Genitourinary Trauma

Genitourinary Trauma

Various types of injuries of the flank, back, or upper abdomen may result in trauma to the kidney, ureter, bladder, or urethra. Trauma to the kidney accounts for about half of all cases of gen-itourinary trauma (Dreitlein, Suner & Basler, 2001).

RENAL TRAUMA

Normally, the kidneys are protected by the rib cage and muscu-lature of the back posteriorly and by a cushion of abdominal wall and viscera anteriorly. They are highly mobile and are fixed only at the renal pedicle (stem of renal blood vessels and the ureter). With traumatic injury, the kidney can be thrust against the lower ribs, resulting in contusion and rupture. Rib fractures or fractures of the transverse process of the upper lumbar vertebrae may be as-sociated with renal contusion or laceration. Injuries may be blunt (automobile and motorcycle crashes, falls, athletic injuries, as-saults) or penetrating (gunshot wounds, stabbings). Failure to wear seat belts contributes to the incidence of renal trauma in motor vehicle crashes. Up to 80% of patients with renal trauma have associated injuries of other internal organs.

Renal trauma may be classified by the mechanism of injury: blunt or penetrating. Blunt renal trauma accounts for 80% to 90% of all renal injuries; penetrating renal trauma accounts for the remaining 10% to 20% (Bayerstock, Simons & McLoughlin, 2001). Blunt renal trauma is classified into one of four groups, as follows:

·      Contusion: bruises or hemorrhages under the renal capsule; capsule and collecting system intact

·      Minor laceration: superficial disruption of the cortex; renal medulla and collecting system are not involved

·       Major laceration: parenchymal disruption extending into cortex and medulla, possibly involving the collecting system

·      Vascular injury: tears of renal artery or vein

The most common renal injuries are contusions, lacerations, ruptures, and renal pedicle injuries or small internal lacerations of the kidney (Fig. 45-8). The kidneys receive half of the blood flow from the abdominal aorta; therefore, even a fairly small renal laceration can produce massive bleeding. About 70% of patients are in shock when admitted to the hospital (Dreitlein et al., 2001).

Clinical manifestations include pain, renal colic (due to blood clots or fragments obstructing the collecting system), hematuria, mass or swelling in the flank, ecchymoses, and lacerations or wounds of the lateral abdomen and flank. Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. There is no relationship between the degree of hematuria and the degree of injury. Hematuria may not occur, or it may be detectable only on microscopic examination. Signs and symptoms of hypovolemia and shock are likely with signifi-cant hemorrhage.

URETERAL TRAUMA

Penetrating trauma and unintentional injury during surgery are the major causes of trauma to the ureters. Gunshot wounds ac-count for 95% of ureteral injuries, which may range from contu-sions to complete transection. Unintentional injury to the ureter may occur during gynecologic or urologic surgery (Mathevet, Valencia, Cousin et al., 2001; Perez-Brayfield, Keane, Krishnan et al., 2001). There are no specific signs or symptoms of ureteral injury; many traumatic injuries are discovered during exploratory surgery. If the ureteral trauma is not detected and urine leakage continues, fistulas are likely to develop.

Intravenous urography detects 90% of ureteral injuries and can be performed on the operating table in patients undergoing emergent surgery. Surgical repair with placement of stents (to divert urine away from the anastomoses) is usually necessary.

BLADDER TRAUMA

Injury to the bladder may occur with pelvic fractures and multi-ple trauma or from a blow to the lower abdomen when the blad-der is full. Blunt trauma may result in contusion evident as an ecchymosis—a large, discolored bruise resulting from escape of blood into the tissues and involving a segment of the bladder wall— or in rupture of the bladder extraperitoneally, intraperitoneally, or both. Complications from these injuries include hemorrhage, shock, sepsis, and extravasation of blood into the tissues, which must be treated promptly (Morey, Iverson, Swan et al., 2001).

URETHRAL TRAUMA

Urethral injuries usually occur with blunt trauma to the lower abdomen or pelvic region. Many patients also have associated pelvic fractures. The classic triad of symptoms comprises blood at the urinary meatus, inability to void, and a distended bladder ( Jordan, Jezior & Rosenstein, 2001).

