Emergencies in Urology - part 5 potx

Table 15.6.3. Classification of bladder injury based on the type of trauma Classification of injury Mechanism of injury Associated injuries Blunt trauma Extrape- ritoneal Blunt pelvic trauma with laceration by bone fragment(s) Pelvic fractures Shearing at ligamentous attachment(s) Other long bone fractures Intrape- ritoneal High velocity blunt lower abdominal trauma High rate of associated intraabdominal injuries High intravesical pressure with rupture at dome High mortality Penetrating trauma Direct injury to the bladder wall Associated injury to otherorgansiscommon Table 15.6.4. AAST organ in- jury severity scale for the bladder and Associated Ab- breviated Injury Scale of the American Association for Automotive Medicine, 1990 (AIS-90) Grade a Injurytype Descriptionofinjury AIS-90 I Hematoma Contusion, intramural hematoma 2 I Laceration Partial thickness 3 II Laceration Extraperitoneal bladder wall laceration <2 cm 4 III Laceration Extraperitoneal (>2 cm) or intraperitoneal (<2 cm) bladder wall laceration 4 IV Laceration Intraperitoneal bladder wall laceration >2 cm 4 V Laceration Intraperitoneal or extraperitoneal bladder wall lacera- tion extending into the bladder neck or ureteral orifice (trigone) 4 a Advanceonegradefor multiple injuries to same organ up to grade III Fig. 15.6.1. AAST classification of bladder injury. Grade 1: contusion, intramural hematoma or partial thickness lacera- tion of the bladder wall (Fig. 15.6.1–6 © Hohenfellner 2007) Fig. 15.6.2. AAST classification of bladder injury. Grade 2: extraperitoneal laceration of the bladder wall <2 cm 250 15 Trauma Fig. 15.6.3. AAST classification of bladder injury. Grade 3: extraperitoneal laceration of the bladder wall >2 cm Fig. 15.6.5. AAST classification of bladder injury. Grade 4: intraperitoneal laceration of the bladder wall >2 cm Fig. 15.6.4. AAST classification of bladder injury. Grade 3: intraperitoneal laceration of the bladder wall <2 cm Fig. 15.6.6. AAST classification of bladder injury. Grade 5: intraperitoneal or extraperitoneal laceration of the bladder wall extending in to the bladder neck or trigone 15.6 Bladder Trauma 251 classification, which was adopted, modified, and rec- ommended by the Orthopaedic Trauma Association (OTA) (Tile 1988, 1996; OTA 1996). The OTA classifica- tion groups pelvic injuries into three main categories: A-type injuries have a stable pelvic ring, B-type have a partial posterior disruption, and C-type have a com- plete posterior disruption. Within this classification, the severity of injury increases from type A to type C (Tile1999),withahigherinjuryseverityscore(ISS),in- cidence of associated injuries, and mortality rate with the latter (Poole et al. 1991; Adams et al. 2002). 15.6.4 Risk Factors 15.6.4.1 Blunt Trauma Driving under the influence of alcohol predisposes to motor vehicle accidents and to a distended bladder as well.Thusitisariskfactorforbladderinjury(Dreitlein et al. 2001). Lateral-impact MVC are known to be associated with an increased incidence of pelvic fractures (Siegel et al. 1993; Loo et al. 1996; Inaba et al. 2004; Rowe et al. 2004), and therefore may result in bladder injury. CrashimpactdataintraumaregistryforMVCoccu- pants with AIS 4 pelvic injuries identified the lateral impact as the most common crash variable, account- ing for more than 80% of injuries to drivers and front seat passengers (Inaba et al. 2004). An evaluation of risk factors for severe pelvic injuries (AIS 4) suggest- ed motorcycle injuries to result in the highest inci- dence of pelvic fractures, with bladder and urethra as the most commonly injured organs. In this study, step- wise logistic regression analysis identified male gen- der and pelvic fracture AIS 4asindependentriskfac- tors (Demetriades et al. 2002). These patients also had significantly more genitourinary injuries, the bladder being the most common (25%) intraabdominal organ injured. 15.6.4.2 Iatrogenic Trauma Risk factors for iatrogenic bladder injury include ad- hesions and pelvic scarring from previous surgery, in- flammation,endometriosis,exposuretoradiation, presence of malignant disease, pregnancy, pelvic or- gan prolapse, multiple cesarean sections, congenital abnormalities, hemorrhage, or failure to empty the bladder before the operation (Daly and Higgins 1988; Harris et al. 1997; Davis 1999; Armenakas et al. 2004; Gomez et al. 2004; Yossepowitch et al. 2004). In a mul- ticenter study, concurrent surgery for stress inconti- nence along with gynecological procedures was found to be the only independent variable for bladder injury in a stepwise logistic regression model, with a relative risk of 4.42 (Vakili et al. 2005). The type of incision during cesarean section is also a risk factor. In a retro- spective analysis of data from 3,164 women undergo- ing cesarean section revealed that the type of incision, thepresenceofadhesions,andanteriorplacentapre- via were independently associated with increased risk of bladder injury (Makoha et al. 2005). The bladder was injured almost seven times as frequently with the midline subumbilical (MLSU) aswith the Pfannenstiel incision (p<0.0001; OR, 6.7). This study has also con- firmed the observation that for both types of incision the risk of bladder injury increases with the number of cesarean sections (Makoha et al. 2004) and for a given number the risk is higher with MLSU than Pfannen- stiel incision. 