Upper Genitourinary Trauma Clinical Presentation

  • Author: Imad S Dandan, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jun 13, 2011
 

History

In blunt trauma, history is obtained regarding the time and mechanism of injury, position of the patient, speed of the vehicle, and use of restraints.

In penetrating trauma, knowing the size of the stabbing weapon or the caliber of the gun and the distance from which it was discharged aids assessment.

Question the paramedics as to the condition of the patient immediately after injury occurred and during transport to the hospital.

In patients with GU trauma, symptoms are nonspecific and may be masked by or attributed to other injuries.

Renal injuries are most commonly from motor vehicle accidents (MVAs). Renal injuries occur in 3% of patients hospitalized with trauma and in 10% of patients with abdominal trauma. Most renal injuries (80%) are minor and do not require surgical intervention.

Suspect renal injury when fractures of lower ribs and/or spinal processes are observed and/or when a history of sudden deceleration or significant lateral force on the patient exists. In penetrating trauma, the trajectory of the bullet or the penetrating object helps indicate the possibility of renal injury.

Iatrogenic ureteral injuries are much more frequent than violent ones. A high incidence of associated organ injuries with ureteral injuries exists (90% in gunshot wounds, 60% in stabbings). Diagnosis of ureteral injury depends mainly on clinical suspicion. History and physical examination are unreliable and often are not sensitive.

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Physical

Flank ecchymosis or mass indicates a retroperitoneal process but is not specific to renal injuries and rarely occurs acutely. The most important indicator of renal trauma is gross or microscopic hematuria. The absence of hematuria, although rare, does not exclude renal injury. Hematuria is absent in 5% of patients.

Presence of abdominal, visceral, solid organ, or vascular injury may indicate the presence of concomitant renal injury, as these injuries often coexist with renal injury in 34% of patients with blunt trauma and in up to 80% of patients with penetrating trauma.

In suspected ureteral injury, physical examination is of minimal use except in diagnosis of associated injuries.

Perform a rectal examination to help establish the presence or absence of a urethral injury prior to Foley catheter insertion. Look for a high-riding prostate, rectal tear, bony abnormality, or frank blood.

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Causes

The most common cause of renal injury is blunt trauma, followed by penetrating trauma. MVAs and gunshot wounds account for 80% of renal injuries. Conversely, the etiology of ureteral trauma is mostly iatrogenic (82%). In noniatrogenic causes of ureteral injury, penetrating trauma accounts for 90% of cases (missile injury in 90%, stabbing injury in 10%) with a blunt avulsing-type mechanism causing the remaining 10% of injuries.

Blunt trauma includes the following:

  • MVAs
  • Motorcycle accidents
  • Falls from high elevations
  • Bicycle accidents
  • Assaults with blunt weapons

Penetrating trauma includes the following:

  • Missile injury: Differentiate between low- and high-velocity missiles.
  • Shotgun wounds: Close-range injuries are equivalent to high-velocity injuries.
  • Stabbings
  • Impalements

Iatrogenic trauma is also reported.

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Contributor Information and Disclosures
Author

Imad S Dandan, MD  Consulting Surgeon, Department of Surgery, Trauma Section, Scripps Memorial Hospital

Imad S Dandan, MD is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, American Medical Association, American Trauma Society, California Medical Association, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Walid A Farhat, MD, FRCS(C)  Associate Professor, Department of Surgery, University of Toronto; Staff Physician, Division of Urology, The Hospital for Sick Children

Walid A Farhat, MD, FRCS(C) is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, College of Physicians and Surgeons of Ontario, and International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Specialty Editor Board

David S Howes, MD  Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

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Ruptured left kidney.
Avulsed left renal artery with thrombosis.
CT scan of abdomen and pelvis showing a urinoma.
Urinoma by CT.
Lateral view of a urinoma.
Contrast-filled urinoma.
Retrograde urethrogram showing a leak in the distal right ureter with an element of obstruction.
 
 
 
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