GENITOURINARY TRAUMA - 03/09/11

Doi : 10.1016/S0733-8627(05)70204-2

David A. Dreitlein, MD ^a, Selim Suner, MD, MS ^a, Joseph Basler, MD ^b

^a Department of Emergency Medicine, Rhode Island Hospital; Brown University School of Medicine, Providence, Rhode Island (DAD, SS)

^b Division of Urology, University of Texas Health Science Center at San Antonio, San Antonio, Texas (JB)

Résumé

Although the majority of injuries to the genitourinary (GU) tract do not result in an immediate threat to life, failure to properly evaluate and treat these injuries may result in significant long-term patient morbidity. GU injuries frequently occur in the setting of multiple organ system trauma, and although other life-threatening injuries must be addressed first, the emergency department physician must be alert to clues pointing to the presence of these injuries. Signs such as flank hematoma, gross hematuria, or blood at the urethral meatus point to the presence of potentially serious genitourinary injuries, which require further evaluation and treatment.^{8 Carlin B.I., Resnick M.I. Indications and techniques for urologic evaluation of the trauma patient with suspected urologic injury Semin Urol 1995 ; 13 : 9-24

Cliquez ici pour aller à la section Références, 57 Sagalowsky A.I., Peters P.C. Genitourinary trauma Campbell's Urology Philadelphia: WB Saunders (1998).
3085-3120

Cliquez ici pour aller à la section Références, 61 Skinner E.C., parisky Y.R., Skinner D.G. Management of complex urologic injuries Surgical Clin N Am 1996 ; 76 : 861-878 [inter-ref]

Cliquez ici pour aller à la section Références}

Urologic injuries occur in 10% to 20% of major trauma patients and may be the result of either blunt or penetrating trauma.^{8 Carlin B.I., Resnick M.I. Indications and techniques for urologic evaluation of the trauma patient with suspected urologic injury Semin Urol 1995 ; 13 : 9-24

Cliquez ici pour aller à la section Références, 11 Dawson C., Whitfield H. ABC of urology, urological trauma and bladder reconstruction BMJ 1996 ; 312 : 1352-1354 [cross-ref]

Cliquez ici pour aller à la section Références, 39 Miller K.S., McAninch J.W. Radiographic assessment of renal trauma: Our 15-year experience J Urol 1995 ; 154 : 352-355 [cross-ref]

Cliquez ici pour aller à la section Références} Injuries to the upper urinary tract (kidney and ureters) generally require a high degree of force, whereas lower tract trauma may result from more localized less forceful injury.^{46 Nash P.A., Bruce J.E., Mcaninch J.W. Nephrectomy for traumatic renal injuries J Urol 1995 ; 153 (3 Pt 1) : 609-611 [cross-ref]

Cliquez ici pour aller à la section Références, 61 Skinner E.C., parisky Y.R., Skinner D.G. Management of complex urologic injuries Surgical Clin N Am 1996 ; 76 : 861-878 [inter-ref]

Cliquez ici pour aller à la section Références} Most urologic injuries do not result in an immediate threat to life; however, an exception to this is of renal hilar disruption, which may cause severe blood loss and is generally accompanied by multisystem injury.^{21 Goldman S.M., Sandler C.M. Upper urinary tract trauma—current concepts World J Urol 1998 ; 16 : 62-68 [cross-ref]

Cliquez ici pour aller à la section Références, 46 Nash P.A., Bruce J.E., Mcaninch J.W. Nephrectomy for traumatic renal injuries J Urol 1995 ; 153 (3 Pt 1) : 609-611 [cross-ref]

Cliquez ici pour aller à la section Références, 61 Skinner E.C., parisky Y.R., Skinner D.G. Management of complex urologic injuries Surgical Clin N Am 1996 ; 76 : 861-878 [inter-ref]

Cliquez ici pour aller à la section Références, 72 Vuckovic I., Tucak A., Gotovac J. , et al. Croatian experience in the treatment of 629 urogenital war injuries J Trauma 1995 ; 39 : 733-736 [cross-ref]

Cliquez ici pour aller à la section Références} Injuries to the bladder and upper urethra rarely cause significant shock alone but are often accompanied by hemodynamically significant pelvic fractures.^{55 Routt M.L., Simonian P.T., Defalco A. , et al. Internal fixation in pelvic fractures and primary repairs of associated genitourinary disruptions: A team approach J Trauma 1996 ; 40 : 784-790 [cross-ref]

Cliquez ici pour aller à la section Références, 57 Sagalowsky A.I., Peters P.C. Genitourinary trauma Campbell's Urology Philadelphia: WB Saunders (1998).
3085-3120

Cliquez ici pour aller à la section Références, 58 Sandler C.M., Goldman S.M., Kawashima A. Lower urinary tract trauma World J Urol 1998 ; 16 : 69-75 [cross-ref]

Cliquez ici pour aller à la section Références, 64 Taffet R. Management of pelvic fractures with concomitant urologic injuries Orthopedic Clin N Am 1997 ; 28 : 389-395 [inter-ref]

Cliquez ici pour aller à la section Références} In contrast, injuries to the lower urethra or external genitalia are often the result of localized trauma. In these cases, injury is often confined to the genitourinary system.^{5 Boon T.A., Van der Werken C. Urethral injuries revisited Injury 1996 ; 27 : 533-537

Cliquez ici pour aller à la section Références, 19 Goldman H.B., Idom C.B., Dmochowski R.R. Traumatic injuries of the female external genitalia and their association with urological injuries J Urol 1998 ; 159 : 956-959 [cross-ref]

Cliquez ici pour aller à la section Références, 44 Munter D.W., Faleski E.J. Blunt scrotal trauma: Emergency department evaluation and management Am J Emerg Med 1989 ; 7 : 227-233 [cross-ref]

Cliquez ici pour aller à la section Références}

Initial detection of urologic injuries requires careful evaluation of the urinary system in the setting of concomitant injuries. Important clues to injury include the presence of lower rib or lumbar vertebral fractures, flank hematoma, pelvic fracture, abnormal prostate examination, blood at the external urethral meatus or gross hematuria. Despite the historical importance placed on the presence of microscopic hematuria, there is no indication to search for urologic injuries in a hemodynamically stable adult patient who has only this finding.^{39 Miller K.S., McAninch J.W. Radiographic assessment of renal trauma: Our 15-year experience J Urol 1995 ; 154 : 352-355 [cross-ref]

Cliquez ici pour aller à la section Références, 59 Schneider R.E. Genitourinary trauma Emergency Medicine: Concepts and Clinical Practice St. Louis: Mosby (1998).
582-601

Cliquez ici pour aller à la section Références} Additionally, the practice of evaluating the GU system by obtaining a routine “one-shot” intravenous pyelograms (IVP) in all trauma patients before surgery is no longer recommended.^{45 Nagy K.K., Brenneman F.D., Krosner S.M. , et al. Routine preoperative “one-shot” intravenous pyelography is not indicated in all patients with penetrating abdominal trauma J Am Coll Surgeons 1997 ; 185 : 530-533 [inter-ref]

Cliquez ici pour aller à la section Références, 50 Patel V.G., Walker M.L. The role of “one-shot” intravenous pyelogram in evaluation of penetrating abdominal trauma Am Surgeon 1997 ; 63 : 350-353

Cliquez ici pour aller à la section Références} This will be discussed further in the text.

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Plan

Address reprint requests to Selim Suner MD, MS, Department of Emergency Medicine, Rhode Island Hospital, Samuels Building second floor, 593 Eddy Street, Providence, RI 02903, e-mail: selim_suner@brown.edu