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RENAL TRAUMA

INCIDENCE
Most common injured organ in trauma, 1% trauma cases, 50% genitourinary trauma
Blunt. 4% significant, Penetrating. 70% significant
Kids <16yo: More prone. Larger kidney, scant fat, under-developed Gerota, rib incompletely ossified
DIAGNOSIS
SUSPECT THE INJURY
Mode of injury: Blunt Rapid deceleration, hyper-extension, Penetrating
Examination: Hemodynamic state, Associated injuries (Rib/ Spinal fractures, Flank Bruising), Haematuria
DECIDE WHO TO SCREEN
1. Gross haematuria
4. Microhaematuria (Blunt >50 RBC, Penetrating >5 RBC)
2. Shock + Blunt trauma
5. Suspicious injuries
3. Major deceleration injury
DIAGNOSIS THE INJURY
Aims: Diagnose and grade injury, Identify any pre-existing anomalies/ pathology (4-19% of adults)
Indications
Requirements
Pros
Cons
ONE SHOT IVP

OT, Unstable pt

CT SCAN

Stable pt

2ml/kg of 60% IV contrast


Single shot 10 mins later
Triple phase delayed film

ULTRASOUND

CT not available
Fast scan + F/U
Isolated renal injury

Tertiary centre

ANGIOGRAM

Quick
Low radiation
Stages 90%
Quick +Non-invasive
Low radiation
Cheap
Ability to embolise

Shockdelayed uptakefalse neg


Higher contrast load
Tunnel of death
IV contrast + delayed films required
Less anatomy , Time consuming
Operator dependent
High contrast load

Grade:
GRADE
I
II
III

DESCRIPTION
Subcapsular, not expanding
<1 cm of renal cortex, not involving collecting system
>1 cm of renal cortex, not involving collecting system

IV
V

Laceration into collecting system or Main artery or vein


Completely shattered kidney or avulsion of kidney

TREATMENT- SURGICAL
ABSOLUTE INDICATIONS
1. Persistent, life threatening haemorrhage
2. Expanding pulsatile retroperitoneal haematoma
RELATIVE INDICATIONS
1. PUJ avulsion
2. Devitalised parenchyma or GSW. Higher risk of re-bleed/ urinoma. (esp if open abdomen)
3. Single kidney or poor renal function + Renal artery occlusion (<20% renal function preserved).
4. Urinoma or abscess, failed percutaneous management
RULES OF RENAL EXPLORATION
1. Good Exposure
4. Haemostasis
2. Early vascular control: Decreases nephrectomy rate from >30% to 15%
5. Debride
3. Watertight +/- stent
6. Omental interposition
Nephrectomy = Last resort. Risk if: Penetrating or GSW, Unstable + major injury (~100%), Main renal artery injury (6586%), Main renal vein injury (25-56%)

TREATMENT - CONSERVATIVE
Grade IV spontaneous resolution 87.1%, Non-viable tissue >20% increased complication rate
Bed rest until urine clears, Monitor: Obs, Hb, Urine, Consider BT, Re-image, Watch for complications
Grade dependent, usually within 1 month
COMPLICATIONS
Blood
vessel
Collecting
system
Infection

Bleed
Hypertension
Urinoma (1%)
PUJO
Abscess

Grade III or IV, 25% risk of delayed bleeding, 2-36 days, AV fistula = risk factor
37 days - years later (mean 34 mths), Little to suggest surgical intervention avoids
3 weeks up to 34 years later, 80-90% resolve spontaneously or with conservative Rx

Follow-up
No follow-up imaging required if patient stable and minimal devitalized kidney
Grade I - III:
Grade IV + V
Initial
Subsequent

CT scan 36-72 hr
Worsening urinary extravasation, Ongoing haemorrhage, Pseudoaneurysm
Less clear guide lines Fever, Flank pain/ mass, Bleeding, ?Hypertension
(US, CT, Nuclear med)

