneally inside the paravertebral gutter. The upper part of the kidneys is located underneath the eleventh and twelfth ribs and extends inferiorly to the fifth lumbar vertebra. The right kidney is more or less lower than the left kidney.

• Vertebral fractures or ribs in this location are frequently connected with kidney damage. The ureter emerges from the renal pelvis and travels down the psoas muscle to the trigone, where it reaches the bladder.

• In children, the bladder expands superiorly into the belly, going down to the pelvic cavity in adolescence. The upper part of the bladder (the dome) is in close touch with the peritoneum and has the weakest muscle wall.

• The puboprostatic ligaments securely hold the lower section of the bladder to the pelvis in males, while the urogenital diaphragm is lightly connected to the bladder in females. The firm attachment in males renders the juncture between the bladder and the urethra vulnerable to shearing injuries. However, females' greater mobility reduces the possibility of interruption at this junction.

What Are the Injuries to the Kidneys?

Similar to any genitourinary trauma, the diagnosis of renal injury starts with an investigation of the type of damage, an assessment for the existence of concomitant injuries, a thorough physical examination, and a urine analysis. Renal trauma accounts for eight to ten percent of all serious intra-abdominal injuries. Renal damage is more likely to develop in blunt trauma than penetrating trauma. Kidney injuries can be categorized according to their severity. Injuries can be described as mild, major, or catastrophic type 1 to type IV.

• A mild injury occurs when damage to the kidney is confined to a bruise or tiny laceration that does not necessitate medical attention.

• A major injury impacts the renal vasculature or the collecting system.

• A catastrophic injury is several lacerations to the kidney or any injury involving the renal pedicle. The most widely used categorization scheme specifies four distinct forms of injuries.

  • A category I injury equals a mild injury, a little laceration or bruise that does not necessitate surgical intervention.

  • Category II injuries are deep lacerations of the collecting system.

  • A Type III injury is distinguished by significant tearing, a damaged kidney, or an injury affecting the renal pedicle. The vast majority of Type III injuries need surgical intervention.

  • A category IV injury occurs when the kidney is severed at the ureteropelvic junction (UPJ) and vascular pedicle. This damage necessitates surgery and is typically followed by a nephrectomy.

What Are the Diagnostic Evaluation of Renal Injuries?

• With the growing use of computed tomography (CT) scanning and ultrasonography, the assessment of individuals with probable renal damage has greatly changed.

• A "one-shot" intravenous pyelogram (IVP) can be performed before or during surgery to validate the function of the second kidney.

• According to current research, the best test for evaluating possible renal injury is a helical CT scan with immediate post-contrast and delayed imaging (which allows imaging of the renal collecting system). CT imaging appears to offer a 90 to 100 percent sensitivity for identifying kidney damage.

What Is the Management of Renal Injuries?

• Treating renal injuries has evolved more conservatively, and it believes that most injuries can currently be handled nonoperatively.

• When surgery is required, every attempt should be made to save the injured kidney. Minor or Type I renal damage should be treated initially with observation only.

• Most Type II injuries may be treated without surgery, but a small percentage may fail to heal or advance, necessitating surgical intervention.

• Major, Type III, and penetrating injuries require necessary surgical examination. Recent research suggests that a portion of these injuries can be followed carefully.

• Type IV injuries necessitate surgical examination and are typically followed by nephrectomy.

What Are the Injuries to the Ureter?

Usually, the ureters are the least damaged part of the urogenital system and are rarely damaged independently. Injuries can be caused by either blunt or penetrating trauma, with penetrating injuries accounting for the vast majority (80 to 90 percent). Due to the rare occurrence of ureter injuries and their complexity, many are identified intraoperatively or when consequences arise after a missed injury.

Penetrating Injuries:

• Direct damage occurs only in just a small fraction of penetrating abdominal or flank wounds because the size of the ureter is small, with reported instances of two to five percent in gunshot wounds to the flank.

• Radiologic diagnosis of ureteral damage can also be challenging, even if intravenous pyelograms (IVP) fail to predict the injury. The best way of diagnosis is knowledge of the risk of damage and comprehensive examination in the operating room by the surgeon.

• Even after surgical investigation, injuries are overlooked in 15 to 70 percent of patients. Intraoperative utilization of indigo carmine dye may aid in the detection of damage. Suturing the ureter over a stent can be used to heal penetrating injuries.

• Penetrating injuries, the repair is generally accomplished by either direct re-anastomosis or stenting and temporary diversion.

