Genitourinary Trauma

Retrograde Urethrogram: Oblique patient positioning if possible, First shoot KUB, Place 60 cc syringe tip in urethra filled c ½ strength contrast. Shoot film during last 10cc

Upper Tract

Renal-often microscopic hematuria. Eval c CT scan. C penetrating, hematuria may be absent, must go by mechanism aloneGrade I
Contusion: Microscopic or gross hematuria; urologic studies normal
Hematoma: Subscapular, nonexpanding without parenchymal laceration
Grade II
Hematoma: Nonexpanding perirenal hematomas confined to renal retroperitoneum
Laceration: <1.0 cm parenchymal depth of renal cortex without urinary extravasation
Grade III
Laceration: >1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
Grade IV
Laceration: Parenchymal laceration extending through the renal cortex, medulla, and collecting system
Vascular: Main renal artery or vein injury with contained hemorrhage
Grade V
Laceration: Completely shattered kidney
Vascular: Avulsion of renal hilum, which devascularizes kidney

EAST RECOMMENDATIONS

A. RENAL TRAUMA

1. Level I

There is insufficient Class I and Class II data to support any standards

regarding management of renal trauma.

2. Level II

1) Preliminary vascular control does not decrease blood loss or increase

renal salvage.

2) Conservative management of shattered but perfused kidneys in

hemodynamically stable patients with minimal transfusion requirements

will result in a low incidence of complications, which can usually be

treated with endourological or percutaneous methods.

3. Level III

1) Preliminary vascular control may prolong operative time

2) The success of nonoperative management may be enhanced by the use

of angiographic embolization.

3) Nonoperative treatment of renal lacerations from blunt trauma

associated with extravasation is associated with few complications, which

can usually be treated with endourological or percutaneous methods.

4) Conservative management of major renal lacerations associated with

devascularized segments is associated with a high rate of urologic

morbidity (38 - 82%). In patients who present with a major renal

laceration associated with devascularized segments, conservative

management is feasible in those who are clinically stable with blunt

trauma. The physician must be especially aware of the probable

complications within this subset of patients.

5) Operative exploration of the kidney should be considered in patients

with major blunt renal injuries with a devascularized segment in

association with fecal spillage or pancreatic injury.

6) Nonoperative treatment of penetrating renal lacerations is appropriate

in hemodynamically stable patients without associated injuries who have

been staged completely with CT scan and/or IVP. A high index of

suspicion is needed to avoid ureteral injuries if a course of nonexploration

is chosen.

7) Penetrating Grade III or IV injuries are associated with a significant

risk of delayed bleeding if treated expectantly. Exploration should be

considered if laparotomy is indicated for other injuries or if the injury is

not completely staged prior to exploratory laparotomy for other injuries.

B. RENOVASCULAR TRAUMA

1. Level I

There is insufficient Class I and Class II data to support any standards

regarding management of renovascular trauma.

2. Level II

There is insufficient Class II data to support any recommendations

regarding management of renovascular trauma.

3. Level III

There is insufficient Class III data to support any recommendations

regarding management of renovascular trauma.

External

Do not need to image sole microscopic hematuria without associated signs and symptoms (Emerg Med J 19:322, 2002)

Retrograde Urethrogram: Technique
· A retrograde urethrogram is performed with the patient supine
· An initial KUB is obtained for comparison.
o Incidental findings on the KUB suggestive of GU injury include:
§ Loss of the psoas shadow 2° to retroperitoneal blood
§ Spinal curvature, usually concave toward the site of injury
because of splinting
§ Pelvic Fracture
§ Lower Rib or Transverse Process fractures
· A Foley catheter is passed approximately 1 to 2 cm to the fossa navicularis and
the balloon is inflated with 1 to 2 mL of saline.
· Alternatively a 60-cc Toomey syringe with a Christmas tree or Cooke adapter
may be gently inserted until snug.
9
· Lateral traction is applied to the penis and 60 mL of water-soluble contrast
material is injected over 30 to 60 seconds.
· The radiograph is exposed as the last 10 mL of contrast material is injected.
· Extravasation of contrast material or failure of contrast material to reach the
bladder is diagnostic of urethral injury, mandates urologic consultation, and
precludes the passage of a urethral catheter by the emergency physician
· If a Foley is in place, a lubricated pediatric feeding tube can be placed, and the
retrograde urethrogram performed.

