EMERGENCY DIAGNOSIS AND MANAGEMENT
About 10% of all injuries seen in the emergency room involve the genitourinary system to some extent. Many of them are subtle and difficult to define and require great diagnostic expertise. Early diagnosis is essential to prevent serious complications.
Initial assessment should include control of hemorrhage and shock along with resuscitation as required. Resuscitation may require intravenous lines and a urethral catheter in seriously injured patients. In men, before the catheter is inserted, the urethral meatus should be examined carefully for the presence of blood.
The history should include a detailed description of the accident. In cases involving gunshot wounds, the type and caliber of the weapon should be determined, since high-velocity projectiles cause much more extensive damage.
The abdomen and genitalia should be examined for evidence of contusions or subcutaneous hematomas, which might indicate deeper injuries to the retroperitoneum and pelvic structures. Fractures of the lower ribs are often associated with renal injuries, and pelvic fractures often accompany bladder and urethral injuries. Diffuse abdominal tenderness is consistent with perforated bowel, free intraperitoneal blood or urine, or retroperitoneal hematoma. Patients who do not have life-threatening injuries and whose blood pressure is stable can undergo more deliberate radiographic studies. This provides more definitive staging of the injury.
Renal injuries are the most common injuries of the urinary system (Figures 18–1, 18–2, 18–3). The kidney is well protected by heavy lumbar muscles, vertebral bodies, ribs, and the viscera anteriorly. Fractured ribs and transverse vertebral processes may penetrate the renal parenchyma or vasculature. Most injuries occur from automobile accidents or sporting mishaps, chiefly in men and boys. Kidneys with existing pathologic conditions such as hydronephrosis or malignant tumors are more readily ruptured from mild trauma.
Algorithm for staging blunt trauma in adults.
Algorithm for staging penetrating trauma in adults.
Algorithm for staging blunt trauma in children.
Blunt trauma directly to the abdomen, flank, or back is the most common mechanism, accounting for 80–85% of all renal injuries (Figure 18–4). Trauma may result from motor vehicle accidents, fights, falls, and contact sports. Vehicle collisions at high speed may result in major renal trauma from rapid deceleration and cause major vascular injury. Gunshot and knife wounds cause most penetrating injuries to the kidney; any such wound in the flank area should be regarded as a cause of renal injury until proven otherwise. Associated abdominal visceral injuries are present in 80% of renal penetrating wounds.