Upper Genitourinary Trauma Clinical Presentation

Updated: Jan 24, 2017
  • Author: Imad S Dandan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

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.

Iatrogenic injury to the ureter can be a devastating complication of modern surgery. Most often, such injuries to the ureters occur during gynecologic, colorectal, and vascular pelvic surgery. [4]

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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. [5] 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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