Term
| what is the leading cause of death between the ages of 1 and 44? |
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Definition
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Term
| what is the most commonly injured organ in the GU? |
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Definition
| the kidney, which is injured in about 10% of abdominal trauma. |
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Term
| what kind of trauma usually affects the kidney? |
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Definition
| blunt trauma: 80-90% and penetrating trauma: 10-20% |
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Term
| how is kidney trauma diagnosed? |
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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. |
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Term
| what characterizes hematuria as an indicator of renal injury? |
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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 |
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Term
| who in terms of kidney trauma requires imaging? |
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Definition
| adults: all penetrating trauma and blunt trauma associated with gross hematuria or microscopic hematuria w/shock. children: any hematuria. |
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Term
| what is the gold standard for initial renal imaging? |
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Definition
| CT scan (replaced intravenous pyelogram) |
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Term
| what is grade 1 kidney trauma? |
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Definition
| hematoma is contained w/in the capsule (contusion) |
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Term
| what is grade 2 kidney trauma? |
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Definition
| laceration is shallow and only goes as far as the outside calyces (does not reach cortico-medullary junction) |
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Term
| what is grade 3 kidney trauma? |
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Definition
| deeper laceration through the coricomedullary junction |
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Term
| what is grade 4 kidney trauma? |
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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. |
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Term
| what is grade 5 kidney trauma? |
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Definition
| a pedicle injury to the main artery or a shattered kidney (multiple, deep lacerations) |
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Term
| how are kidney trauma grades 1-3 (and most grade 4 traumas) treated? |
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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. |
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Term
| what are the absolute and relative indications for sx on renal trauma pts? |
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Definition
| absolute: expanding or pulsatile hematoma. relative: extravasation, non-viable tissue, arterial injury, or *incomplete staging. |
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Term
| when presented with an unexpected retroperitoneal hematoma, what needs to be checked? |
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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. |
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Term
| how is the abdomen opened up to work on the kidneys? |
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Definition
| a cut from the xiphoid to the pubic symphysis is made and renal vessels are tagged and looped (vascular control) |
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Term
| what are the reconstructive principles in terms of renal sx? |
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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. |
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Term
| what is the 2nd most commonly injured organ in the GU? |
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Definition
| the bladder, usually due to pelvic fractures. |
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Term
| what diagnostic tests are run for bladder trauma pts? |
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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. |
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Term
| how is bladder trauma classified? |
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Definition
| minor (contusions) and major (intraperitoneal/extraperitoneal ruptures) |
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Term
| what determines whether major bladder trauma is going to be intra- or extraperitoneal? |
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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. |
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Term
| how is minor bladder trauma treated? |
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Definition
| foley catheter until hematuria resolves (3-5 days) |
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Term
| how is extraperitoneal bladder rupture treated? |
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Definition
| foley catheter in for 7-10 days and repeat cystogram prior to removal of catheter. |
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Term
| how is intraperitoneal bladder rupture treated? |
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Definition
| operative exploration/repair is necessary. |
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Term
| what % of penetrating bladder injuries require operative repair? |
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Definition
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Term
| how is the surgical operation to repair bladder trauma performed? |
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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. |
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Term
| how is the urethra divided anatomically? |
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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. |
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Term
| what kinds of injuries occur to the anterior urethra? posterior? |
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Definition
| anterior: straddle injuries (urethra pinched between object and pubic symphysis) and penetrating injuries. posterior: distraction (pelvic fracture) injuries |
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Term
| how is a urethral injury diagnosed? |
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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 |
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Term
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Definition
| a butterfly shaped fascia which blood from a urethral injury can fill |
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Term
| how are straddle urethral injuries treated? |
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Definition
| initially with a suprapubic tube, when repair 3-6 months later via perineal exploration once all the blood has dissipated. |
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Term
| how do many straddle injury pts present? |
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Definition
| 6 mos to 2 yrs later, stricture/scarring causes trouble w/urination. |
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Term
| what is the association of pelvic fracture w/posterior urethral injury? |
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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. |
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Term
| are posterior urethral injury pts at a high risk for significant bleeding? |
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Definition
| yes - interventional radiology may be necessary to stop bleeding |
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Term
| why is a posterior urethral injury called a "distraction" injury? |
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Definition
| b/c the blood pulls the two parts of the urethra apart as the pelvis fills w/blood |
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Term
| if there is blood at the urethral meatus, should a foley catheter be passed? |
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Definition
| no, it can increase the severity of the injury |
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Term
| how is urethral trauma managed? |
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Definition
| a retrograde urethrogram needs to be obtained in the lateral decubitus position to determine whether the urethra is intact. |
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Term
| before sx to repair a disrupted urethra, what things need to be done? |
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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. |
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Term
| how is sx to repair a disrupted urethra performed? |
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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. |
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Term
| how are scrotal injuries diagnosed? |
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Definition
| clinical hx, pain, hematoma, skin loss/laceration, and observation of entrance/exit wounds if penetration trauma. |
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Term
| what is the "eggplant sign"? |
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Definition
| penile fracture, where the corporal bodies fill w/high tension and if they burst - blood can fill the penis in a deforming manner. |
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Term
| how are clinical diagnoses confirmed? (often pain/hematoma/edema can limit the physical exam) |
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Definition
| clinical diagnoses can be confirmed via ultrasound - to assess integrity/viability of intrascrotal contents |
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Term
| what is the hallmark finding for a ruptured testicle? |
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Definition
| **heterogeneous echotexture** (alteration to the normal homogeneous texture). violation of the tunica albuginea may also be visible (not hallmark). |
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Term
| how is testicular rupture treated? |
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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. |
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Term
| what is a penile fracture associated with? |
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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) |
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Term
| why does penile fracture require sx? |
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Definition
| b/c the penis can heal in a crooked position |
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Term
| how are penile fractures repaired? |
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Definition
| expose via circumcision incision (allows access to both the corpora/urethra), debride the hematoma, and reapproximate the tunica albuginea |
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Term
| how is a penile amputation repaired? |
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Definition
| preserve amputated penis is cold saline, then micro-reimplant of corpora, urethra, dorsal arteries, and nerves (can exclude cavernosal arteries). |
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Term
| how does genital skin loss occur? treatment? |
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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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