CASE SUMMARY: RENAL TRAUMA


Sue Min Ooi, Perth, sueminooi@yahoo.com for queries
History
32 year old male cycling home 2230 hours @ 40 km/hr. Fell onto tar road, no LOC.
Presented at local hospital at midnight with right flank pain and macroscopic
haematuria. No known medical illness.
Examination
Awake and responsive. Haemodynamically stable. R flank tenderness, bruising.
Macroscopic haematuria. 2 survey - 3 cm chin laceration.
Action: IV access and fluids, ADT vaccine, bloods, CT organized. IDC U/A blood,
protein.
Progress
1 hour later, pale, clammy, SBP 90-100. 2L stat crystalloid. CT large retroperitoneal
haematoma with active arterial bleeding. Right renal laceration. HR 80, SBP 100, Hb
129, UEC 140/4.7/4.3/88.
Action: Blood transfusion commenced. Transferred to tertiary centre.
FBP 106/28.8/231 after 3 units packed cells. SBP 100-110. CT (arterial, venous,
excretory phases) large retroperitoneal haematoma displacing kidney anteriorly, Gd
IV lower pole laceration, no urine leak.
Action: Angiography, super-selective embolisation Cook 2mm x 3cm coil.
Day 3-4
Central chest pain, desaturation to 60% RA. CXR bibasal consolidation. CTPA 3
filling defects R UL pulmonary artery, L LL segmental arteries.
Action: IV heparinisation commenced.
Day 5-6
Hb 75. Persistent chest and abdominal pain. CT abdomen increased size of
haematoma. Selective angiography no abnormalities, occluded posterior segmental
branch.
Action: IV heparin ceased. Pneumatic calf device applied. 4 units packed cells
transfused. IV Timentin.
Days 7-24
Haemodynamically stable. Discharged day 24.
Action: Mobilisation, physiotherapy. Oral Augmentin Duoforte. Serial CT.
Reintroduction of heparin SC heparin 5000 units tds and IV heparin low dose.
Commenced warfarin day 18. Target INR 1.8 - 2.0.
Representation 3 weeks later
Increasing pain in right abdomen and groin over last 5 days. P/A fullness R flank, mild
tenderness, R thigh swelling. Doppler US lower limb negative. CT showed large
loculated collection.
Action: Ultrasound guided aspiration 2.4 L haemoserous fluid drained. Creatinine
negative. Symptoms resolved post-procedure.
Outpatient review 3 months later
VQ scan negative. CT abdomen haematoma almost resolved. Small interpolar defect
in right kidney. GP to monitor BP, renal function.
ISSUES
1. Grade IV renal laceration with segmental arterial bleeding
a. Stabilisation
b. Exploration vs embolisation
2. DVT prophylaxis in trauma patient
a. Subcutaneous heparin? (bleeding risks > DVT?)
b. TEDS and pneumatic calf compression device
3. Pulmonary embolism secondary to IVC compression and trauma
a. Heparinisation +/- IVC filter
4. Large retroperitoneal haematoma
a. Compression of structures (IVC, external iliac vein)
b. Liquefaction long resolution time vs aspiration
5. Medium to long-term implications
a. Page kidney, hypertension, renal impairment

URETERIC TRAUMA
S. Jaboub/NSW 2007
Incidence: Relatively rare<1%
Types,Cuases &Mechanism of Ureteric Injury:
A. External ureteric injuries
1. Penetrating < 4%
2. Blunt< 1%
B. Iatrogenic Injuries:
1.A/P Surgery 0.5- 1%
2.Endourology 0.5- 1%
CAUSES:
External ureteric injuries/( 40%)
A - 95% Penetrating ( GSWs /STAB)
B - 5% Blunt ureteric injuries (RTAs/Fall)
Internal (Iatrogenic) Ureteric Trauma: ( 60%)
A. Open Surgery (Pelvic/Abdominal)
B. Lap. Surgery
C. Endourology
Examples of Internal (Iatrogenic) Ureteric Trauma :
Hysterectomy (54%) .Colorectal surgery (14%) Ovarian tumor removal
transabdominal urethropexy (8%).
Intraoperative Internal (Iatrogenic) Ureteric Trauma findings are:
Contusion,TearLigation,Thermal injuryPartial Transection
CompleteTransection &Avulsion.
A A for Surgery of Trauma Organ Injury Severity Scale for the Ureter:
I Haematoma Contusion or hematoma without devascularization
II Laceration <50% transection
III Laceration 50transection
IV Laceration Complete transection with <2 cm devascularization
V Laceration with Avulsion >2 cm devascularization
History
Iatrogenic (cause & location),Blunt ( Children),Penetrating( Lower chest, Back&
Abdomen);Radiation Therapy,Symptoms( not common&Silent obstruction.
Symptoms & Signs
Ileus,Prolonged fever & Sepsis
Persistent fluids( drain, wound& vagina)
Urine leak ( Cr. 300mol/L)