Filling the bladder with 350 cc of contrast and then doing CT is far more sensitive

perform in patients with known pelvic fxs, gross hematuria, or severe pelvic trauma

Mix 50 cc Hypaque 60 and 450 cc NS, make sure at least 350 cc goes into the bladder

Conclusions: CT cystography is equivalent to conventional cystography for detecting the presence or absence of blunt bladder injury. CT cystography can be performed as an integral part of the CT screening undergone by many blunt trauma patients and, in the vast majority of these patients, it can alleviate the need for a separate conventional cystogram. (J Trauma 2006;61(2), August 2006, pp 410-422)

CT cystography was performed in the following manner. When the patient was placed on the CT table, the urinary drainage bag was separated from the Foley catheter and the Foley catheter was suctioned with a 60-mL catheter-tipped syringe until the urinary bladder was completely emptied. A premixed 0.9% sodium chloride IV fluid bag containing 350 mL of cystography contrast (see formulations below) was connected to the Foley catheter via a vented IV tubing set and a large catheter adapter (part #8039, Procedure Products Research, Vancouver, WA). The contrast bag was raised to a height of 3 to 4 feet above the patient using an IV pole. The contrast was allowed to drip into the bladder by gravity while the CT technologist performed routine prescanning procedures.

Imaging was initiated after one of the following endpoints was reached: (1) 350 mL of contrast was completely instilled into the bladder, (2) continued bladder detrusor activity limited the volume that could be instilled to less than 350 mL despite adequate time for bladder relaxation, or (3) the patient reported significant abdominal/pelvic discomfort, necessitating the cessation of further contrast instillation. A variety of CT cystography contrast concentrations, ranging from 12 to 32 mg of iodine (mgI) per mL, were tried during the first 3 years of the study (250 patients). Based on the preferences of the interpreting radiologists after the initial evaluation period, the concentration used for all subsequent patients was 28 mgI/mL. This final CT cystography contrast formulation consisted of 35 mL of iothalamate meglumine 60% ionic contrast (Conray; Mallinckrodt, St Louis, MO) mixed with 315 mL of 0.9% sodium chloride in a 250-mL IV fluid bag; the bag distends to hold the extra volume. CT images of the abdomen and pelvis, including the contrast-filled bladder, were obtained using the standard trauma technique described above (Fig. 1). No additional pelvic scans or postdrainage scans were performed, unless they were needed to help clarify an area of diagnostic uncertainty. In 9% of cases (44 of 495), CT cystography was performed as a separate examination immediately after the initial abdominal/pelvic CT, with reimaging of the lower abdomen and entire pelvis after retrograde filling of the bladder as described above. Conventional cystography, when used, was performed after the abdominal/pelvic CT, with the exact timing dictated by the patient's clinical condition and medical management (with a range of 0.5–12 hours after the CT was performed).

Conventional cystography was performed in the following manner. The Foley catheter was suctioned with a 60-mL syringe, as described above. A preliminary anteroposterior (AP) radiograph of the pelvis was obtained. A 300-mL bottle of diatrizoate meglumine 30% ionic contrast (150 mgI/mL) (Reno-Dip, Bracco Diagnostics, Princeton, NJ) was connected to the Foley catheter via vented IV tubing set with a large catheter adapter. The contrast was instilled into the bladder via gravity in the same manner and with the same endpoints as described for CT cystography. The Reno-Dip bottle contains only 300 mL of contrast, so an additional 50 mL of contrast was added in most patients before completion of the gravity drip to bring the total amount instilled to 350 mL. An AP radiograph was obtained of the pelvis after instillation of approximately 100 mL of contrast, and again after instillation of 350 mL of contrast (or after a bladder filling endpoint was reached, as previously described). Oblique radiographs were obtained if the patient could be safely turned, followed by an AP radiograph after draining the contrast from the bladder. If there was any uncertainty as to whether residual contrast seen on the postdrainage radiograph represented extravasated bladder contrast, 150 mL of 0.9% sodium chloride solution was instilled into the bladder by gravity and then a repeat AP radiograph was obtained after draining the bladder a second time. The vast majority of the conventional cystograms were performed using portable radiographic equipment in the trauma emergency room; the others were performed using fixed radiographic equipment, without fluoroscopic imaging, in the radiology section of the emergency room.

