CASE SCIENCE

SESSION
UROGENITAL & PELVIC
TRAUMA
Nurhayati Nufus
Ina Ratna
Preceptor :
dr. Liza Nursanty, SpB,
M.Kes, FINaCS

SMF Bedah
RS Al-Islam Bandung
Program P3D - Fakultas
Kedokteran
Universitas Islam
Bandung
Tahun 2016

KIDNEY ANATOMY

Retroperitoneal
T11-L3 ( right T12-L3) (left T11-L2)
The right kidney is separated from the

liver by the hepatorenal recess

The left kidney is related to the
stomach, spleen, pancreas, jejunum,
and descending colon

KIDNEY INJURY

More than half these injuries involve

patients under the age of 30 years and
men area affected four times as
frequently as women 80 % blunt trauma

Classification
Minor renal injury (85% of all cases)

subcapsullar and superficial laceration

Major renal injury (14% of all cases)
retroperitoneal and perinephric
haematomata,
Renal vascular injuries (1% of all
cases)segmental arteries or veins to
partial or complete avulsion of the main
renal pedicle.

Injury Grading
Grade Injury Type/Description
I Haematuria+normal urologic studies or Small nonexpanding subcapsular haematoma
If bilateral Grade II
II Haematoma confined to retroperitoneum or
Lac<1cm deep without urinary extravasation
If bilateralGrade III
III Lac>1cm deep without urinary extravasation
IV Deep lacerations or Renovascular injury with
contained haematoma
V Renal fracture or Avulsion/devascularised kidney

Treatment
Minor renal injuries are managed conservatively

by strict bedrest, antibiotics and monitoring of

vital signs, haematocrit and the injured kidney
Mayor renal injury Indications for surgical
intervention are:
signs of continued blood loss, such as falling
haematocrit;
increasing size of retroperitoneal or perinephric
haematoma; and
marked urine extravasation or vascular injury

URETERS
ANATOMY

The ureters are muscular ducts (25-30

cm long)
They run inferiorly from the apex of
the renal pelves at the hila of the
kidneys, the pelvic brim at the
bifurcation of the common iliac
arterieslateral wall of the pelvis
the urinary bladder

1 the junction of

pelvis and ureter, as

it crosses the
2 external iliac
vessels and pelvic
brim
3 as it penetrates
the wall of the
urinary bladder

URETERS INJURY

Ureteric injuries are uncommon

Most ureteric injuries are iatrogenic,

with penetrating trauma (pelvic

surgery)
the second most frequent cause
Blunt trauma

Injury to the ureter may be recognized at

the time of surgery or may present in

the postoperative
pyrexia, flank or lower quadrant pain,
paralytic ileus or fistula. Haematuria, gross
or microscopic, is present in 90% of cases.
Diagnosis
intravenous urography

Treatment
If recognized immediately: repair with

stenting (e.g. over Double-j' stent)

If late diagnosis: attempt repair but high
nephrectomy rate (30%)

Management
Minor defect: gentle expert urethral

catheterisation.
Major defect: SPC + delayed urethroplasty

ANATOMY of
BLADDER &
URETHRA

The bladder is a hollow, muscular organ

adapted for storing and expelling urine.

When it is empty, it lies posterior to the
pubic symphysis in the pelvis and is
extraperitoneal.
The dome of the bladder is covered
with peritoneum, and when the bladder
is full, it can rise into the abdomen and
is palpable on physical examination.
The
normal
bladder
can
store
approximately 350 to 450 mL.

The muscularis propria, also referred to

as the bladder detrusor, forms the

muscular wall of the bladder. Close to the
urethra, the muscle fibers become
organized into three layers: an inner
longitudinal, middle-circular, and outerlongitudinal.
The arterial blood supply to the bladder

comes from the superior, middle, and

inferior vesical arteries, which are all
branches of the internal iliac artery. The
venous return from the bladder drains

In men, urinary continence is maintained by

the internal and external sphincters.

The internal sphincter, composed of smooth

muscle, is formed by the middle circular layer

of the bladder wall as it invests the prostate
gland. Contraction of this sphincter during
ejaculation prevents retrograde ejaculation by
directing the semen toward the urethral
meatus.
The external sphincter surrounds the urethra at

the level of the distal prostate gland and is

composed of both smooth and striated muscle
fibers.

In women, continence is maintained by the

resistance provided by the coaptation of

the urethral mucosa and the external
striated sphincter surrounding the distal
two-thirds of the urethra.

BLADDER INJURIES

Bladder injuries are diagnosed by cystography

(a postvoid view enhances the accuracy of

cystography), CT, or during laparotomy.
Blunt ruptures of the intraperitoneal portion

are closed with a running single-layer closure

using 3-0 absorbable monofilament suture.
Blunt extraperitoneal rupture is treated with a
Foley catheter; direct operative repair is not
necessary. Cystograms can be used to
determine when the Foley catheter can be
removed, usually in 10 to 14 days.

