Lower Urinary Tract Trauma: Difference between revisions

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=== Diagnosis and Evaluation ===

==== ~~~~History and Physical Exam~~~~ ====

==== History and Physical Exam ====

===== Physical Exam =====

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*# '''Intraperitoneal low density free fluid on abdominal imaging (urinary ascites)'''

==== ~~~~Imaging~~~~ ====

==== Imaging ====

* '''Indications for cystography in stable patients'''

** '''2020 AUA Guidelines'''

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=== Diagnosis and Evaluation ===

==== ~~'''~~History and Physical Exam~~'''~~ ====

==== History and Physical Exam ====

===== Physical Exam =====

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=== Management ===

* '''Regardless of the type of injury, securing catheter drainage of the bladder is the immediate goal of treatment'''.

*'''Blind catheter passage prior to retrograde urethrogram should be avoided, unless exceptional circumstances indicate an attempt at emergent catheter drainage for monitoring.[https://pubmed.ncbi.nlm.nih.gov/33053308/ §]'''

**If retrograde urethrogram demonstrates partial urethral disruption (contrast passes proximal to site of injury), then a a single attempt with a well-lubricated catheter may be attempted by an experienced team member

==== Male ====

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* '''Pelvic fracture urethral injury: immediate suprapubic tube (percutaneous or open) with delayed repair'''

** '''Immediate'''

***

***'''Suprapubic tube'''

****'''Remains the gold standard for urinary drainage'''

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==== Penile fracture ====

===== ~~~~Definition~~~~ =====

===== Definition =====

'''Penile fracture: disruption of the tunica albuginea with rupture of the corpus cavernosum'''

* '''Penile fracture: disruption of the tunica albuginea with rupture of the corpus cavernosum'''

===== ~~Pathogenesis =====~~

===== Pathogenesis =====

* '''Most commonly occurs during vigorous sexual intercourse,''' when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury.

* '''Most commonly occurs during vigorous sexual intercourse''', when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury.

** Campbell's 11th edition: In the Middle East, self-inflicted fractures predominate owing to the practice of taqaandan, in which the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence.

** Review article

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*# 1-2 cm in length

===== ~~~~Diagnosis and Evaluation~~~~ =====

===== Diagnosis and Evaluation =====

'''Diagnosis of penile fracture can me made reliably by history and physical exam'''

* '''~~History and ~~physical exam'''

* '''Diagnosis of penile fracture can me made reliably by history and physical exam'''

** '''History'''

*** '''Indicators of penile fracture'''

====== History and Physical Exam ======

***# '''Penile ecchymosis or swelling'''

* '''History'''

***# '''Cracking, popping, or snapping sound during intercourse or manipulation and immediate detumescence.'''

** '''Indicators of penile fracture'''

** '''Physical exam'''

**# '''Penile ecchymosis or swelling'''

*** '''Penis'''

**# '''Cracking, popping, or snapping sound during intercourse or manipulation and immediate detumescence.'''

****'''Swollen'''

* '''Physical exam'''

****'''Ecchymotic'''

** '''Penis'''

*****'''If Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical “eggplant deformity.”'''

***'''Swollen'''

***** '''If Buck fascia is disrupted, the hematoma can extend to the scrotum, perineum, and suprapubic regions (see above “butterfly hematoma”).'''

***'''Ecchymotic'''

****'''Fracture line in the tunica albuginea may be palpable'''

****'''If Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical “eggplant deformity.”'''

****'''Deviates to the side opposite the tunical tear because of hematoma and mass effect'''

**** '''If Buck fascia is disrupted, the hematoma can extend to the scrotum, perineum, and suprapubic regions (see above “butterfly hematoma”).'''

