• Assess for blood at the meatus, gross hematuria, flank bruising, pelvic instability

UA to assess for microhematuria

Renal imaging - CT triphasic

• Corticomedullary (25-80s) - identify vascular injuries
• Nephrographic (90s) - delineate parenchymal injuries
• Excretory (3 min) - collecting system
• 

Delayed phase (5-10 min) to look for renal injury, extravasation

Renal trauma

• Absolute indications for intervention
• Hemodynamic instability
• Gr 5 vascular injury (main renal vessel involvement)
• Expanding/pulsatile hematoma seen on ex lap for related injuries (indicative of Gr 5 vascular injury)
• Relative indications for renal exploration
• UPJ avulsion/large renal pelvis laceration
• Coexisting bowel/pancreas injuries
• Persistent urinoma, perinephric abscess with failed percutaneous management
• Renal artery thrombosis of both or of solitary kidney, or failed endovascular management
• Image with CT triphasic if:
• Microhematuria/gross hematuria and: suspicious mechanism of injury, or hypotensive
• Reimage if:
• Gr IV-V laceration (in 72 hours), or if clinically worsening (fever, pain, blood loss, etc)
• If considering trauma nephrectomy witout prior imaging, need to make sure the contralateral kidney exists: On-table IVP/urogram:
• Omnipaque non-diluted, 1 cc/lb or 2 cc/kg, as a bolus. Take XR after ~ 10-15 min
• No guidelines on bedrest/hematocrit checks
• Yearly BP checks with PCP to screen for post-trauma hypertension

Ureteral trauma

• CT IVP if trauma
• If already got contrast a few hrs ago, can get KUB to see where contrast is. If just got contrast < 30 min ago, put them back in the scanner to get the delayed phase
• Stent, nephrostomy, or surgical repair (if immediate, or within first week of iatrogenic injury)
• If endoscopic injury - stent
• Short defect - U-U, pyeloplasty or ureterocalycostomy (if proximal)
• Longer defect - Boari, ileal interposition, autotransplant, psoas hitch (longitudinal stitch to avoid genfem/femoral nerve), trans U-U, ureteral reimplant +/- psoas
• Or just nephrectomy if kidney is not working well and other one is OK

Stent x 4-6 weeks; imaging 4 wks after stent removal

Bladder trauma

• CT cystogram (or retrograde cystography) if:
• Gross hematuria + pelvic fracture or mechanism concerning for pelvic fracture
• Should be retrograde, gravity filling of the bladder with contrast, minimum 300 mL or until the patient reaches tolerance.
• Cytogram via delays on CT IVP is insufficient - won't distend enough to eval for injury
• Scan at maximal fill and then after bladder drainage.
• Intraperitoneal vs extraperitoneal
• Intraperitoneal - must take back to the OR
• Extraperitoneal - can be managed with catheter if uncomplicated - 2-3 wks with f/u cystogram
• Unless complex - persistent leak, vag/rectal injury, bladder neck injury (risk of incontinence/fistula), pelvic fx with risk of bony fragments
• If surgery is happening anyways, should go in and repair
• Foley only is OK - no advantage to SPT + Foley together
• TURBT - reduce risk of perforation by using bipolar, staccato resection, paralysis
• Intraoperative assessment bladder for water-tightness - at least 300 mL
• Leave at least a 20Fr Foley to pass clots
• Open bladder injury - leave at least 7-10 days

Urethral trauma

• Urethral anatomy
• Mechanism:
• Pelvic fracture urethral disruption (PFUD) - complete disruption at the membranous urethra; cannot pass a catheter. 95% rate of urethral disruption regardless of primary realignment vs SPT placement
• Straddle injury - typically partial thickness urethral tear, can probably pass a catheter. Can develop stricture from spongiofibrosis
• Exam: Blood at meatus, retention, palpable bladder, high riding prostate
• RUG (retrograde urethrogram) if blood at the meatus
• Position supine, oblique at 45 degrees. Place Foley in fossa, penis on stretch (use a Raytec tied around head to keep hand out of field), 1 cc water in balloon (no lube), inject 20-60cc contrast
• If pelvic fracture and can't position, can just do it supine but not ideal
• Can have reflux into ejaculatory ducts and SVs which is normal
• If female, cystoscopy more useful
• If Foley has already been placed: no imaging needed if suspicion for urethral injury is low and no blood at meatus
• If continued blood at meatus - pericatheter RUG (place angiocath next to Foley)
• If emergent setting and must have Foley - a single attempt at catheter placement BY UROLOGY with 18 Fr Coude is acceptable.
• Otherwise, cysto over a wire, or place SPT. If in OR, can do antegrade and retrograde cystoscopy. Do a pericatheter RUG afterwards
• If pelvic fracture/ORIF, can place SPT - no data for increased risk of infection
• If female - should be repaired during initial hospitalization. If Foley, high fistula rates. Also typically has high vaginal injury rate.
• Foley blown up in urethra - Foley x 5-7 days, void trial

Genital trauma

Testicular trauma

• Rupture = laceration of tunica albuginea, requires surgical repair
• Intratesticular hematoma should be assumed to have rupture → surgical exploration
• < 72 hrs: 80-90% salvage rate; > 72 hrs: 32-45% salvage rate
• Contusion, hematocele (intrascrotal hematoma) do not require surgery - pain control, ice, and rest. Large painful hematoceles can be drained.
• Penetrating injury
• Surgical exploration (testicular injury/rupture likely)
• Blunt injury
• Surgical exploration not needed if testis is palpable and normal
• If difficult to palpate, scrotal US to determine if rupture present
• Rupture appears as heterogeneous area; fracture site (loss of smooth contour) seen in 20% of cases
• Intratesticular hematoma cannot be reliably distinguished - inconclusive scrotal US → surgical exploration
• Consider tunica vaginalis flap for repair

Penile trauma

Penile fracture

• Tear of the corpora cavernosa
• Typically a/w sexual intercourse (woman on top, erect penis hits pubic bone or perineum)
• "popping/cracking", rapid detumescence, penile pain and swelling
• Ask if they have been able to have an erection since then
• 10-15% also with urethral injury - ask about hematuria and voiding
• May feel penile shaft deformity, hematoma on exam
• Prompt surgical exploration and repair - delay leads to ED, Peyronie's, pain with intercourse
• Include cystoscopy on consent to evaluate urethra at time of
• Repair within 24 hours? Unclear if immediate vs delayed repair affects rates of erectile dysfunction
• If unclear (e.g. exam consistent w/ fracture but only partial loss of erections), can consider imaging such as penile MRI?

Penetrating penile injury -> surgical exploration, repair

Penile amputation - wrap in saline soaked gauze and place on ice; call plastics for revascularization of dorsal +/- cavernosal arteries

Buck's fascia intact: 'sleeve'

Buck's fascia broken: 'butterfly' perineal hematoma. extravasation limited by Colle's fascia (=Darto's/Scarpa's) lining the perineal area; fuses with fascia lata