• Blunt Injuries: Blunt ureter injuries are common in youngsters and typically occur near the ureteropelvic junction (UPJ). Since the children's spine is so mobile, significant hyperextension of the lower trunk, such as in a car accident, can cause shearing of the ureter from the kidney at the UPJ. A CT scan or IVP can be used to diagnose UPJ disturbance. Disruption is frequently identified following surgical exploration because it is frequently linked to significant injuries and hemodynamic instability.

What Are the Injuries to the Bladder?

Bladder trauma can be classified as blunt or penetrating and intraperitoneal or extraperitoneal. The bulk of instances includes blunt injuries ranging from 60 to 85 percent. Bladder rupture caused by physical trauma can be:

• Intraperitoneal (the peritoneal surface has been ruptured with urinary extravasation into the abdomen).

• Extraperitoneal (urine leaking is restricted to the perivascular space).

• Combined Intraperitoneal and Extraperitoneal Damage: It occurs in five to 20 percent of instances. In the case of penetrating trauma, a similar distinction might be established.

• Intraperitoneal Bladder Rupture:

• When the force of a direct hit is transferred to a full bladder, it causes intraluminal pressure to increase. The bladder wall will burst if the pressure surpasses 300 mmHg.

• This is most commonly seen at the dome of the bladder, which is the weakest area in the wall. Since the peritoneum is mirrored on the bladder's upper region, a dome tear leads to urine leaking into the abdominal cavity.

• A motor vehicle collision is the most prevalent damage mechanism in intraperitoneal bladder injury. The seatbelt can transmit forces to the urinary bladder, and injuries are more common in patients with a full bladder.

• Women are more prone than males to experience intraperitoneal bladder rupture, probably due to weaker muscle in the bladder wall.

• It is also more prevalent in youngsters due to the bladder's higher placement in the belly (rather than being shielded by the bony pelvis as in adults) and the thinner, less developed bladder wall muscles.

• Extraperitoneal Bladder Rupture:

• Extraperitoneal bladder rupture is usually often linked with pelvic fractures. Bladder damage happens in five to ten percent of all pelvic fractures. Lacerations to the bladder by bone spicules are usually assumed to cause bladder damage.

• It has also been hypothesized that damage occurs as a consequence of rips at ligamentous attachments or tears as a consequence of the force of blunt trauma.

• The bladder is encircled by loose connective tissue (the Retzius gap), which can lead to the formation of an extraperitoneal urinoma. Most bladder neck rips happen on the lateral side of the bladder neck, either ipsilateral or contralateral to the pelvic fracture.

• The initial urinary discharge following the Foley catheter implantation is the most critical indicator of the presence of a bladder injury. The lack of gross hematuria in patients without pelvic fractures can confidently rule out bladder injury.

• On physical examination, additional signs of bladder damage are blood at the urethral meatus, difficulty urinating, a strongly palpable intra-abdominal bladder, and suprapubic pain or no urine flow after Foley catheter placement.

How Is the Bladder Rupture Diagnosed?

• CT or traditional cystography can be used to evaluate the bladder. Before inserting a Foley catheter for retrograde cystography, be verified that there is no urethral damage. CT and traditional cystography are also good methods for detecting bladder wall damage.

• The contrast substance will spread into the abdomen and pool around intestinal loops if the intraperitoneal bladder ruptures. To conduct cystography, inject 200 to 300 cc's of water-soluble contrast media using a Foley catheter with a Toomey syringe. When the bladder is full, a slight contraction causes a short rise in the syringe's contrast.

• The infusion should have ceased, and Foley clamped at this point. It is important to note that post-void X-rays are required since the full bladder may conceal minor posterior or anterior extravasations.

• Also, caution must be taken when inserting the contrast medium since leaking the contrast medium onto the patient or backboard might result in false positive cystograms.

How Is Bladder Rupture Treated?

All intraperitoneal bladder ruptures necessitate surgical investigation and direct repair by a layered closure. Blunt extraperitoneal injuries can be treated surgically, surgically, or nonsurgically using suprapubic or Foley catheter drainage.

Conclusion:

The treatment of genitourinary damage is difficult. The decision between conservative and surgical treatment for genitourinary trauma is critical for the best possible result, especially in cases with renal damage. Repairing external genital injuries as soon as possible can give excellent outcomes. On the other hand, patients should be warned of the likelihood of sexual dysfunction.