Appropriate cystography contrast volume adjustments for children aged 2 to 11 years were made using the following formula:

Volume of contrast to be instilled = (age in years + 2) × 30 mL.

Before CT imaging, these patients had retrograde gravity-drip infusion of 350 mL of contrast (21 mgI/mL) into the bladder, along with oral and IV contrast. CT imaging of the abdomen and pelvis was performed routinely, without delayed or separate bladder imaging. In 1998, Vaccaro et al.18 described their technique for CT cystography, which involved routine abdominal/pelvic CT with oral and IV contrast and retrograde bladder filling with 350 mL of contrast (29 mgI/mL).

Postdrainage films are an essential component of the conventional cystogram because the contrast-filled bladder may obscure a small amount of extravasated contrast on the two-dimensional radiograph. However, computed tomography allows for evaluation of the pelvis via two-dimensional, cross-sectional images, and extravasated contrast can be visualized despite the presence of a bladder distended with contrast (Fig. 4). For this reason we do not routinely include postdrainage images as part of our CT cystography technique.

Indications for Evaluation for Bladder Injury
Which patients with blunt abdominal/pelvic trauma should undergo imaging evaluation for bladder injury? This is a difficult question. Ideally, a set of criteria could be established that would include all patients with bladder injury and minimize the number of studies performed on patients with noninjured bladders. In the study reported here, our inclusion criteria for bladder imaging were gross hematuria, pelvic fracture, and/or high clinical suspicion.

A large majority of bladder ruptures are associated with gross hematuria; therefore, many authors suggest that the presence of gross hematuria is a strong indication for bladder imaging in patients with blunt trauma.1,21,22 To add to this body of literature, we report that in our study of 495 patients, 45 of the 46 patients with bladder injury would have undergone cystography if gross hematuria had been the only indication for blunt bladder imaging. To diagnose the remaining patient, who had microscopic hematuria with less than 25 red blood cells per high-powered field (RBC/HPF), pelvic fracture would have had to be added to the inclusion criteria, and it was.

Morgan et al.22 reported a series of 157 patients prospectively evaluated for bladder injury with CT cystography, 12 of who had bladder ruptures. In that series of 12 bladder injuries, 2 patients had gross hematuria, 6 patients had gross hematuria and pelvic injury, and 4 patients had pelvic injury with large microscopic hematuria, which the authors defined as greater than 25 RBC/HPF. Furthermore, the study found no bladder ruptures in the 10 patients with pelvic fracture and small microscopic hematuria (less than 25 RBC/HPF). No bladder ruptures were found in the 99 patients who had neither gross hematuria nor pelvic injury.

Iverson and Morey 23 reviewed the literature from 1980 to 2000 and concluded that gross hematuria with pelvic fracture was the only absolute indication for cystography after blunt trauma. They went on to state that their review of existing data did not support the need for lower urinary tract imaging in all patients with either pelvic fracture or gross hematuria alone. However, the authors concluded that gross hematuria alone, pelvic fracture with microscopic hematuria, or even isolated microscopic hematuria are relative indications for cystography when clinical indicators of bladder rupture are also present (e.g., suprapubic pain, inability to void, low urine output, perineal trauma, etc.).

A review of our trauma registry showed that a number of patients who presented to the trauma center during the time of this ongoing investigation with findings that fit the study's criteria for CT cystography (gross hematuria, pelvic fracture, or high clinical suspicion) received only conventional abdominal/pelvic CT. One such patient, a 70-year-old woman involved in a motor vehicle collision resulting in pelvic fracture and microscopic hematuria, did not undergo bladder evaluation with either CT cystography or conventional cystography. The patient was later found to have an EP-type bladder rupture, which was thought to have greatly contributed to the sepsis and death that followed early removal of her Foley catheter. It is because of such cases that we recommend the inclusion of pelvic fracture as an indication for cystography in patients with blunt abdominal/pelvic trauma, despite the absence of gross hematuria. Since the vast majority of hemodynamically stable patients with significant blunt torso trauma receive abdominal/pelvic CT imaging, and our described method of CT cystography has proven to add little time or cost to the procedure, we advocate relatively liberal use of CT cystography to avoid missed diagnoses.

Genitourinary (GU) Trauma

Lower Tract

Upper Tract

External