15.6.5 Diagnosis The two most common signs and symptoms of major bladderinjuriesaregrosshematuria(82%)andab- dominal tenderness (62%) (Carroll and McAninch 1984). Other findings may include inability to void, bruisesoverthesuprapubicregion,andabdominaldis- tention (Sagalowsky 1998). Extravasation of urine may result in swelling in the perineum, scrotum, and thighs, as well as along the anterior abdominal wall within the potential space between the transversalis fascia and the parietal peritoneum. Hematuria at the conclusion of an otherwise uneventful procedure, clearfluid inthe oper- ative field, gas distention of the urinary drainage bag during laparoscopy, and/or visible bladder laceration should alarm the surgeon to iatrogenic bladder injury (Armenakas et al. 2004; Gomez et al. 2004) 15.6.5.1 Macroscopic (Gross) Hematuria Gross hematuria indicates urologic trauma. Review of the existing literature reveals that traumatic bladder rupture is strongly correlated with the combination of pelvic fracture and gross hematuria. Morey et al. re- ported gross hematuria in all of their patients with bladder rupture, and 85% had pelvic fractures (Morey et al. 2001). Therefore, the classiccombination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims (Carroll and McAninch 1984; Rehm et al. 1991; Morey 2005). While grossly clear urine in a trauma pa- tient without a pelvic fracture virtually eliminates the possibility of a bladder rupture, up to 2%–10% of pa- tients with bladder rupture may have only microhema- turia or no hematuria at all (Schneider 1993). 252 15 Trauma Tarman et al. (2002) reviewed 8,021 pediatric trauma patients retrospectively, including 212 consecutive pa- tients with pelvic fractures. Among patients with pelvic fractures, only one patient (0.5%) had an extraperito- neal bladder rupture. Lower urogenital injury occurred in six patients (2.8%). The absence of gross hematuria effectively ruled out serious injury in this cohort. Con- sequently, these authors concluded that further urologi- cal work-up is unnecessary in stable patients with pelvic fractures and isolated microhematuria. Patients with gross hematuria, multiple associated injuries, or signifi- cant abnormalities found on their physical examination are recommended to undergo further urological evalu- ation with appropriate imaging modalities such as ret- rograde urethrography and cystography. 15.6.5.2 Microscopic Hematuria In thetrauma patient with apelvic ring fracture, micro- scopic hematuria should be considered as a possible in- dicator of bladder laceration, and further investigation is warranted. Existing data do not support lower uri- nary tract imaging in all patients with either pelvic fracture or microscopic hematuria alone. Also, the threshold of red blood cells in urine that triggers fur- ther investigation is a point of controversy. A threshold ranging from 25 to 200 red blood cells per high power field (rbc/phf) has been suggested to indicate signifi- cant injury to the bladder (Werkman et al. 1991; Fuhr- man et al. 1993; Morgan et al. 2000). These observations seems not to be valid for pediatric trauma patients, as indicated previously in a clinical series (Tarman et al. 2002).Incontrast,Abou-Jaoudeetal.foundthata threshold of 20 rbc/hpf as an indication for radiological evaluation would have missed 25% of cases with blad- der injury. In contrast to other reported series, they suggested that lower urogenital tract evaluation in pe- diatric trauma patients, especially in the presence of pelvic fractures, should be based as much on clinical judgmentasonthepresenceofhematuria(Abou-Jaou- de et al. 1996). 15.6.5.3 Cystography Retrograde cystography in evaluation of bladder trau- ma is considered the standard diagnostic procedure (Stine et al. 1988; Rehm et al. 1991; Baniel and Schein 1994). Cystography is accepted as the most accurate ra- diological study for diagnosing bladder rupture (Deck et al. 2000). When adequate bladder filling and post- void images are obtained, they have an accuracy rate of 85%–100%. The diagnosis of bladder rupture is usual- ly made easily on cystography when the injected con- trast medium is identified outside the bladder Fig. 15.6.7. Extraperitoneal rupture demonstrated on cystogra- phy. Extravasation of contrast material is limited to the peri- vesical space Fig. 15.6.8. Extraperitoneal rupture on cystography (Figs. 15.6.7–9). Adequate distention of the urinary bladder is crucial to demonstrate perforation, especial- ly in instances of penetrating trauma, since most in- stances of a false-negative retrograde cystography were found in this situation (Cass 1984; Baniel and Schein 1994). Cystography requires at least plain films, filled films, and postdrainage films. Half-filled film and obliques are optional. For the highest diagnostic accu- racy, the bladder must be distended by instillation of at 15.6 Bladder Trauma 253 Fig. 15.6.9. Intraperitoneal bladder rupture on cystography. Bowel loops are outlined by the extravasated contrast in the abdominal cavity least 350 cc of contrast medium with gravity. Bladder injury may be identified only on the postdrainage film in approximately 10% of the cases. False-negative find- ings may result from improperly performed studies with instillation of less than 250 ml of contrast medium or omission of a postdrainage film (Morey et al. 1999). Only a properly performed cystography should be used to exclude bladder injury. 