*'''~~Imaging~~'''

***'''Fracture line in the tunica albuginea may be palpable'''

**'''Indication (1)'''

***'''Deviates to the side opposite the tunical tear because of hematoma and mass effect'''

***'''History and physical examination are equivocal for penile fracture'''

****'''Usually unnecessary as diagnosis can often be made based on history and physical exam'''

====== Imaging ======

**'''Options (2):'''

*'''Indication (1)'''

**#'''Ultrasound (preferred)'''

**'''History and physical examination are equivocal for penile fracture'''

**#* '''Preferred over MRI because it is rapid, readily available, noninvasive, inexpensive, and accurate'''

***'''Usually unnecessary as diagnosis can often be made based on history and physical exam'''

**#* Most useful for ruling out fracture in patients with low clinical suspicion or to identify the location of the tear, potentially guiding the choice of incision

*'''Options (2):'''

**# '''Penile-perineal MRI'''

*#'''Ultrasound (preferred)'''

**#* '''Most accurate test'''

*#* '''Preferred over MRI because it is rapid, readily available, noninvasive, inexpensive, and accurate'''

**#* '''Can be considered if ultrasound equivocal to prevent unnecessary surgical exploration'''.

*#* Most useful for ruling out fracture in patients with low clinical suspicion or to identify the location of the tear, potentially guiding the choice of incision

*** '''Both penile Doppler and cavernosography have very high false negative rates and are not recommended in the evaluation of suspected penile fracture.''' [SASP 2016]

*# '''Penile-perineal MRI'''

** '''If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed'''

*#* '''Most accurate test'''

~~'''~~Other~~'''~~

*#* '''Can be considered if ultrasound equivocal to prevent unnecessary surgical exploration'''.

** '''Both penile Doppler and cavernosography have very high false negative rates and are not recommended in the evaluation of suspected penile fracture.''' [SASP 2016]

* '''If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed'''

====== Other ======

* '''Urethral evaluation (urethroscopy or retrograde urethrogram)'''

** '''Urethral injury occurs in 10-22% of cases of penile fracture'''

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***#'''Inability to void'''

===== ~~~~Management~~~~ =====

===== Management =====

* '''Suspected penile fractures should be promptly explored and surgically repaired'''

* '''Surgical reconstruction results in (7):'''

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====== Technique ======

* Approach

* '''Approach (2)'''

**Ventral vertical penoscrotal incision

*#'''Ventral vertical penoscrotal incision'''

***Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.

*#*Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.

** Distal circumcising incision

*# '''Distal circumcising incision'''

***May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.

*#*May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.

*See [https://www.youtube.com/watch?v=T0hoHpDxeCE Video]

