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High-Yield Facts

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  • Perform a urinalysis on all major trauma patients as well as those suspected of having isolated genitourinary (GU) injury.

  • Penetrating trauma between the nipples and perineum requires resuscitation efforts and careful evaluation for intra-abdominal and renal trauma.

  • Renal trauma can lead to acute tubular necrosis with renal failure, delayed bleeding, infection, or abscess secondary to urinary extravasation.

  • Consider bladder rupture in children who present with abdominal trauma with gross hematuria, blood at the urethral meatus, inability to void, or little urine upon urinary catheter placement.

  • Genital injuries in a child must always be concerning for abuse.

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Introduction

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Genitourinary (GU) tract injuries occur in 10% of abdominal trauma patients. The kidney is the most commonly injured organ in the urinary tract, followed by the bladder, urethra, and ureter.1,2 Renal injury occurs from trauma to the back, flank, lower thorax, or upper abdomen. Compared with adults, the pediatric kidney is more vulnerable to injury because there is less protection afforded by the pliable rib cage, weaker abdominal muscles, the relatively larger size of the kidneys in proportion to the rest of the child's body, less perirenal fat, and congenital abnormalities. Preexisting renal abnormalities, for example, ureteropelvic junction (UPJ) obstruction, hydroureteronephrosis, horseshoe kidney, are three- to fivefold more common in children undergoing a screening CT scan for trauma than in adults.3 Patients with a preexisting congenital renal abnormality present with a history of hematuria disproportionate to the severity of trauma.3 Blunt trauma accounts for 80% to 95% of all renal injuries and the most common cause of blunt trauma is motor vehicle collisions.1,48 Other common causes are sports activities. Penetrating trauma accounts for approximately 10% of all renal injuries.1,4

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Hemodynamically stable patients with hematuria and suspected urinary system injury are best evaluated by a contrast-enhanced CT scan. If CT scanning is not available, an intravenous pyelogram (IVP) is an alternative. Cystography and urethrography remain useful techniques in the initial evaluation and follow-up of urinary bladder and urethral injuries.9 Sexual and physical abuse should be considered in patients with perineal injuries, for example, burns, inconsistent mechanism of injury, previous injury, child's history, etc.

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Initial Assessment and Management

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As in all major traumas, management of GU injuries begins with the basics of advanced trauma life support. After stabilizing the patient, specific organ systems are evaluated. The kidneys may be sources for major bleeding in patients with hypovolemic shock; however, shock due to an isolated renal fracture is uncommon since the kidneys are surrounded by a tight fascia which limits parenchymal bleeding to 25% or less of total blood volume. The vast majority of urologic injuries are not life-threatening; however, failure to diagnose them and any delay in treatment can lead to significant morbidity. Table 27-1 shows the initial assessment and management of GU injuries. A ...

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