15.6.5.4 Excretory Urography (Intravenous Pyelography) Intravenouspyelography(IVP)isinadequateforevalu- ation of bladder and urethra after trauma because of di- lution of the contrast material within the bladder, and resting intravesical pressure is simply too low to dem- onstrate a small tear (Ben-Menachem et al. 1991) IVP has a low accuracy, on the order of 15%–25% and vari- ous clinical studies indicated that IVP has an unaccept- ably high false-negative rate of 64%–84%, which pre- cludes its use as a diagnostic tool in bladder injuries (Werkman et al. 1991). 15.6.5.5 Ultrasound Although the use of US in bladder rupture has been de- scribed (Bigongiari et al. 2000), it has not been routine- ly used for evaluation of bladder injury. The presence of peritoneal fluid in the presence of normal viscera or failure to visualize the bladder after the transurethral introduction of saline is considered highly suggestive of bladder rupture (Bigongiari et al. 2000). In practice, US is not definitive in bladder or urethral trauma and is not routinely used. Focused abdominal sonography for trauma (FAST) has gained popularity in the evaluation of blunt abdominal trauma in adults to detect free in- traperitoneal fluid, with a sensitivity of 63%–99% in published series (Fernandez et al. 1998; Yoshii et al. 1998; Nunes et al. 2001; Von Kuenssberg Jehle et al. 2003). Several reports have indicated that FAST can also re- liably detect free intraperitoneal fluid in children, with acceptable sensitivity and specificity rates (Holmes et al. 2001; Soudack et al. 2004). However, a positive FAST in a hemodynamically stable child is of limited use, be- cause in one survey only 26% (5/19) of pediatric emer- gency attending physicians considered ultrasound equally available with CT, and none considered it more readily available than CT (Baka et al. 2002). The inabili- ty of FAST to distinguish the origin of free fluid in the abdomensuchasblood,ascites,orurineremainsan- other disadvantage of this modality (Jones et al. 2003). Therefore, the exact role of FAST in detection of bladder injury remains to be determined. 15.6.5.6 Computed Tomography CT is clearly the method of choice for the evaluation of patients with blunt or penetrating abdominal and/or pelvic trauma. However, routine CT is not reliable in the diagnosis of bladder rupture even if an inserted urethral catheter is clamped. CT demonstrates intra- peritoneal and extraperitoneal fluid but cannot differ- entiateurinefromascites.AswithIVP,thebladderis usuallyinadequatelydistendedtocauseextravasation throughabladderlacerationorperforationduring routine abdominal and pelvic studies. Therefore, a neg- ativestudycannotbeentirelytrusted,androutineCT thereforecannotruleoutbladderinjury(Meeetal. 1987; Cass 1989; Ben-Menachem et al. 1991). Horstman et al. reviewed the cystograms and CT scans of 25 pa- tients who had both studies as the initial evaluation of blunt abdominal trauma (Horstman et al. 1991). Five out of 25 had bladder rupture, three extraperitoneal and two intraperitoneal. All injuries were detected by both studies. The authors felt that delayed imaging or contrast instillation (CT cystography) can provide the adequate bladder distention needed to demonstrate contrast extravasation from the injury site during CT. Similarly, in a series of 316 patients, Deck et al. diag- nosed 44 cases with bladder ruptures. In patients who underwentformalsurgicalrepair,82%hadoperative 254 15 Trauma findings that exactly matched the CT cystography in- terpretation (Deck et al. 2000). Thus, either retrograde cystography or CT cystography are the diagnostic pro- cedures of choice for suspected bladder injury (Schnei- der 1993). CT cystography may be used in place of a conventional cystography (overall sensitivity 95% and specificity 100%), especially in patients undergoing CT scanning for other associated injuries (Deck et al. 2001). However, this procedure should be performed using retrograde filling of the bladder with a minimum of 350 cc of dilute contrast material (Wah and Spencer 2001). CT cystographic features may lead to accurate clas- sification of bladder injury (Figs. 15.6.10, 11) and allow prompt, effective treatment with less radiation expo- sure and without the added cost of conventional cysto- graphy (Vaccaro and Brody 2000). Fig. 15.6.10. CT cystography demonstrating extraperitoneal extravasation of contrast material Fig. 15.6.11. Extraperitoneal rupture on CT cystography 15.6.5.7 Angiography Angiographyisrarelyifeverindicated.Itcanbeuseful in identifying an occult source of bleeding and for ther- apeutic embolization (Ben-Menachem et al. 1991). 15.6.5.8 Magnetic Resonance Imaging Since it is extremely difficult to monitor a seriously in- jured patient in a strong magnetic field, MRI currently has little place in the evaluation of acute bladder (Ben- Menachem et al. 1991). 