Editing Lower Urinary Tract Trauma (section)

=== Diagnosis and Evaluation ===

==== <span style="color:#ff0000">History and Physical Exam</span> ====

===== Physical Exam =====
* '''<span style="color:#ff0000">Indicators of urethral trauma (5):</span>'''
*# '''<span style="color:#ff0000">Blood at the urethral meatus</span>'''
*#* '''<span style="color:#ff0000">Most common finding</span>'''
*# '''<span style="color:#ff0000">Inability to urinate</span>'''
*# '''<span style="color:#ff0000">Perineal/genital ecchymosis</span>'''
*# '''<span style="color:#ff0000">In males, high-riding prostate on physical exam</span>'''
*# '''<span style="color:#ff0000">In females, labial edema and/or blood in the vaginal vault</span>'''
* '''<span style="color:#ff0000">If Buck’s fascia disrupted, blood and urinary extravasation into the scrotum may occur</span>'''
** '''<span style="color:#ff0000">Recall, Colle’s, Scarpa’s and Dartos are continuous.</span>'''
** '''<span style="color:#ff0000">If Buck’s fascia (deep to Dartos) is disrupted, urine will travel outside Buck’s but below Dartos in penis, up into scrotum below dartos layer and up abdominal wall below Scarpa’s. The posterior limit is Colle’s fascia. This pattern describes the “butterfly” urinoma/hematoma</span>'''
*** '''See [https://o.quizlet.com/kF16urqAKtHYl6JkCBdEvA.png Figure]'''

==== <span style="color:#ff0000">Imaging</span> ====
* '''<span style="color:#ff0000">Modality: retrograde urethrogram (RUG)</span>'''
** See [https://radiopaedia.org/cases/traumatic-urethral-injury-on-retrograde-urethrogram figure] of retrograde urethrogram of traumatic proximal urethral injury
** '''<span style="color:#ff0000">Should be performed immediately when urethral injury is suspected</span>'''
*** '''May demonstrate partial or complete urethral disruption, providing guidance for how to best manage bladder drainage in the acute setting'''
***'''<span style="color:#ff0000">Blind catheter passage prior to RUG should be avoided, unless exceptional circumstances indicate an attempt at emergent catheter drainage for monitoring</span>'''
**** Patients with pelvic fracture urethral injury (PFUI) are often unable to urinate due to their injuries. Trauma resuscitations typically involve aggressive hydration and a critical need to closely monitor patient volume status
**** In the acute setting of a partial urethral disruption, a single attempt with a well-lubricated catheter may be attempted by an experienced team member.
** '''<span style="color:#ff0000">Technique</span>'''
**# '''<span style="color:#ff0000">Position the patient obliquely with the bottom leg flexed at the knee and the top leg kept straight</span>'''
**#* If severe pelvic or spine fractures are present, leaving the patient supine and placing the penis on stretch to acquire the image is appropriate.
**# '''Introduce a catheter tipped syringe or a 12Fr Foley catheter into the fossa navicularis'''
**# '''Place the penis on gentle traction'''
**# '''Inject 20-25 mL undiluted water-soluble contrast material and capture images'''
** '''<span style="color:#ff0000">Occasionally a Foley catheter has been placed before evaluating the urethra</span>'''
*** '''<span style="color:#ff0000">If no meatal blood is present and suspicion of injury is low, further imaging is not warranted.</span>'''
*** '''<span style="color:#ff0000">If blood is present, a pericatheter RUG should be performed to identify potential missed urethral injury.</span>'''
**** A pericatheter RUG can be done by injecting contrast material through a 3Fr catheter or angiocatheter held in the fossa navicularis to distend the urethra and prevent contrast leak per meatus.

==== <span style="color:#ff0000">Other</span> ====
* '''<span style="color:#ff0000">Endoscopy</span>'''
** '''<span style="color:#ff0000">In female patients with suspected urethral injury, direct inspection by urethroscopy is suggested in lieu of RUG</span>'''