Flank pain( +/- Haematuria),mass& incontinence in female (UVF),Vague abdominal


pain&Ureteric tissue presence in specimen .
Diagnosis
External injuries
- High index of suspicion
Iatrogenic injuries
- Early 7days days
- Delayed (days yrs)
Diagnostics Studies
Laboratory: ( FBC,EUCUA, Drain Cr.& S-Cr.)
Imaging:( RGP Ureteropyeloscopy)
Special Studies:( CT-scan A/P & IVP)
Special Studies:( Indigo carmine & Methylene blue)
Intraoperative Diagnosis
A. Endoscopic:Contusions & Perforation C/E RGP+JJ stent
B. Intraoperative open Surgery
Single shot IVP&Optimal exposure,Packing Bowel,Control bleeding,Good
light,B/L examination of both Ureters.
Initial Management:
ABCDE ATLS
Haemodynamic stability
Associated Injury
Determine location extent & severity of injury( Preoperative-&Intraoperative)
Surgical Options( open vs minimal invasive)
When to Delay Repair ?
Delay Repair in :
1. Unstable Pt. for Prolonged Surgery&
GA
2. Evidence of active infection e.g. urinoma & abscess
3. Significant oedema& inflammation
4. Rx : Drainage,IV ABS Apyrexial

Definitive MX of Ureteric Injury


Options Depend on:
1.Immeiate Recognition 2.Level & Extent 3. Associated Injuries

Surgical Options:
Upper Ureteral Injuries:
1.Ureteroureterostomy
2.Autotransplantation
.3Bowel Interposition
Midureteral Injuries :
1.Ureteroureterostomy 2.Transureteroureterostomy3. ureteroureterostomy with renal
mobilization
Lower Ureteral Injuries :

1.Ureteroneocystostomy 2.Psoas Bladder Hitch 3.Boari Flap

Follow up
Open Repair C/E,R/O JJ Stent &RGP

2-3 Wks

Endoureterotomy C/E,R/O JJ Stent &RGP 6-8 Wks


IVP +Lasix 6 Wks, 6/12 & 18/12

Upper Ureteric Trauma -Case Presentation


Pascal Mancuso
Mechanism
8yo Boy
Passenger in MVA
Travelling at 80km/h
T-barred on passenger side of vehicle collision with tree on drivers side
Rapid deceleration
Presentation
Airway: patent
C-Spine: hard collar placed at scene by ambulance
Breathing: Decreased AE at R base
Circulation: Haemodynamically stable
Secondary Survey
Pain at R lower ribs posterolaterally
Tender R loin
Soft abdomen
IDC inserted: easily passed into bladder. UA shows large blood
Trauma Series:- C-Spine and Pelvic XRay normall
CXR: #Rib10, no haemo or pneumo-thorax
CT abdomen/pelvis with IV contrast arranged normal kidneys, free retroperitoneal
fluid adjacent to upper ureter. No other solid or hollow visceral injury
Management
Taken to OT for R RPG and attempt at R ureteric stent RPG shows contrast
extravasation from the proximal ureter
Not possible to pass retrograde stent Radiologist unable to insert an antegrade stent
Intraoperative Findings
1cm defect in the ureter 2cm distal to PUJ
Incomplete transection approx 75% circumferential defect
Pink, bleeding edges
Procedure
Primary ureteroureterostomy with spatulation of both ends of ureter
Single-length stent inserted
Interrupted 3/0 monocryl sutures used for anastomosis
Principles
Tension free
Preserve peri-ureteric adventitia
Post-op
IDC for 24-48 hours
Drain to remain in for at least 24 hours after IDC removed longer if large drainage
seen
Stent removal and RPG at 6-8/52