15.6.5.9 Cystoscopy Cystoscopy appears an extremely useful tool in the di- agnosis of iatrogenic bladder injuries. The results of a multicenter study as well as a comprehensive review of the literature indicated that the majority (49.4%– 64.7%) of bladder injuries during gynecological opera- tions would be missed if cystoscopy were not per- formed at the end of each procedure (Gilmour et al. 1999; Vakili et al. 2005). The detection rate of bladder injury by cystoscopy ranges from 85% to 94.1% in dif- ferent series (Harris et al. 1997; Vakili et al. 2005). 15.6.6 Treatment The first priority in the treatment of bladder injuries is stabilization of the patient and treatment of associated life-threatening injuries. 15.6.6.1 Blunt Trauma: Extraperitoneal Rupture Most patients with extraperitoneal rupture can be managed safely by catheter drainage only, even in the presence of extensive retroperitoneal or scrotal extrav- asation. Virtually all ruptures are healed in 3 weeks (Morey et al. 1999). However, involvement of the blad- der neck (Carroll and McAninch 1984), the presence of bone fragments in the bladder wall, or entrapment of thebladderwallnecessitatesurgicalintervention (Dreitlein et al. 2001). In the absence of bladder neck involvement and/or associated injuries that require surgical intervention such as open pelvic fractures and rectal or vaginal lacerations, extraperitoneal bladder ruptures caused by blunt trauma are managed by cath- eter drainage only (Cass and Luxenberg 1987). The presence of open pelvic fractures and/or rectal injuries precludes conservative management due to the high 15.6 Bladder Trauma 255 risk of serious infectious complications (Cass and Lu- xenberg 1989). In patients undergoing surgery for oth- er organ injuries, the laceration of the bladder wall should also be repaired transvesically, if the patient is stable at the time of the operation (Gomez et al. 2004). 15.6.6.2 Blunt Trauma: Intraperitoneal Rupture Intraperitoneal ruptures occurring after blunt trauma should always be managed by surgical exploration. This type of injury involves a high degree of force, and because of the severity of associated injuries carries a high mortality rate of 20%–40% (Cass 1989; Rehm et al. 1991). Lacerations are usually large in these in- stances with potential risk of peritonitis due to urine leakage, if left untreated (Deck et al. 2000). Abdominal organs should be inspected for possible associated in- juries, and urinoma must be drained. The technique of surgical repair depends on the surgeon’s preference but a two-layer closure with absorbable sutures achieves a safe repair of the bladder wall. A suprapubic catheter can be used in addition to a urethral catheter to ensure the adequacy of the drainage. However, in a recent study, patients with Foley catheter drainage alone had equally good outcome (Volpe et al. 1999). 15.6.6.3 Penetrating Trauma All bladder perforations due to a penetrating trauma should undergo emergency exploration and repair (Deck et al. 2000). Penetrating trauma to the pelvis pre- sentsaseriouschallengebecauseofthecomplexanato- my of the region. Penetrating trauma patients present- ing with shock have a high incidence of vascular injury and subsequent exsanguination, and associated viscer- al injuries may complicate their management, resulting inahighmortalityrate.However,stablepatientscanbe managed without operation, when appropriate diag- nostic techniques fail to demonstrate an injury (Dun- can et al. 1989). Gunshot wounds to the bladder usually result in intraperitoneal leaks, which require proper drainage and repair of the associated lacerations of the bladderwallaswellasadjacentorgans.However,inthe occasional patient with extraperitoneal rupture, non- operative management with Foley catheter drainage can be used successfully (Velmahos and Degiannis 1997). 15.6.6.4 Iatrogenic Trauma In patients with immediate diagnosis, bladder repair accomplished by a transabdominal or transvaginal two-layer closure effectively treats 98% of cases and the rest are managed by Foley catheter drainage (Armena- kas et al. 2004). 15.6.6.5 Complications In patients with bladder trauma, complications are usually the result of failure to diagnose the injury and repair promptly. This may result in urinoma formation, urinary leakage into the peritoneal cavity, ileus, perito- nitis, hematoma, abscess formation, fistula formation (rectal, vaginal, or cutaneous), and urinary tract infec- tion. Bladder injury with extravasation of urine with or without prostatic injury may complicate the course of recovery by impairing the coagulation mechanism. The prostatic capsule contains abundant activators of plas- minogen and urine contains high levels of urokinase, a potent plasminogen activator (Andersson 1980). Both tissue activator and urokinase accelerate the dissolu- tion of clots and may consequently increase and pro- long hemorrhage (Hedlund 1969). Epsilon amino ca- proic acid (EACA) can be effective in controlling hema- turia after surgical procedures compared with placebo, and its use was not accompanied by significant compli- cations (Miller et al. 1980). Tranexamic acid (amino- methyl cyclohexane carboxylic acid, AMCA) is a stron- gerinhibitorofplasminogenactivationthanEACAand may significantly decrease the amount of blood loss and control the bleeding when administered in a total dose of 3–12 g for 4–21 days (Hedlund 1975; Dunn and Goa 1999) without any increase in the incidence of thrombosis compared to placebo (Hedlund 1975). Early angiography and transcatheter embolization in patients with major blood requirements after pelvic trauma may help to avoid the need for and complica- tions of multiple transfusions and large pelvic hemato- mas. Precise localization of bleeding sites and occlu- sion of the bleeding artery by either an injection of au- tologous clot or Gelfoam embolization can be success- fully achieved (Matalon et al. 1979; Wong et al. 2000; Ben-Menachem 1988). 