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GENERAL CONSIDERATIONS

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Approximately 10% of multiple trauma patients are diagnosed with genitourinary injury, most commonly in the setting of other multiple blunt force injuries. Significant injury to the genitourinary system is an uncommon cause of serious morbidity or mortality. A number of genitourinary injuries are not immediately apparent and are rarely responsible for significant hemodynamic compromise. Initial evaluation of the trauma patient should focus on stabilization and resuscitation, prioritizing hemodynamic instability. See Chapter 22 for the approach to the multiple trauma patients.

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Penetrating injuries to the abdomen and trunk, as well as blunt injuries to the torso should heighten the clinician’s suspicion for the possibility of occult genitourinary trauma. Blood at the urethral meatus or vaginal introitus are likely indicators of injury. Gross hematuria noted with the first spontaneous void or with Foley catheter placement should prompt further evaluation.

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Greater than 90% of genitourinary injuries are safely managed nonoperatively with a low rate of long-term serious sequelae. A decrease in nephrectomies and laparotomies has coincided with improvements in modern imaging techniques and injury assessment. The role of careful observation, urinary drainage, and selected interventional radiologic procedures has largely supplanted operative management.

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Antonis  MS, Phillips  CA, Bialvas  M: Genitourinary imaging in the emergency department. Emerg Med Clin North Am. 2011;29(3):553–567
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Ramchandani  P, Buckler  PM: Imaging of genitourinary trauma. AJR Am J Roentgenol. 2009;192(6):1514–1523
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Shenfeld  OZ, Gnessin  E: Management of urogenital trauma: State of the art. Curr Opin Urol. 2011;21(6):449–454
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Shewakramani  S, Reed  KC: Genitourinary trauma. Emerg Med Clin North Am. 2011;29(3):501–518
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BLUNT RENAL TRAUMA

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Clinical Findings
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Most pediatric renal injuries are a result of blunt force trauma. These injuries are most commonly noted in the multiply injured patient and are less life-threatening than other system injuries. Renal injury should be considered in a patient with significant trauma to the torso. Contusions, abrasions, and lacerations to the flank or abdominal wall should be noted. A “seat belt sign” or contusion over the lower abdomen is concerning. Children with genitourinary trauma have three to five times the rate of congenital renal malformations compared with similar adult cohorts.

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Pelvic fractures have a high degree of correlation with both upper and lower genitourinary trauma, including renal injury. Evaluate the stability of the pelvis and observe for blood at the urethral meatus or vaginal introitus. Gross hematuria is major warning for renal, renovascular, and lower genitourinary system trauma. The clinician should observe the first urine (or Foley catheter) output from the patient, as initial obvious hematuria may fade with the dilutional effects of aggressive crystalloid infusion.

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Treatment
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Resuscitation of the patient in shock with suspected renal injury should follow standard life support algorithms ...

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