Lower Ureteric Trauma Case Discussion - Christopher Tracey


{ 68 yo female
z Laparoscopic converted to open right oophorectomy (Gynae)
z PMHx nil
z PSHx
{ TAH age 30
{ AP repair
z Meds nil
z Soc
{ Lives with husband, retired
z Initial good post operative course but deteriorated day 2
{ Ileus
{ Elevated WCC
{ Abdominal Pain
z Placed on TPN and conservatively managed
z Histopathology report on day 7
{ Serous cystadenofibroma
{ Segment of ureter with complete transverse sections
{ Pt transferred to urology service
{ Bloods
z Na 142, K 3.3, Cl 98, Ur 7.5, Cr 111, Bicarb 32, Alb 27
z Hb 101, WCC 8.4, Plt 356
{ Imaging performed to assess injury
z CT scan abdomen and pelvis
{ Triple phase with delayed films at 7 and 30 min
{ Large pelvic collection in continuity with right distal ureter.
Dilated left system due to pelvic collection.
{ Management
z Pt resuscitated
z Triple antibiotics
z Taken to theatre for laparotomy and repair ureter
{ Midline incision with re-opening of Pfannenstiel incision
z Operation
{ Extensive Adhesiolysis
{ Right ureteric re-implantation
{ Psoas hitch with Heineke-Mikulicz plasty and Z-plasty
like incisions in bladder wall to improve length
{ Superior vesical pedicle not divided
{ Politano-Leadbetter non refluxing anastomosis
{ Omental flap over repair
{ Post op
z Uneventful recovery
z Ileus settled day 5
z Cystogram at day 11 prior to TOV
z Discharged day 13

Bladder Trauma
Classification by mechanism of injury: Blunt, penetrating, iatrogenic
Clinical Features
Gross haematuria (>95%)
Suprapubic pain/tenderness
Inability to void
Signs of pelvic/perineal trauma
Delayed presentation: Abdo distension, ileus, urinary ascites, Cr,
acidosis, sepsis
Assessment: Indications for Imaging (Plain or CT cystogram)
Absolute: Gross haematuria with pelvic # (rupture ~30%)
Relative:(Incidence of bladder rupture <1%)
Gross haematuria w/o pelvic #
Microhaematuria with pelvic #
Isolated microhaematuria
Pathology: Contusion?, extraperitoneal rupture 54-58%, intraperitoneal rupture
38-40%, combined 5-8%
Cystographic findings
Starburst Flame Teardrop bladder
Extraperitoneal
Invariably pelvic
Rupture
Intraperitoneal
Rupture

Contrast in cul-de-sac, outlines bowel loops/ viscera.


10% visible only on post-drainage film

Management
Extraperitoneal Rupture
Conservative Mx
Catheter drainage (22-24F 2-way)
and ABs
Cystogram prior to removal of IDC
85% heal by D10, 99% D21
Surgical repair
Failure of catheter drainage
(recurrent clots /
persistent extravasation /
bony spikes)
Concomitant rectal / vaginal injury
Bladder neck injury
Internal fixation of pelvic
# ( infection risk)
Laparotomy for other cause

Intraperitoneal Rupture
Formal surgical repair
2 layer watertight closure
Absorbable suture
Large bore Foley (no need for SPC) x
10/7
Perivesical drain
Antibiotics? Routine postop until
removal of IDC

