genital trauma lecture 2011 -...
TRANSCRIPT
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GENITOURINARY TRAUMAINTRODUCTION AND BASIC PRINCIPLES
Dr E M Moshokoa
UROLOGY
UNIVERSITY OF PRETORIA
Lower Urinary tract
Bladder fullness
Urethra anterior
posterior
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Injuries
• Life threatening
• QOL
• Blunt and penetrating trauma
– Extraperitoneal rupture- 60%
– Intraperitoneal rupture-30%
– Combined-10%
• 80% pelvic fractures
• 15% associated with urethral rupture
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BLADDER TRAUMA
• Clinical picture
– Gross heamaturia – 95%
– S/P tenderness
– Pelvic/perineal bruising
– Ileus
– Absent bowel sounds
– sepsis(late) + High urea and creatinine
BLADDER TRAUMA
• Diagnosis
– Urethragram – normal – pass catheter
– Cystogram
• Control X – Ray
• 300 – 400 ml contrast
• AP + lateral
• Empty bladder
• AP
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BLADDER TRAUMA
Management
• Intraperitoneal rupture
– Surgical repair
• Extraperitoneal rupture– Look for bone fragment
– Concomitant injuries
• Two options
» Large bore catheter – F20
» Surgical repair
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• Intraperitoneal rupture
– High mortality rate
– Surgical repair
• Penetrating injuries
– Surgical repair
URETHRAL TRAUMA
The urethra in the male is divided for
treatment purposes
• anterior- (penile and bulbar) segments
• posterior (membranous and prostatic)
segments.
Urethral trauma in the female is much less
common than in the male
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Mechanism of injury
Posterior
• Pelvic rami fracture
• Penetrating injury
Anterior
• Straddle injury
• Blunt trauma
• Penetrating trauma
Aim is to restore
• Patency
• Potency
• Continence
– Failure to restore
• bladder
• outlet
– Failure to empty
• bladder
• outlet
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URETHRAL TRAUMA
• Clinical picture
– Meatal blood
– Urinary retention
– Heamatoma/bruising of perineum
– Heamaturia
– Swollen penis
– Floating prostate
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URETHRAL INJURY
TREATMENT
Posterior
• Manage life threatening injuries
• Urethragram
– Intact = catheterize cystogram
– Partial = Gentle catheterization
– Complete = suprapubic catheter cystogram (10-17%) surgical + endoscopic re alignment -72hours (surgeon’s preference)
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TREATMENT
Rail roading
Normal Urethragram
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Concerns!
• Bladder size
• Alignment of the
urethra
• Sphincter function
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URETHRAL TRAUMA
TREATMENT
Anterior
• Penetrating – explore surgically (caution with debrediment) – primary anastomosis (bowing of penis) –
– Unsure = dressings + s/p catheter
• Blunt/crushing injuries – urethragram suprapubic catheter
Urethral trauma
• Complications
– Stricture
– Impotence
– Incontinence
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GENITOPERINEAL INJURY
Initial management
• Analgesia
• Sedation
• Antibiotics
• Irrigation
• Debridement
CLASSIFICATION OF
GENITOPERINEAL INJURY
1. Penetrating trauma
2. Blunt trauma
3. Zipper entrapment
4. Burns (thermal, chemical or electrical)
5. Avulsion injuries
6. Penile fracture
7. Penile amputation
8. Penile strangulation
9. Human and animal bites
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Penile fractures
• Clinical
– Popping sound
– Pain
– Immediate detumescence
– Penile heamatoma + bruising
• Surgical exploration
– Circumsision skin incision
– Deglove penile skin
– Repair tunica albuginea
SCROTUM AND TESTIS
SCROTAL TRAUMA
Penetrating Blunt
Exploration Sonar
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SCROTUM AND TESTIS
BLUNT TRAUMA – WHO TO EXPLORE
• Uncertain clinical/sonar findings
• Massive heamatocele
• Intra testicular heamatoma
• Testicular rupture
Testicular rupture
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Intra testicular haematoma
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• Life threatening
• Fertility
• Impotence
• others : Metabolic Syndrome