*Equipment

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** Evacuate hematoma

***Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated

**Identify defect

**'''Identify defect'''

***Proximal corpora is the most common site of rupture

****Induction of an artificial erection with saline or colored dye may aid in locating the corporeal ~~laceration.~~

****'''Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration♦'''

***Laceration usually transverse in direction

***Obtain adequate exposure of defect

**Repair defect

***Repair defect in tunica albuginea with interrupted 2-0 or 3-0 PDS sutures.

** If urethral injury

** '''If urethral injury'''

***Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter.

***'''Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter'''

***Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter.

***'''Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter'''

** Test repair

***Apply tourniquet proximal to repaired defect

@@ Line 50: / Line 50: @@
 === Diagnosis and Evaluation ===
-==== <span style="color:#ff0000">History and Physical Exam</span> ====
+==== History and Physical Exam ====
 ===== Physical Exam =====
@@ Line 69: / Line 69: @@
 *# '''<span style="color:#ff0000">Intraperitoneal low density free fluid on abdominal imaging</span> (urinary ascites)'''
-==== <span style="color:#ff0000">Imaging</span> ====
+==== Imaging ====
 * '''<span style="color:#ff0000">Indications for cystography in stable patients</span>'''
 ** '''<span style="color:#ff0000">2020 AUA Guidelines</span>'''
@@ Line 166: / Line 166: @@
 === Diagnosis and Evaluation ===
-==== '''<span style="color:#ff0000">History and Physical Exam</span>''' ====
+==== <span style="color:#ff0000">History and Physical Exam</span> ====
 ===== Physical Exam =====
@@ Line 206: / Line 206: @@
 === Management ===
 * '''<span style="color:#ff0000">Regardless of the type of injury, securing catheter drainage of the bladder is the immediate goal of treatment</span>'''.
+*'''<span style="color:#ff0000">Blind catheter passage prior to retrograde urethrogram should be avoided</span>, unless exceptional circumstances indicate an attempt at emergent catheter drainage for monitoring.[https://pubmed.ncbi.nlm.nih.gov/33053308/ §]'''
+**If retrograde urethrogram demonstrates partial urethral disruption (contrast passes proximal to site of injury), then a a single attempt with a well-lubricated catheter may be attempted by an experienced team member
 ==== <span style="color:#ff0000">Male</span> ====
@@ Line 212: / Line 214: @@
 * '''<span style="color:#ff0000">Pelvic fracture urethral injury: immediate suprapubic tube (percutaneous or open) with delayed repair</span>'''
 ** '''<span style="color:#ff0000">Immediate</span>'''
+***
 ***'''<span style="color:#ff0000">Suprapubic tube</span>'''
 ****'''<span style="color:#ff0000">Remains the gold standard for urinary drainage</span>'''
@@ Line 282: / Line 285: @@
 ==== Penile fracture ====
-===== <span style="color:#ff0000">Definition</span> =====
+===== Definition =====
-'''<span style="color:#ff0000">Penile fracture: disruption of the tunica albuginea with rupture of the corpus cavernosum</span>'''
+* '''<span style="color:#ff0000">Penile fracture: disruption of the tunica albuginea with rupture of the corpus cavernosum</span>'''
-===== <span style="color:#ff0000">Pathogenesis</span> =====
+===== Pathogenesis =====
-* '''Most commonly occurs during vigorous sexual intercourse,''' when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury.
+* '''<span style="color:#ff0000">Most commonly occurs during vigorous sexual intercourse</span>''', when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury.
 ** Campbell's 11th edition: In the Middle East, self-inflicted fractures predominate owing to the practice of taqaandan, in which the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence.
 ** Review article
@@ Line 309: / Line 313: @@
 *# 1-2 cm in length
-===== <span style="color:#ff0000">Diagnosis and Evaluation</span> =====
+===== Diagnosis and Evaluation =====
-'''<span style="color:#ff0000">Diagnosis of penile fracture can me made reliably by history and physical exam</span>'''
-* '''<span style="color:#ff0000">History and physical exam</span>'''
+* '''<span style="color:#ff0000">Diagnosis of penile fracture can me made reliably by history and physical exam</span>'''
-** '''<span style="color:#ff0000">History</span>'''
-*** '''<span style="color:#ff0000">Indicators of penile fracture</span>'''
+====== History and Physical Exam ======
-***# '''<span style="color:#ff0000">Penile ecchymosis or swelling</span>'''
+* '''<span style="color:#ff0000">History</span>'''
-***# '''<span style="color:#ff0000">Cracking, popping, or snapping sound during intercourse or manipulation and immediate detumescence.</span>'''
+** '''<span style="color:#ff0000">Indicators of penile fracture</span>'''
-** '''<span style="color:#ff0000">Physical exam</span>'''
+**# '''<span style="color:#ff0000">Penile ecchymosis or swelling</span>'''
-*** '''<span style="color:#ff0000">Penis</span>'''
+**# '''<span style="color:#ff0000">Cracking, popping, or snapping sound during intercourse or manipulation and immediate detumescence.</span>'''
-****'''<span style="color:#ff0000">Swollen</span>'''
+* '''<span style="color:#ff0000">Physical exam</span>'''
-****'''<span style="color:#ff0000">Ecchymotic</span>'''
+** '''<span style="color:#ff0000">Penis</span>'''
-*****'''<span style="color:#ff0000">If Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical “eggplant deformity.”</span>'''
+***'''<span style="color:#ff0000">Swollen</span>'''
