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genito-urinary trauma clinical
R-GU
49
Medical
Graduate
10/04/2010

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Term
what is the leading cause of death between the ages of 1 and 44?
Definition
trauma
Term
what is the most commonly injured organ in the GU?
Definition
the kidney, which is injured in about 10% of abdominal trauma.
Term
what kind of trauma usually affects the kidney?
Definition
blunt trauma: 80-90% and penetrating trauma: 10-20%
Term
how is kidney trauma diagnosed?
Definition
penetrating: usually by exterior wounds. blunt trauma: either by *flank ecchymosis and/or urinalysis showing micro/gross *hematuria (important in determining who needs to be imaged), however degree of hematuria may not predict trauma severity and can be absent.
Term
what characterizes hematuria as an indicator of renal injury?
Definition
hematuria is usually the first indicator of renal injury and the sample tested should be the first voided or catheterized specimen. dipstick hematuria correlates with 5-10 RBCs/HPF
Term
who in terms of kidney trauma requires imaging?
Definition
adults: all penetrating trauma and blunt trauma associated with gross hematuria or microscopic hematuria w/shock. children: any hematuria.
Term
what is the gold standard for initial renal imaging?
Definition
CT scan (replaced intravenous pyelogram)
Term
what is grade 1 kidney trauma?
Definition
hematoma is contained w/in the capsule (contusion)
Term
what is grade 2 kidney trauma?
Definition
laceration is shallow and only goes as far as the outside calyces (does not reach cortico-medullary junction)
Term
what is grade 3 kidney trauma?
Definition
deeper laceration through the coricomedullary junction
Term
what is grade 4 kidney trauma?
Definition
most common: violation of the collecting system for urine drainage. less common: renal artery thrombosis (*cortical rim sign - cortex of capsule has collateral flow*) OR injury to a segmental artery/vein.
Term
what is grade 5 kidney trauma?
Definition
a pedicle injury to the main artery or a shattered kidney (multiple, deep lacerations)
Term
how are kidney trauma grades 1-3 (and most grade 4 traumas) treated?
Definition
no sx, put pt on bedrest until hematuria resolves (hematomas dissolve). gerota's fascia should tamponade bleeding and keep them from bleeding out while healing.
Term
what are the absolute and relative indications for sx on renal trauma pts?
Definition
absolute: expanding or pulsatile hematoma. relative: extravasation, non-viable tissue, arterial injury, or *incomplete staging.
Term
when presented with an unexpected retroperitoneal hematoma, what needs to be checked?
Definition
that the pt does in fact have 2 kidneys and since palpation is unreliable - a single-shot IVP (intravenous pyelogram) is administered which is IV contrast followed by a single film 10 min later.
Term
how is the abdomen opened up to work on the kidneys?
Definition
a cut from the xiphoid to the pubic symphysis is made and renal vessels are tagged and looped (vascular control)
Term
what are the reconstructive principles in terms of renal sx?
Definition
total renal exposure (need to see entire kidney), debridement (take non-viable tissue components out), hemostasis (stop bleeding), water-tight closure (close collecting system) and defect coverage. CT/renal scans in 3 months if pt is compliant.
Term
what is the 2nd most commonly injured organ in the GU?
Definition
the bladder, usually due to pelvic fractures.
Term
what diagnostic tests are run for bladder trauma pts?
Definition
*urinalysis: almost 100% of bladder injuries have hematuria w/98% being gross hematuria. *radiographic cystogram: definitive study for dx, fill bladder w/contrast and look for a perforation - done both empty (drainage scan) and full.
Term
how is bladder trauma classified?
Definition
minor (contusions) and major (intraperitoneal/extraperitoneal ruptures)
Term
what determines whether major bladder trauma is going to be intra- or extraperitoneal?
Definition
extraperitoneal: bladder not full at time of trauma, 65% of cases. intraperitoneal: bladder full at time of trauma or most children, 25% of cases.
Term
how is minor bladder trauma treated?
Definition
foley catheter until hematuria resolves (3-5 days)
Term
how is extraperitoneal bladder rupture treated?
Definition
foley catheter in for 7-10 days and repeat cystogram prior to removal of catheter.
Term
how is intraperitoneal bladder rupture treated?
Definition
operative exploration/repair is necessary.
Term
what % of penetrating bladder injuries require operative repair?
Definition
100%
Term
how is the surgical operation to repair bladder trauma performed?
Definition
a midline incision is made, the bladder is opened trans-peritoneally, orifices are checked 2 layers are repaired and a super feeder tube is usually added.