15.6.7 Damage Control Severe multiple traumatic injuries may cause acidosis, hypothermia, and coagulopathy, which have been asso- ciated with very high mortality rates (Zacharias et al. 1999). Focusing the initial resuscitative efforts to stabi- lize the patient with the control of the hemorrhage (temporary packing) and gross contamination along with appropriate bladder drainage with and subse- quent intensive care may allow for later definitive re- pair of the injuries in a patient who will otherwise die. 256 15 Trauma References Abou-Jaoude WA et al (1996) Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pedi- atr Surg 31:86; discussion 90 Adams JE et al (2002) Analysis of the incidence of pelvic trau- ma in fatal automobile accidents. Am J Forensic Med Pathol 23:132 Agostini A et al (2006) Immediate complications of tension- free vaginal tape (TVT): results of a French Survey. Eur J Ob- stet Gynecol Reprod Biol 124:237 Aihara R et al (2002) Fracture locations influence the likeli- hood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures. J Trauma 52:205; discussion 208 Andersson L (1980) Antifibrinolytic therapy in genitourinary tract surgery. J Clin Pathol Suppl (R Coll Pathol) 14:60 Anonymous (1996) Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma 10 [Suppl 1]:v, 1 Armenakas NA et al (2004) Iatrogenic bladder perforations: longterm followup of 65 patients. J Am Coll Surg 198:78 AzamUetal(2001)Thetension-freevaginaltapeprocedurein women with previous failed stress incontinence surgery. J Urol 166:554 Baka AG et al (2002) Current use and perceived utility of ultra- sound for evaluation of pediatric compared with adult trau- ma patients. Pediatr Emerg Care 18:163 Baniel J, Schein M (1994) The management of penetrating trauma to the urinary tract. J Am Coll Surg 178:417 Ben-Menachem Y (1988) Pelvic fractures: diagnostic and ther- apeutic angiography. Instr Course Lect 37:139 Ben-Menachem Y et al (1991) Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent manage- ment. AJR Am J Roentgenol 157:1005 Bigongiari LR et al (2000) Trauma to the bladder and urethra. American College of Radiology. ACR Appropriateness Crite- ria. Radiology 215:733 Bircher M, Giannoudis PV (2004) Pelvic trauma management within the UK: a reflection of a failing trauma service. Injury 35:2 Bond SJ et al (1991) Predictors of abdominal injury in children with pelvic fracture. J Trauma 31:1169 Brenneman FD et al (1997) Long-term outcomes in open pelvic fractures. J Trauma 42:773 Carlin BI, Resnick MI (1995) Indications and techniques for urologic evaluation of the trauma patient with suspected urologic injury. Semin Urol 13:9 Carroll PR, McAninch JW (1984) Major bladder trauma: mech- anisms of injury and a unified method of diagnosis and re- pair. J Urol 132:254 Cass AS (1984) False negative retrograde cystography with bladder rupture owing to external trauma. J Trauma 24:168 Cass AS (1989) Diagnostic studies in bladder rupture. Indica- tions and techniques. Urol Clin North Am 16:267 Cass AS, Luxenberg M (1987) Features of 164 bladder ruptures. J Urol 138:743 Cass AS, Luxenberg M (1989) Management of extraperitoneal ruptures of bladder caused by external trauma.Urology 33:179 Clancy TV et al (2001) A statewide analysis of level I and II trauma centers for patients with major injuries. J Trauma 51:346 Coppola PT, Coppola M (2000) Emergency department evalua- tion and treatment of pelvic fractures. Emerg Med Clin North Am 18:1 Daly JW, Higgins KA (1988) Injury to the ureter during gyne- cologic surgical procedures. Surg Gynecol Obstet 167:19 Davis JD (1999) Management of injuries to the urinary and gastrointestinal tract during cesarean section. Obstet Gyne- col Clin North Am 26:469 Deck AJ et al (2000) Computerized tomography cystography for the diagnosis of traumatic bladder rupture. J Urol 164:43 Deck AJ et al (2001) Current experience with computed tomo- graphic cystography and blunt trauma. World J Surg 25:1592 Delorme E (2001) Transobturator urethral suspension: mini- invasive procedure in the treatment of stress urinary incon- tinence in women. Prog Urol 11:1306 Demetriades D et al (2002) Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. JAmCollSurg195:1 Dobrowolski ZF et al (2002) External and iatrogenic trauma of the urinary bladder: a survey in Poland. BJU Int 89:755 Dreitlein DA et al (2001) Genitourinary trauma. Emerg Med Clin North Am 19:569 Duncan AO et al (1989) Management of transpelvic gunshot wounds. J Trauma 29:1335 Dunn CJ, Goa KL (1999) Tranexamic acid: a review of its use in surgery and other indications. Drugs 57:1005 Eastridge BJ, Burgess AR (1997) Pedestrian pelvic fractures:5- year experience of a major urban trauma center. J Trauma 42:695 Espinoza R, Rodriguez A (1997) Traumatic and nontraumatic perforation of hollow viscera. Surg Clin North Am 77:1291 Failinger MS, McGanity PL (1992) Unstable fractures of the pelvic ring. J Bone Joint Surg Am 74:781 Fallon B et al (1984) Urological injury and assessment in pa- tients with fractured pelvis. J Urol 131:712 Fernandez L et al (1998) Ultrasound in blunt abdominal trau- ma.JTrauma45:841 Ferrera PC, Hill DA (1999) Good outcomes of open pelvic frac- tures. Injury 30:187 Flancbaum L et al (1988) Blunt bladder trauma: manifestation of severe injury. Urology 31:220 Fuhrman GM et al (1993) The single indication for cystogra- phy in blunt trauma. Am Surg 59:335 Gilmour DT et al (1999) Lower urinary tract injury during gy- necologic surgery and its detection by intraoperative cystos- copy. Obstet Gynecol 94:883 Gokcen EC et al (1994) Pelvic fracture mechanism of injury in vehicular trauma patients. J Trauma 36:789; discussion 795 Gomez RG et al (2004) Consensus statement on bladder inju- ries. BJU Int 94:27 Harkki-Siren P et al (1998) Urinary tract injuries after hyster- ectomy. Obstet Gynecol 92:113 Harris RL et al (1997) The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Ob- stet Gynecol 177:1367; discussion 1369 Hedlund PO (1969) Antifibrinolytic therapy with Cyklokapron in connection with prostatectomy. A double blind study. Scand J Urol Nephrol 3:177 Hedlund PO (1975) Postoperative venous thrombosis in be- nign prostatic disease. A study of 316 patients, using the 125I-fibrinogen uptake test. Scand J Urol Nephrol 27 [Suppl]:1 Holmes JF et al (2001) Emergency department ultrasonogra- phy in the evaluation of hypotensive and normotensive chil- dren with blunt abdominal trauma. J Pediatr Surg 36:968 Horstman WG et al (1991) Comparison of computed tomogra- phy and conventional cystography for detection of traumat- ic bladder rupture. Urol Radiol 12:188 Inaba K et al (2004) The increasing incidence of severe pelvic injury in motor vehicle collisions. Injury 35:759 Ismail N et al (1996) Death from pelvic fracture: children are different. J Pediatr Surg 31:82 Jones AE et al (2003) Sonographic intraperitoneal fluid in pa- tients with pelvic fracture: two cases of traumatic intraperi- toneal bladder rupture. J Emerg Med 25:373 References 257 Khan RM et al (2004) A survey of urinary bladder injuries in Abbottabad. J Ayub Med Coll Abbottabad 16:47 Koraitim MM et al (1996) Risk factors and mechanism of ure- thral injury in pelvic fractures. Br J Urol 77:876 Kuuva N, Nilsson CG (2002) A nationwide analysis of compli- cations associated with the tension-free vaginal tape (TVT) procedure. Acta Obstet Gynecol Scand 81:72 Loo GT et al (1996) Airbag protection versus compartment in- trusion effect determines the pattern of injuries in multiple trauma motor vehicle crashes. J Trauma 41:935 Madiba TE, Haffejee AA (1999) Causes and outcome of bladder injuries in Durban. East Afr Med J 76:676 Makinen J et al (2001) Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 16:1473 Makoha FW et al (2004) Multiple cesarean section morbidity. Int J Gynaecol Obstet 87:227 Makoha FW et al (2005) Choice of abdominal incision and risk of trauma to the urinary bladder and bowel in multiple ce- sarean sections. Eur J Obstet Gynecol Reprod Biol Matalon TS, Athanasoulis CA et al (1979) Hemorrhage with pelvic fractures: efficacy of transcatheter embolization. AJR Am J Roentgenol 133:859 McConnell JD et al (1982) Rupture of the bladder. Urol Clin North Am 9:293 McGahan PJ et al (2005) Ultrasound detection of blunt urologi- cal trauma: a 6-year study. Injury 36:762 Mee SL et al (1987) Computerized tomography in bladder rup- ture:diagnosticlimitations.JUrol137:207 Mendez LE (2001) Iatrogenic injuries in gynecologic cancer surgery. Surg Clin North Am 81:897 Meschia M et al (2001) Tension-Free vaginal tape: analysis of outcomes and complications in 404 stress incontinent wom- en. Int Urogynecol J Pelvic Floor Dysfunct 12 [Suppl 2]: S24 Miller RA, May MW et al (1980) The prevention of secondary haemorrhage after prostatectomy: the value of antifibrino- lytic therapy. Br J Urol 52:26 Minaglia S et al (2004) Bladder injury during transobturator sling. Urology 64:376 Moore EE et al (1992) Organ injury scaling. III: Chest wall, ab- dominal vascular, ureter, bladder, and urethra. J Trauma 33:337 Morey AF (2005) Sonographic intraperitoneal fluid in patients with pelvic fracture: two cases of traumatic intraperitoneal bladder rupture. J Urol 174:2264 Morey AF et al (1999) Reconstructive surgery for trauma of the lower urinary tract. Urol Clin North Am 26:49 Morey AF et al (2001) Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma 51:683 Morgan DE et al (2000) CT cystography: radiographic and clini- cal predictors of bladder rupture. AJR Am J Roentgenol 174:89 Muir L et al (1996) The epidemiology of pelvic fractures in the Mersey Region. Injury 27:199 Murshidi MS (1988) Intraperitoneal rupture of the urinary bladder during transurethral resection of transitional cell carcinoma. Acta Urol Belg 