NMC: Nov 2007

Bladder Trauma Case presentation summary Dr. R. Tong


22 year old male
MCA: Driver vs Tree, 100km/hr
No past history
Primary survey:
Airway clear, Spont. breathing
Haemodynamically stable.
Retrograde amnesia, GCS 15
Secondary survey:
Lacerations to scalp
Lower abdominal pain and pelvic pain
No blood at meatus IDC inserted by emergency
-> Easy passage
-> Macroscopic haematuria
Investigations:
Pelvis XRay: Fracture bilateral pubic rami, Left acetabulum, Right sacral ala.
CT Abd/Pelvis:
Extensive intraperitoneal fluid, small splenic laceration, Kidneys normal, bladder dome defect.
Bloods:
Hb 143, WCC 30.7, Plt 218
Na 143, K 3.5, Cl 108, HCO3 26, Cr 210, Urea 9.0
Laparotomy:
Findings: Free urine, Mild bowel contusions, Organs normal, 3cm perforation of bladder
dome, Ureteric orifices normal.
Closure: 2 layers, 2/0 chromic catgut
Urethral catheter, Extravesical drain.
Day 10 retrograde cystogram
- No leak
- Successful trial of void

24/24 IV antibiotic

Urethral Trauma
Posterior urethral injuries

Male urethra involved in up to 19% of pelvic fractures

Female urethra rarely injured (0-6% of pelvic fractures)

90% of posterior urethral injuries occur with blunt trauma

Shearing forces disrupt the prostatomembranous junction


o
Studies have shown that this is usually distal to the membranous urethra (but may involve the
membranous urethra and in severe trauma the prostatic urethra)
Pelvic fractures

Type of fracture associated with different risk of urethral trauma


o
Straddle fractures with SIJ disruption have the highest incidence of associated urethral trauma
Types of injury and assessment on retrograde urethrogram

Contusion: Blood at the meatus with normal RUG (no treatment required)

Stretch: Contrast into the bladder with elongated urethra (SPC or IDC)

Partial rupture: Contrast into the bladder with some extravasation (SPC or IDC)

Complete disruption: No contrast into the bladder with extravasation into the perineum
o
Can be subdivided into <2 and >2cm disruption
o
Requires open or endoscopic treatment, primary or delayed
Diagnosis and initial management

Primary survey and resuscitation

If there is no blood at the meatus, urethral injury is very unlikely

H&P and appropriate imaging

Retrograde urethrogram for suspected urethral injury


Management

Primary repair
o
Poor visualisation
o
High impotence and incontinence rates (56%, 21%)*
o
Restricture rate 49% (most managed endoscopically*

Delayed primary repair


o
SPC placed at presentation
o
Repair performed when patient stable (10 - 14 days)
o
Stricture free rate of up to 80%*
o
No data on incontinence or erectile dysfunction

Primary realignment
o
Urethroplasty simplified in aligned urethra
o
Early series showed higher rates of erectile dysfunction and incontinence when compared to
delayed repair
o
EAU meta-analysis of 20 series*:
o
Erectile dysfunction 35.3%
o
Incontinence 5.2%
o
Restricture rate 60.2%

Delayed urethroplasty
o
Requires placement of SPC
o
Minimum 3 months post injury
#
o
Stricture rate 97%
o
Restricture rate after delayed repair 10%*
#
o
Incontinence 4%
#
o
Erectile dysfunction 19%

Delayed endoscopic optical incision


o
Cut to the light
o
Restricture rate of 80%
o
Low incidence of erectile dysfunction
o
Only recommended for short strictures with good urethral alignment

Delayed urethroplasty versus primary realignment


o
All patients will require complex urethral surgery following SPC for delayed urethroplasty
o
Most strictures following primary realignment can be managed endoscopically
$
o
1.6 vs 3.1 procedures in favour of primary realignment
o
Similar rates of erectile dysfunction and incontinence in both groups
Conclusions

Delayed repair historically considered the gold standard

Primary realignment similar incidence of incontinence and erectile dysfunction in recent series

Primary repair poor outcomes

Delayed primary repair inferior option to primary realignment

Endoscopic cut to the light should only be considered for small defects
References

* EAU Guidelines on urologic trauma January 2006 39-63


#
Koraitim J Urol 1996; 156(4): 1288 1291

Mouraviev et al J Urol 2005; 173(3): 873-876

AUA Update Series Lesson 2005 30 Volume 24: Primary realignment of the traumatic urethral distraction

Urethral Trauma
Case Presentation
Nick Buchan
Brisbane
Trainee Week
Victoria 2007

The Case
23 year old male.
MVA. Seat belted.
High speed frontal impact.
Car completely destroyed. Airbag deployed.
Other driver killed.
Patient conscious at the scene.