Penetrating bladder injuries are treated in

the same fashion, although injuries near

the trigone should be repaired through an
incision in the dome so that iatrogenic
injury to the intravesicular ureter is
avoided by direct visualization.

URETHRA injuries

Blunt disruption of the posterior urethra is

managed by bridging the defect with a Foley

catheter (through the urethral meatus and
through an incision in the bladder).
Penetrating injuries are treated by direct
repair.

Anatomy of female
reproduction

EXTERNAL
(VULVA)

GENITALIA

The vulva is bounded by the symphysis pubis

anteriorly, the anal sphincter posteriorly, and the

ischial tuberosities laterally.
The labia majora form the cutaneous boundaries
of the lateral vulva. The labia majora are fatty
folds covered by hair-bearing skin in the adult.
They
fuse
anteriorly
with
the
anterior
prominence of the symphysis pubis, the mons
veneris. Posteriorly, the labia majora meet in a
structure that blends with the perineal body and
is referred to as the posterior commissure.

Adjacent and medial to the labia majora are the

labia minora, smaller folds of connective tissue

covered laterally by non-hair-bearing skin and
medially by vaginal mucosa. The anterior fusion
of the labia minora forms the prepuce of the
clitoris; posteriorly, the labia minora fuse in the
fossa navicularis, or posterior fourchette.
The term vestibule refers to the area medial to
the labia minora bounded by the fossa
navicularis and the clitoris. Both the urethra
and the vagina open into the vestibule.
The clitoris lies superior to the urethral meatus.

MUSCULATURE OF PELVIC
FLOOR
The levator ani muscles (Fig. 40-2) form

the
muscular floor of the pelvis. These muscles
include, from anterior to posterior, bilaterally, the
pubococcygeus, puborectalis, iliococcygeus, and
coccygeus muscles. The first two of these
muscles contribute fibers to the fibromuscular
perineal body.

The urogenital hiatus is bounded laterally by the

pubococcygeus muscles and anteriorly by the

symphysis pubis. It is through this muscular
defect that the urethra and vagina pass

Distal or caudad to the levator ani muscles, or levator

sling is the perineal membrane. This structure is

bounded by the ischial tuberosities inferolaterally and
by the pubic arch superiorly.
Lateral

to the perineal membrane are the

ischiocavernosus muscles. These structures parallel
and are attached to the inferior rami of the symphysis
pubis and, like the bulbocavernosus muscles, contain
erectile tissue that becomes engorged during sexual
arousal. The bulbocavernosus muscles arise in the
inferoposterior border of the symphysis pubis and
around the distal vagina before inserting into the
perineal body.

The transverse perinei muscles arise from the

inferior rami of the symphysis just anterior to the

pubic tuberosities and insert medially into the
perineal body, lending muscle fibers to this structure
as well.

INTERNAL GENITALIA
The central uterus and cervix are suspended

by
the
lateral
fibrous
cardinal,
or
Mackenrodt's, (uterosacral) ligaments, which
insert into the paracervical fascia medially
and into the muscular sidewalls of the pelvis
laterally.
Posteriorly, the uterosacral ligaments provide
support for the vagina and cervix as they
course from the sacrum lateral to the rectum
and insert into the paracervical fascia.

The bilateral fallopian tubes arise from the upper

lateral cornua of the uterus and course

posterolaterally and anterior to the ovaries. Each
widens in the distal third, or ampulla.
The ovaries are attached to the uterine cornu by
the proper ovarian ligaments. These structures
exit the pelvis through the internal inguinal ring
and course through the inguinal canal (canal of
Nuck) and external inguinal ring to the
subcutaneous tissue of the mons veneris. They
insert into the connective tissue of the labia
majora. The ovaries are seemingly suspended
from the lateral pelvis by their vascular pedicles,
the infundibulopelvic ligaments

The peritoneum enfolding the adnexa (tube,

round ligament, and ovary) is referred to as the

broad ligament.
The peritoneal recesses in the pelvis anterior
and posterior to the uterus are referred to as the
anterior and posterior cul-de-sacs. The latter is
also called the pouch or cul-de-sac of Douglas.
On transverse section, include the lateral
paravesical and pararectal spaces, and, from
anterior to posterior, the retropubic or prevesical
space of Retzius and the vesicovaginal,
rectovaginal, and retrorectal or presacral spaces.

The pelvic brim demarcates the obstetric, or true,

from the false pelvis contained within the iliac

crests.
The muscles of the pelvic sidewall include the
iliacus, the psoas, and the obturator; with the
exception of the middle sacral artery, which
originates at the aortic bifurcation, the blood
supply arises from the internal iliac arteries. The
internal iliac, or hypogastric, arteries divide into
anterior and posterior branches. The latter supply
lumbar and gluteal branches and give rise to the
pudendal arteries. From the anterior division of the
hypogastric arteries arise the obturator, uterine,
superior, and middle vesical arteries.

The nerve supply to the pelvis is composed of

the sciatic, obturator, and femoral nerves.