Term
how is the urethra divided anatomically?
Definition
*the anterior urethra (bulbar, pendulus, and the meatus) which is connected to the corporal bodies. *the posterior urethra (membranous and prostatic urethra) which is connected to the pubic symphysis by the suspensatory ligament.
Term
what kinds of injuries occur to the anterior urethra? posterior?
Definition
anterior: straddle injuries (urethra pinched between object and pubic symphysis) and penetrating injuries. posterior: distraction (pelvic fracture) injuries
Term
how is a urethral injury diagnosed?
Definition
hx (straddle, penetrating injury, pelvic fracture), blood at the meatus (present in 75% of anterior injuries). hematuria, inability to void, perineal hematoma, inability to pass catheter, and high-riding prostate
Term
what is colles fascia?
Definition
a butterfly shaped fascia which blood from a urethral injury can fill
Term
how are straddle urethral injuries treated?
Definition
initially with a suprapubic tube, when repair 3-6 months later via perineal exploration once all the blood has dissipated.
Term
how do many straddle injury pts present?
Definition
6 mos to 2 yrs later, stricture/scarring causes trouble w/urination.
Term
what is the association of pelvic fracture w/posterior urethral injury?
Definition
posterior urethral injuries are present in 5% of all pelvic fractures - but pelvic fractures are present in 98% of all posterior urethral disruptions. there is a higher incidence of posterior urethral disruption w/anterior ring fracturs and bilateral rami fractures.
Term
are posterior urethral injury pts at a high risk for significant bleeding?
Definition
yes - interventional radiology may be necessary to stop bleeding
Term
why is a posterior urethral injury called a "distraction" injury?
Definition
b/c the blood pulls the two parts of the urethra apart as the pelvis fills w/blood
Term
if there is blood at the urethral meatus, should a foley catheter be passed?
Definition
no, it can increase the severity of the injury
Term
how is urethral trauma managed?
Definition
a retrograde urethrogram needs to be obtained in the lateral decubitus position to determine whether the urethra is intact.
Term
before sx to repair a disrupted urethra, what things need to be done?
Definition
document status of erectile function pre-op. discuss risks of incontinence. MRI. urine cx. imaging to determine how close together separated urethra ends have come together during time allowed for hematoma to dissapate.
Term
how is sx to repair a disrupted urethra performed?
Definition
pt is in exaggerated lithotomy position, a cut is made from the perineum to the anus and the fibrotic distraction defect is removed. a sound (curved rod) is run from the bladder out and the urethra is sewed back together.
Term
how are scrotal injuries diagnosed?
Definition
clinical hx, pain, hematoma, skin loss/laceration, and observation of entrance/exit wounds if penetration trauma.
Term
what is the "eggplant sign"?
Definition
penile fracture, where the corporal bodies fill w/high tension and if they burst - blood can fill the penis in a deforming manner.
Term
how are clinical diagnoses confirmed? (often pain/hematoma/edema can limit the physical exam)
Definition
clinical diagnoses can be confirmed via ultrasound - to assess integrity/viability of intrascrotal contents
Term
what is the hallmark finding for a ruptured testicle?
Definition
**heterogeneous echotexture** (alteration to the normal homogeneous texture). violation of the tunica albuginea may also be visible (not hallmark).
Term
how is testicular rupture treated?
Definition
determine if rupture/contusion. (contusion does not require operation) operative management needs to occur w/in 72 hrs of injury. midline scrotal incision, exposure of injured testicle debride exposed tubules, and salvage what's left of the testicles/start hormonal maintenance if necessary.
Term
what is a penile fracture associated with?
Definition
an audible pop and quick loss of erection. penile fractures occur w/urethral injury in 20% of cases (corporal bodies sit on top of the urethra, so commonly injured)
Term
why does penile fracture require sx?
Definition
b/c the penis can heal in a crooked position
Term
how are penile fractures repaired?
Definition
expose via circumcision incision (allows access to both the corpora/urethra), debride the hematoma, and reapproximate the tunica albuginea
Term
how is a penile amputation repaired?
Definition
preserve amputated penis is cold saline, then micro-reimplant of corpora, urethra, dorsal arteries, and nerves (can exclude cavernosal arteries).
Term
how does genital skin loss occur? treatment?
Definition
genital skin loss may occur as a result of traumatic shear injury or as the result of an infection. debridement of nonviable tissue and then the scrotum needs to be closed (can lose 60% of skin, graft if need more).
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