Initial presentation to Hospital.


A: Clear. C-spine protection. On backboard.
B: A/E symmetric. O2 sats n. No crepitus. Trachea central.
C: BP:100/60 HR:100.
D: GCS=15 PERL.
Pt exposed.
C/O lower abdominal as well as right hip and leg pain.

Secondary Survey
Mild suprapubic tenderness.
Pelvic instability.
Probable right tibial #.
Blood at the meatus.
DRE normal.

Initial Management
Fluid resus. Stabilized vital signs.
Plain X-rays trauma series.
C-spine, CXR normal.
Pelvis unstable #. With fractures through the pubic symphysis, pubic rami
on the right and SI joint.
Mid tibial fracture.

Retrograde Urethrogram
- Key points.
1.
2.

Plain film to reveal


fractures.
Supine slightly oblique
positioning.

3.

4.
5.
6.

7
8

14-16 Fr Foley.
2mls in balloon. 2cms
inside urethra.
50-100mls of water soluble contrast under gentle pressure. Need to distend urethra.
Fluoroscopy if possible.
Post void x-ray.

RUG - Complete Posterior Urethral Tear.


Mechanism of Injury.
Shearing injury through the membranous urethra.

Partial Urethral Tear


Extravasation.
Contrast in bladder.

10

Initial Urological Management


Supra-pubic catheterization.
Subsequently transferred to theatre for external fixation of pelvis.

11

Definitive Urological Management.


The supra pubic catheter remained in-situ for four months.
A delayed end to end bulbo-prostatic anastomotic urethroplasty was
undertaken.
Crural seperation was required.

12
13

Delayed Urethroplasty.
Follow Up at 6 weeks.
Catheter removed at 2 weeks following a peri-catheter urethrogram
showing no leak.
No erectile function at present.
No significant LUTS.
Back to work as School Teacher.