Sympathetic fibers course along the major
arteries and parasympathetics form the
superior and inferior pelvic plexus.
The ureters enter the pelvis as they cross the

distal common iliac arteries laterally and then

course inferior to the ovarian arteries and
veins until they cross under the uterine
arteries just lateral to the cervix. Course
downward and medially over the anterior
surface of the vagina before entering the base
of the bladder.

Gynecologic
injuries

Gynecologic injuries are rare. Occasionally

the vagina will be lacerated by a sharp bone

fragment from a pelvic fracture. Penetrating
injuries to the vagina, uterus, fallopian tubes,
and ovaries are also uncommon.
The usual hemostatic techniques are used to
control bleeding, and suture repair is used to
close defects that communicate with a lumen.
Transection at the injury site with proximal
ligation and distal salpingectomy is a more
prudent approach.

Trauma in pregnancy also is rare.

Blunt trauma can cause uterine rupture,

which almost always results in fetal

demise. The outcomes of penetrating
uterine injuries are more variable and
are dependent on penetration of the
uterine cavity, damage to the placenta,
and fetal injury. Spontaneous abortion is
a frequent outcome. If the fetus is viable
by dates or examination, an emergency
cesarean section should be considered.

Diagnosis : The bleeding associated with

genital
trauma
may
be
diagnosed
secondary to a history of rape or genital
injury. In the presence of genital bleeding
secondary to trauma, the lesion must be
evaluated carefully

Anatomy pelvic

 Pelvis is the part of the trunk inferoposterior to the

abdomen and is the area of transition between the

trunk and the lower limbs.
The pelvis :
a. Greater pelvis
The greater pelvis is surrounded by the superior
pelvic girdle.
The greater pelvis is occupied by inferior abdominal
viscera, affording them protection similar to the way
the superior abdominal viscera are protected by the
inferior thoracic cage.
b. Lesser pelvis
The lesser pelvis is surrounded by the inferior pelvic
girdle, which provides the skeletal framework for both
the pelvic cavity and the perineum

PELVIC GIRDLE
The pelvic girdle is a basin-shaped ring of bones
that connects the vertebral column to the two
femurs
The pelvic girdle is formed by three bones
Right and left hip bones (coxal bones; pelvic
bones): large, irregularly shaped bones, each of
which develops from the fusion of three bones,
the ilium, ischium, and pubis.
Sacrum: formed by the fusion of five, originally
separate, sacral vertebrae

Pelvic INJURIES

Diagnosis
1. History Taking
2. Physical Examination
- Digital examination finding of gross blood on
strongly suggests injury to these organs.
- Proctoscopy or speculum examination may
reveal the injury
- Urethral injuries are suspected by the findings of
blood at the meatus, scrotal or perineal
hematomas, and a high-riding prostate by rectal
exam.

3. Haematology Routine
4. Gross blood on urinalysis lacerated

bladder
5. Plain x-rays gross abnormalities
6. CT scans the pelvic for stability.
7. Angiography is indicated if thrombosis
of the arterial system is suspected

Clinical manifestation

Pelvic

fractures can cause exsanguinating

retroperitoneal hemorrhage without associated
major vascular injury (branches of the internal
iliac vessels and the lower lumbar arteries are
often responsible,h emorrhage also comes from
small veins and from the cancellous portion of
the fractured bones.
Large retroperitoneal hematomas can also
cause a hemoperitoneum, particularly if
overlying peritoneum ruptures

Methods for Haemorrhage Control

Anterior external fixation is not intended to

provide definitive fracture stabilization in most

instances. Its advocates intend for the device to
decrease pelvic volume, tamponade bleeding, and
to prevent secondary hemorrhage which may
occur if the fractured bones shift
Military Anti

Shock Trousers (MAST) can

provide some stability for the fracture and
probably tamponade venous hemorrhage. The
disadvantages are the loss of access to the
abdomen and the risk of lower extremity
compartment syndrome.

Angiography

with embolization is
very effective for controlling arterial
hemorrhage, but arterial hemorrhage
occurs in only 10 to 20% of patients with
active hemorrhage from pelvic fractures.

Pelvic

packing may control venous

hemorrhage. The only reason to consider
its use is when a pelvic hematoma is
inadvertently entered or if it has ruptured.

Complication

pelvic sepsis
osteomyelitis

Infection Preventive
The pelvic wound is manually dbrided and
then irrigated daily with a high-pressure,
pulsatile irrigation system until granulation
tissue covers the wound
To reduce the risk of infection, a sigmoid
colostomy is recommended.

62

REFERENCES
1. Brunicardi, F Charles, Andersen, D, Biliar, TR, Dunn,

DL. Schwartzs Principles of Surgery. Ed 8. New york :

McGraw-Hill; 2004.
2. Moore, Keith L, Dalley AF, Agur, AMR. Clinically

Oriented Anatomy. Ed 6 . Philladelphia: Lippincott

Williams & Wilkins; 2010.