-***** '''<span style="color:#ff0000">If Buck fascia is disrupted, the hematoma can extend to the scrotum, perineum, and suprapubic regions (see above “butterfly hematoma”).</span>'''
+***'''<span style="color:#ff0000">Ecchymotic</span>'''
-****'''<span style="color:#ff0000">Fracture line in the tunica albuginea may be palpable</span>'''
+****'''<span style="color:#ff0000">If Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical “eggplant deformity.”</span>'''
-****'''<span style="color:#ff0000">Deviates to the side opposite the tunical tear</span> because of hematoma and mass effect'''
+**** '''<span style="color:#ff0000">If Buck fascia is disrupted, the hematoma can extend to the scrotum, perineum, and suprapubic regions (see above “butterfly hematoma”).</span>'''
-*'''<span style="color:#ff0000">Imaging</span>'''
+***'''<span style="color:#ff0000">Fracture line in the tunica albuginea may be palpable</span>'''
-**'''<span style="color:#ff0000">Indication (1)</span>'''
+***'''<span style="color:#ff0000">Deviates to the side opposite the tunical tear</span> because of hematoma and mass effect'''
-***'''<span style="color:#ff0000">History and physical examination are equivocal for penile fracture</span>'''
-****'''<span style="color:#ff0000">Usually unnecessary as diagnosis can often be made based on history and physical exam</span>'''
+====== Imaging ======
-**'''<span style="color:#ff0000">Options (2):</span>'''
+*'''<span style="color:#ff0000">Indication (1)</span>'''
-**#'''<span style="color:#ff0000">Ultrasound (preferred)</span>'''
+**'''<span style="color:#ff0000">History and physical examination are equivocal for penile fracture</span>'''
-**#* '''Preferred over MRI because it is rapid, readily available, noninvasive, inexpensive, and accurate'''
+***'''<span style="color:#ff0000">Usually unnecessary as diagnosis can often be made based on history and physical exam</span>'''
-**#* Most useful for ruling out fracture in patients with low clinical suspicion or to identify the location of the tear, potentially guiding the choice of incision
+*'''<span style="color:#ff0000">Options (2):</span>'''
-**# '''<span style="color:#ff0000">Penile-perineal MRI</span>'''
+*#'''<span style="color:#ff0000">Ultrasound (preferred)</span>'''
-**#* '''<span style="color:#ff0000">Most accurate test</span>'''
+*#* '''Preferred over MRI because it is rapid, readily available, noninvasive, inexpensive, and accurate'''
-**#* '''Can be considered if ultrasound equivocal to prevent unnecessary surgical exploration'''.
+*#* Most useful for ruling out fracture in patients with low clinical suspicion or to identify the location of the tear, potentially guiding the choice of incision
-*** '''<span style="color:#ff0000">Both penile Doppler and cavernosography have very high false negative rates and are not recommended in the evaluation of suspected penile fracture.</span>''' [SASP 2016]
+*# '''<span style="color:#ff0000">Penile-perineal MRI</span>'''
-** '''<span style="color:#ff0000">If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed</span>'''
+*#* '''<span style="color:#ff0000">Most accurate test</span>'''
-'''<span style="color:#ff0000">Other</span>'''
+*#* '''Can be considered if ultrasound equivocal to prevent unnecessary surgical exploration'''.
+** '''<span style="color:#ff0000">Both penile Doppler and cavernosography have very high false negative rates and are not recommended in the evaluation of suspected penile fracture.</span>''' [SASP 2016]
+* '''<span style="color:#ff0000">If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed</span>'''
+====== Other ======
 * '''<span style="color:#ff0000">Urethral evaluation (urethroscopy or retrograde urethrogram)</span>'''
 ** '''<span style="color:#ff0000">Urethral injury occurs in 10-22% of cases of penile fracture</span>'''
@@ Line 347: / Line 355: @@
 ***#'''<span style="color:#ff0000">Inability to void</span>'''
-===== <span style="color:#ff0000">Management</span> =====
+===== Management =====
 * '''<span style="color:#ff0000">Suspected penile fractures should be promptly explored and surgically repaired</span>'''
 * '''<span style="color:#ff0000">Surgical reconstruction results in (7):</span>'''
@@ Line 360: / Line 368: @@
 ====== Technique ======
-* Approach
+* '''<span style="color:#ff0000">Approach (2)'''
-**Ventral vertical penoscrotal incision
+*#'''<span style="color:#ff0000">Ventral vertical penoscrotal incision'''
-***Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.
+*#*Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.
-** Distal circumcising incision
+*# '''<span style="color:#ff0000">Distal circumcising incision'''
-***May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.
+*#*May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.
 *See [https://www.youtube.com/watch?v=T0hoHpDxeCE Video]
 *Equipment
@@ Line 391: / Line 399: @@
 ** Evacuate hematoma
 ***Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated
-**Identify defect
+**'''Identify defect'''
 ***Proximal corpora is the most common site of rupture
-****Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration.
+****'''<span style="color:#ff0000">Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration♦'''
 ***Laceration usually transverse in direction
 ***Obtain adequate exposure of defect
 **Repair defect
 ***Repair defect in tunica albuginea with interrupted 2-0 or 3-0 PDS sutures.
-** If urethral injury
+** '''If urethral injury'''
-***Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter.
+***'''Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter'''
-***Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter.
+***'''Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter'''
 ** Test repair
 ***Apply tourniquet proximal to repaired defect