Penetratinggenitalinjuries
` Excludeotherlifethreateninginjuriesinfieldofmissile
` UrethrographyandpelvicCTessential.
Penis
Testis
Superficialwoundsirrigateandclose
Penetratingtraumabilateralin30%
Deeperstructures:SPC,immediateexploration,
Managementissurgicalexplorationwithdebridementof
deadtissueandprimaryreconstructionwherepossible
haemostasis,debridementofnecrotictissueand
primaryreconstruction
Completespermaticcordtransectioncanberepairedif
patientstable.
Penileamputation
` Usuallyselfinflictedduringepisodeofacutepsychosis.Notuncommon
` Reattachmentpossibleif<24hrscoldischaemia,<6warm
` Carefulreattachmentwithmicrovasculartechniques.Posteriortoanterior.Reapproximatespongiosumandurethra
(overidc)first,thentunicaalbugineaofcavernosa,thendorsalarteries,deepdorsalveinandnerve,skin.SPC.
Penilefracture
` Classichistorytrauma,poppingsound,painandimmediatedetumescence
` Swellingandbruising,mayfeeldefectintunica,rollingsign
` Upto30%haveurethralinjurytoo
` ImagingMRIandcavernosographymostreliable.
` Managementexploration,clotevacuationandrepairofdefect.Urethroscopy
Penilesofttissueinjuries
` Dogandhumanbites,zipperinjuries,selfinflictedpenilemodification,improperusevacuumerectiondevice(or
vacuumcleaner)
` Generallyiftraumaticcanundergoprimaryrepairafterdebridementandwithantibioticcover.Heavilycontaminated
woundsshouldbedebridedandcleaned,coveredwithwetdressings.Delayedprimaryreconstructioncanbe
performedwheninfectioncontrolled
Scrotalsofttissueinjuries
` Debridementandwashingofwound+++.Primaryclosureusuallypossible.
` Infectedwoundsshouldnotbeimmediatelyclosed.Wetdressingstoprotecttestes,orplaceinthighpouchesuntil
reconstruction
` Canusesplitthicknessskingrafts,orsecondarygranulationofwound
BluntTesticularinjury
` Usuallyunilateral
` 50%bluntscrotalinjuriesassociatedwithtesticularrupture
` ImaginghighresolutionUStolookforbleeding,contusion,vascularcompromiseand/orrupture.CTandMRImay
behelpful
` Explorationwithevacuationofclot,resectionofnecrotictubulesandclosureoftunicaalbuginea.
Testiculardislocation
` Bilateralin25%ofcases
` Twoclassifications
Subcutaneouswithepifascialdisplacementoftestis
Internaltestispositionedinsuperficialexternalinguinalring,inguinalcanal,abdominalcavity
` Manuallyreplaced+/orchipexy.Manualfixationofentranceofcordintoscrotumisalsorecommended
GenitalBurns
` Thermalburnsirrigateandcoverwithwetdressings+creamoftheday
` Chemicalirrigatewithappropriateneutralisingsubstanceandcover
Femalegenitalinjuries
` Assault,childbirth,consensualintercourse,bluntpelvictrauma
` Vulvarhaematomasmostcommonandmaybeassociatedwithvoidingdifficulties
` Needtoexcludeconcomitantbladder/pelvicorganinjurywithCT.
` Bloodatintroituswithhistoryoftraumanecessitatesinternalspeculumexamusuallyunderanaesthesia
Femalecircumcision/genitalmutilation
` 4types
TypeIexcisionprepucewithpart/allofclitoris
TypeIIexcisionofclitoriswithpart/totalexcisionoflabiaminora
TypeIIIexcisionofpart/allofexternalgenitaliawithstitching/narrowingofvaginalopening
TypeIVprickingpiercingincisingofclitoris/labia,stretchingofclitoris/labia,cauterisationofclitorisand
surroundingtissue,scrapingoftissuearoundvaginalorifice,cuttingofvagina,introducingcorrosive
substances/herbsintovaginatoinducebleedingandhencetighteningornarrowingandanyotherprocedure
notincludedinabove.

References
` Moreyetal,ConsensusonGenitourinaryTrauma:externalgenitalia.BJUInt2004;94:507515
` WessellsH,LongL,PenileandGenitalInjuries.UrolClinNAm2006;33:117126
` BuckleyJ,McAninchJ,DiagnosisandManagementofTesticularRuptures.UrolClinNAm2006;33:111116
` KellyE,HillardPJA,FemaleGenitalMutilation.CurrOpinObstetGynecol2005;17:490494
` EAUguidelines2006edition
` CampbellsUrology8thedition

Anthony Hutton
NSW section

Genital Trauma Blunt Scrotal Trauma


Case Presentation

History
24 yo male jockey
Bucked from horse with associated straddle injury
Immediate right testicular pain and swelling
Wearing helmet, no HI, no LOC, no other injuries
Presented to ED 3hrs post injury
Examination
Obvious discomfort
ABCDE and secondary survey NAD
Scrotum
- left testicle normal
- right hemiscrotum dusky, large tender mass upper scrotum c/w haematoma
No meatal blood, no perineal bruising
Investigations
Urine microscopy no microscopic haematuria
Scrotal ultrasound Right testicle mixed echogenic appearance, with minimal normal
appearing testicular tissue. Moderate right haematocoele. No intratesticular
vascularity.
Treatment
Proceeded to scrotal exploration consented for possible orchidectomy.
At operation
- scrotal approach
- moderate haematocoele
- large intra-testicular haematoma
- superior pole rupture with extrusion of seminiferous tubules
- following debridement extensive intra-testicular haematoma nonviable
- Proceeded to orchidectomy
Post-op
Uneventful recovery
Final pathology confirmed intra-testicular haematoma with diffuse interstitial
haemorrhage, very small rim of viable tissue. No evidence of malignancy.