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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.
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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.
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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.
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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.
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When genitourinary tract injury is suspected on the basis of the history and physical examination, additional studies are required to establish its extent.
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Catheterization and Assessment of Injury
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Assessment of the injury should be done in an orderly fashion so that accurate and complete information is obtained. This process of defining the extent of injury is termed staging. The algorithms (Figures 18–1, 18–2, and 18–3) outline the staging process for urogenital trauma.
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Blood at the urethral meatus in men indicates urethral injury; catheterization should not be attempted if blood is present, but retrograde urethrography should be done immediately. If no blood is present at the meatus, a urethral catheter can be carefully passed to the bladder to recover urine; microscopic or gross hematuria indicates urinary system injury. If catheterization is traumatic despite the greatest care, the significance of hematuria cannot be determined, and other studies must be done to investigate the possibility of urinary system injury.
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Abdominal computed tomography (CT) with contrast media is the best imaging study to detect and stage renal and retroperitoneal injuries. It can define the size and extent of the retroperitoneal hematoma, renal lacerations, urinary extravasation, and renal arterial and venous injuries; additionally, it can detect intra-abdominal injuries (liver, spleen, pancreas, bowel). Spiral CT scanning, now common, is very rapid, but it may not detect urinary extravasation or ureteral and renal pelvic injuries. We recommend repeat scanning 10 minutes after the initial study to aid the diagnosis of these conditions.
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Retrograde Cystography
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Filling of the bladder with contrast material is essential to establish whether bladder perforations exist. At least 300 mL of contrast medium should be instilled for full vesical distention. A film should be obtained with the bladder filled and a second one after the bladder has emptied itself by gravity drainage. These two films establish the degree of bladder injury as well as the size of the surrounding pelvic hematomas.
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Cystography with CT scan is excellent for establishing bladder injury. At the time of scanning, this likewise must be done with retrograde filling of the bladder with 300 mL of contrast media to ensure adequate distention to detect injury.
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A small (12F) catheter can be inserted into the urethral meatus and 3 mL of water placed in the balloon to hold the catheter in position. After retrograde injection of 20 mL of water-soluble contrast material, the urethra will be clearly outlined on film, and extravasation in the deep bulbar area in case of straddle injury—or free extravasation into the retropubic space in case of prostatomembranous disruption—will be visualized.
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Arteriography may help define renal parenchymal and renal vascular injuries. It is also useful in the detection of persistent bleeding from pelvic fractures for purposes of embolization with Gelfoam or autologous clot.
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Intravenous Urography
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Intravenous urography can be used to detect renal and ureteral injury. This is best done with high-dose bolus injection of contrast media (2.0 mL/kg) followed by appropriate films.
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Cystoscopy and Retrograde Urography
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Cystoscopy and retrograde urography may be useful to detect ureteral injury, but are seldom necessary, since information can be obtained by less invasive techniques.
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Abdominal sonography has not been shown to add substantial information during initial evaluation of severe abdominal trauma.