56:68 Musemeche CA et al (1987) Selective management of pediatric pelvic fractures: a conservative approach. J Pediatr Surg 22:538 Nunes LW et al (2001) Diagnostic performance of trauma US in identifying abdominal or pelvic free fluid and serious ab- dominal or pelvic injury. Acad Radiol 8:128 Ochsner MG Jr et al (1989) Pelvic fracture as an indicator of in- creased risk of thoracic aortic rupture. J Trauma 29:1376 Olsson I, Kroon U (1999) A three-year postoperative evalua- tion of tension-free vaginal tape. Gynecol Obstet Invest 48:267 Ostrzenski A, Ostrzenska KM (1998) Bladder injury during laparoscopic surgery. Obstet Gynecol Surv 53:175 Poole GV et al (1991) Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. Ann Surg 213:532; discussion 538 Poole GV et al (1992) Complications of pelvic fractures from blunt trauma. Am Surg 58:225 Reed MH (1976) Pelvic fractures in children. J Can Assoc Radi- ol 27:255 Rehm CG et al (1991) Blunt traumatic bladder rupture: the role of retrograde cystogram. Ann Emerg Med 20:845 Reichard SA et al (1980) Pelvic fractures in children-review of 120 patients with a new look at general management. J Pedi- atr Surg 15:727 Rowe SA et al (2004) Pelvic ring fractures: implications of vehi- cle design, crash type, and occupant characteristics. Surgery 136:842 Sagalowsky AI, Peters PC (1998) Genitourinary trauma. In: WalshPC,RetikAB,VaughnED,WeinAJ(eds)Campbell’s urology, 7th edn. WB Saunders, Philadelphia, p 3116 Sandler CM et al (1981) Radiology of the bladder and urethra in blunt pelvic trauma. Radiol Clin North Am 19:195 Sandler CM et al (1986) Bladder injury in blunt pelvic trauma. Radiology 158:633 Sandler CM et al (1998) Lower urinary tract trauma. World J Urol 16:69 Schneider RE (1993) Genitourinary trauma. Emerg Med Clin North Am 11:137 Selikowitz SM (1977) Penetrating high-velocity genitourinary injuries. Part II: Ureteral, lower tract, and genital wounds. Urology 9:493 Siegel JH et al (1993) Safety belt restraints and compartment intrusions in frontal and lateral motor vehicle crashes: mechanisms of injuries, complications, and acute care costs. J Trauma 34:736; discussion 758 Siegmeth A et al (2000) Associated injuries in severe pelvic trauma. Unfallchirurg 103:572 Skolarikos A et al (2005) Does the management of bladder per- foration during transurethral resection of superficial blad- der tumors predispose to extravesical tumor recurrence? J Urol 173:1908 Soudack M et al (2004) Experience with focused abdominal so- nography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound 32:53 Soulie M et al (2001) The tension-free transvaginal tape proce- dure in the treatment of female urinary stress incontinence: a French prospective multicentre study. Eur Urol 39:709; dis- cussion 715 Stine RJ et al (1988) Diagnostic and therapeutic urologic pro- cedures. Emerg Med Clin North Am 6:547 Tamussino KF et al (2001) Tension-free vaginal tape operation: results of the Austrian registry. Obstet Gynecol 98:732 Tarman GJ et al (2002) Lower genitourinary injury and pelvic fractures in pediatric patients. Urology 59:123; discussion 126 Tiguert R et al (2000) Management of shotgun injuries to the pelvis and lower genitourinary system. Urology 55:193 Tile M (1988) Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 70:1 Tile M (1996) Acute pelvic fractures: I causation and classifica- tion.JAmAcadOrthopSurg4:143 Tile M (1999) The management of unstable injuries of the pel- vic ring. J Bone Joint Surg Br 81:941 Torode I, Zieg D (1985) Pelvic fractures in children. J Pediatr Orthop 5:76 Ulmsten U (2001) An introduction to tension-free vaginal tape (TVT)–a new surgical procedure for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dys- funct 12 [Suppl 2]:S3 Vaccaro JP, Brody JM (2000) CT cystography in the evaluation of major bladder trauma. Radiographics 20:1373 258 15 Trauma Vakili B et al (2005) The incidence of urinary tract injury dur- ing hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol 192:1599 Velmahos GC, Degiannis E (1997) The management of urinary tract injuries after gunshot wounds of the anterior and pos- terior abdomen. Injury 28:535 Volpe MA et al (1999) Is there a difference in outcome when treating traumatic intraperitoneal bladder rupture with or without a suprapubic tube? J Urol 161:1103 Von Kuenssberg Jehle D et al (2003) Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med 21:476 Wah TM, Spencer JA (2001) The role of CT in the management of adult urinary tract trauma. Clin Radiol 56:268 Weber S et al (1987) Transurethral prostatectomy complicated by intraperitoneal extravasation of irrigating fluid. Can J Anaesth 34:193 Werkman HA et al (1991) Urinary tract injuries in multiply-in- jured patients: a rational guideline for the initial assessment. Injury 22:471 Wolk DJ et al (1985) Extraperitoneal bladder rupture without pelvic fracture. J Urol 134:1199 Wong YC, Wang LJ et al (2000) Mortality after successful trans- catheter arterial embolization in patients with unstable pel- vic fractures: rate of blood transfusion as a predictive factor. J Trauma 49:71 Yoshii H et al (1998) Usefulness and limitations of ultrasonog- raphy in the initial evaluation of blunt abdominal trauma. J Trauma 45:45; discussion 50 Yossepowitch O et al (2004) Urological injuries during cesare- an section: intraoperative diagnosis and management. J Ur- ol 172:196 Young JW, Resnik CS (1990) Fracture of the pelvis: current con- cepts of classification. AJR Am J Roentgenol 155:1169 Young JW et al (1986) Lateral compression fractures of the pel- vis: the importance of plain radiographs in the diagnosis and surgical management. Skeletal Radiol 15:103 Zacharias SR et al (1999) Damage control surgery. AACN Clin Issues 10:95; quiz 141 References 259 [...]