Medical Management

The goals of management in patients with genitourinary trauma are to control hemorrhage, pain, and infection; to preserve and restore renal function; and to maintain urinary drainage. In renal trauma, all urine is saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Hemat-ocrit and hemoglobin levels are monitored closely; decreasing val-ues indicate hemorrhage.

The patient is monitored for oliguria and signs of hemorrhagic shock because a pedicle injury or shattered kidney can lead to rapid exsanguination (lethal blood loss). An expanding hematoma may cause rupture of the kidney capsule. To detect hematoma, the area around the lower ribs, upper lumbar vertebrae, flank, and ab-domen is palpated for tenderness. A palpable flank or abdominal mass with local tenderness, swelling, and ecchymosis suggests renal hemorrhage. The area of the original mass can be outlined with a marking pencil so that the examiner can evaluate the area for change.

Renal trauma is often associated with other injuries to the ab-dominal organs (liver, colon, small intestines); therefore, the pa-tient is assessed for skin abrasions, lacerations, and entry and exit wounds of the upper abdomen and lower thorax because these may be associated with renal injury.

With renal trauma, such as a contusion of the kidney, heal-ing may take place with conservative measures. If the patient has microscopic hematuria and a normal intravenous urogram, out-patient management is possible. If gross hematuria or a minor laceration is present, the patient is hospitalized and kept on bed rest until hematuria clears. Antimicrobial medications may be prescribed to prevent infection from perirenal hematoma or uri-noma (a cyst containing urine). Patients with retroperitoneal hematomas may develop low-grade fever as absorption of the clot takes place.

SURGICAL MANAGEMENT

In renal trauma, any sudden change in the patient’s condition may indicate hemorrhage and requires surgical intervention.

Depending on the patient’s condition and the nature of the in-jury, major lacerations may be treated through surgical interven-tion or conservatively (bed rest, no surgery). Vascular injuries require immediate exploratory surgery because of the high inci-dence of involvement of other organ systems and the serious com-plications that may result if these injuries are untreated. The patient is often in shock and requires aggressive fluid resuscitation. The damaged kidney may have to be removed (nephrectomy).

Early postoperative complications (within 6 months) include rebleeding, perinephritic abscess formation, sepsis, urine extrava-sation, and fistula formation. Other complications include stone formation, infection, cysts, vascular aneurysms, and loss of renal function. Hypertension can be a complication of any renal surgery but usually is a late complication of renal injury.

In bladder trauma, treatment for rupture of the bladder in-volves immediate exploratory surgery and repair of the lacera-tion, suprapubic drainage of the bladder and the perivesical space (around the bladder), and insertion of an indwelling uri-nary catheter. In addition to the usual care following urologic surgery, the drainage systems (suprapubic, indwelling urethral catheter, and perivesical drains) are closely monitored to ensure adequate drainage until healing takes place. The patient with a ruptured bladder may have gross bleeding for several days after repair.

In urethral trauma, unstable patients who need monitoring of urine output may need a suprapubic catheter inserted.

The patient is catheterized after urethrography is performed to minimize the risk of urethral disruption and extensive, long-term complications, such as stricture, incontinence, and impotence. Surgical repair may be performed immediately or at a later time. Delayed surgical repair tends to be the favored procedure because it is associated with fewer long-term complications, such as im-potence, strictures, and incontinence. After surgery, an indwelling urinary catheter may remain in place for up to 1 month.

Nursing Management

The patient with genitourinary trauma (particularly renal trauma) should be assessed frequently during the first few days after injury to detect flank and abdominal pain, muscle spasm, and swelling over the flank.

During this time, patients can be instructed about care of the incision and the importance of an adequate fluid intake. In addi-tion, instructions about changes that should be reported to the physician, such as fever, hematuria, flank pain, or any signs and symptoms of decreasing kidney function, are provided. Guide-lines for increasing activity gradually, lifting, and driving are also provided in accordance with the physician’s prescription.

Follow-up nursing care includes monitoring the blood pres-sure to detect hypertension and advising the patient to restrict ac-tivities for about 1 month after trauma to minimize the incidence of delayed or secondary bleeding. The patient should be advised to schedule periodic follow-up assessments of renal function (creatinine clearance, serum BUN and creatinine analyses). If a nephrectomy was necessary, the patient is advised to wear medical identification.