... 15. 7.2.2 15. 7.2.3 15. 7.2.4 15. 7.3 Diagnosis and Management of Genital Trauma 264 15. 7.4 15. 7.4.1 15. 7.4.2 15. 7.4.3 15. 7.4.4 Blunt Trauma of the Male Genitalia 264 Blunt Penile Trauma 264 Blunt Testicular Trauma 264 Blunt Female Trauma 2 65 Penetrating Trauma of the External Genitalia 2 65 Penetrating Trauma in Men 2 65 Penetrating Women Trauma 2 65 15. 7 .5 Treatment of External Genital Trauma 2 65 15. 7 .5. 1 Blunt... Surg 44:214 2 75 15 Trauma 15. 9 Urethral Trauma L Mart´nez-Pineiro ı ˜ 15. 9.1 Anatomical and Etiological Considerations 276 15. 9.1.1 Posterior Urethral Injuries 276 Stable Pelvic Fracture 277 Unstable Pelvic Fractures 277 Urethral Injuries in Children 278 Urethral Injuries in Women 278 Penetrating Injuries to the Perineum 279 15. 9.1.2 Anterior Urethral Injuries 279 Blunt Trauma 279 Intercourse-Related Trauma... Trauma 2 65 Blunt Penile Trauma 2 65 Blunt Testicular Trauma 266 Blunt Vulvar Trauma 266 15. 7 .5. 2 Penetrating Trauma 266 Penetrating Penile Trauma 266 15. 7 .5. 3 Penetrating Testicular Trauma 267 15. 7 .5. 4 Penetrating Vulvar Trauma 267 References 267 15. 7.1 Introduction Traumatic injuries to the genitourinary tract are seen in 2.2 % – 10.3 % of patients admitted to emergency units (Brandes et al 19 95; Marekovic... Trauma 279 Penetrating Trauma 280 Constriction Band-Related Trauma 280 Iatrogenic Trauma 280 15. 9.2 15. 9.2.1 15. 9.2.2 15. 9.2.3 Diagnosis: Initial Emergency Assessment 282 Clinical Assessment 282 Radiographic Examination 283 Endoscopic Examination 284 15. 9.3 Management 284 15. 9.3.1 Anterior Urethral Injuries 284 Blunt Injuries 284 Open Injuries 284 15. 9.3.2 Posterior Urethral Injuries 286 Partial Urethral... investigation in the initial assessment of urethral injuries but can be very useful in determining the position of the pelvic hematomas and the high-riding bladder when a suprapubic catheter is indicated Computed tomography and MRI have no place in the initial assessment of urethral injuries However, they are useful in defining the distorted pelvic anatomy after severe injury and assessing associated injuries... whereas during internal dislocation of the testis it is positioned in the superficial external inguinal ring, inguinal canal, or abdominal cavity Depending on the magnitude of blunt power acting on the scrotum, testicular rupture may occur in approximately 50 % of blunt scrotal traumas (Cass and Luxenberg 1991) It can occur under intense, traumatic compression of the testis against the inferior pubic... is indicated in any case of penetrating trauma 15. 7 .5. 4 Penetrating Vulvar Trauma Although penetrating vulvar trauma is rarely seen, it is even more important to emphasize that vulvar hematoma and/or blood at the vaginal introitus are an indication for vaginal exploration in order to identify possible associated vaginal and/or rectal injuries under sedation or general anesthesia (Husmann 1998) In case... age However, 5 % of trauma patients are less than 10 years old, again undermining the broad spectrum of traumatic injuries requiring different specialists for management (Monga and Hellstrom 1996) There are certain popular sports with an increased risk for blunt and/or penetrating genital trauma, such as off-road bicycling, horse-back riding, motorcycle riding, especially on bikes with a dominant gas... of rabies infection in animals, vaccination must be given to prevent life-threatening infections (Dreesen and Hanlon 1998) The estimated worldwide number of deaths due to rabies infection amounted to approximately 55 ,000 in 2004, most commonly in rural areas of Africa and Asia In addition to vaccination, local wound management is an essential part of postexposure rabies prophylaxis If rabies infection... Extravasation of contrast at injury site without visualization of bladder VI Complete or partial disruption of posterior urethra with associated tear of the bladder neck or vagina Penetrating Injuries to the Perineum These can occur involving the urethra, as well as being iatrogenic injuries caused by endoscopic instrumentation or during surgery for vaginal repair In developing countries, urethral and . Trauma 2 65 15. 7.4.4 Penetrating Trauma of the External Genitalia 2 65 Penetrating Trauma in Men 2 65 Penetrating Women Trauma 2 65 15. 7 .5 Treatment of External Genital Trauma 2 65 15. 7 .5. 1 Blunt. severe injury. Urology 31:220 Fuhrman GM et al (1993) The single indication for cystogra- phy in blunt trauma. Am Surg 59 :3 35 Gilmour DT et al (1999) Lower urinary tract injury during gy- necologic. antifibrino- lytic therapy. Br J Urol 52 :26 Minaglia S et al (2004) Bladder injury during transobturator sling. Urology 64:376 Moore EE et al (1992) Organ injury scaling. III: Chest wall, ab- dominal