S005-PELVIC&UROLOGIC

A 22-year-old man involved in a high-speed automobile collision has multiple injuries, including a pelvic fracture. At the initial physical examination no blood is seen at the meatus. A poorly informed intern attempts insertion of a Foley catheter, but resistance is met. What is the best next step in management?

1. REMOVE the Foley catheter IMMEDIATELY 2. Do a RETROGRADE URETHROGRAM NB: Back out! Although the blood at the meatus or the perineal hematoma were not there to warn you, this is a URETHRAL INJURY. Do the RETROGRADE URETHROGRAM

A 19-year-old man is involved in a motorcycle accident. Among many other injuries he has a pelvic fracture. He has blood at the meatus and scrotal hematoma. What is the most likely diagnosis?

ANTERIOR URETHRAL INJURY NB: If there is BLOOD at the MEATUS or PERINEAL HEMATOMA, do NOT try to insert a Foley catheter! Start with a RETROGRADE URETHROGRAM

A patient involved in a high-speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is hematuria, and retrograde cystogram is normal. CT scan shows renal injuries that do not require surgery. Six weeks later the patient develops acute shortness of breath and a flank bruit. What is the best next step in management?

ARTERIOGRAM and SURGICAL CORRECTION NB: This is a weird one, but so fascinating that some medical school professor may not be able to resist the temptation to include it. The patient developed a TRAUMATIC ARTERIOVENOUS FISTULA at the renal pedicle, and subsequent heart failure. Management is ARTERIOGRAM and SURGICAL CORRECTION

A 22-year-old woman involved in a high-speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter reveals gross hematuria. What is the most likely diagnosis?

BLADDER INJURY NB: It must be a BLADDER INJURY. Assessment will require RETROGRADE CYSTOGRAM. When done, obvious intraperitoneal extravasation may be seen (rupture at the dome), but if "negative" you need ANOTHER FILM after the bladder is empty. Ruptures at the trigone leak retroperitoneally, and the leak may be obscured by the bladder full of dye

A patient involved in a high-speed automobile collision has multiple injuries, including rib fractures and abdominal contusions (but no pelvic fracture). Insertion of a Foley catheter shows that there is gross hematuria. What is the best next step in management?

CT SCAN NB: The blood has to be coming from the KIDNEYS

A 35-year-old man is about to be discharged from the hospital where he was under observation for multiple blunt trauma sustained in a car wreck. It is then discovered that he has microscopic hematuria. What is the best next step in management?

DISCHARGE the PATIENT from the HOSPITAL NB1: GROSS TRAUMATIC HEMATURIA in the adult ALWAYS has to be investigated. TRAUMATIC MICROHEMATURIA does NOT NB2: Hematuria of any type if UNRELATED to TRAUMA has to be investigated to rule out cancer of the kidney, bladder, or ureter

In a rollover car accident, a 42-year-old woman is thrown out of the car, and subsequently the car lands on her and crushes her. At evaluation in the ER it is determined by physical examination that she has a pelvic fracture. She arrived hypotensive and did not respond to fluid resuscitation. Hemodynamic parameters have continued to deteriorate. Sonogram performed at the ER shows no intraabdominal bleeding. What is the best next step in management?

EXTERNAL FIXATION of the PELVIC FRACTURE NB: A tough situation. People can bleed to death from pelvic fractures, and thus it seems that we ought to do something about it. But that is easier said than done. Surgical exploration is NOT the answer; these injuries are typically NOT in the surgical field afforded by a laparotomy. Several steps have been proposed, but there is NO universal agreement as to their effectiveness. EXTERNAL FIXATION is considered the right answer by many, whereas others think that ARTERIOGRAPHIC EMBOLIZATION is the way to go (it is effective for ARTERIAL bleeding, but NOT for venous hemorrhage).

A 41-year-old man presents to the ER reporting that he slipped in the shower and injured his penis. Examination reveals a large penile shaft hematoma with normal appearing glans. What is the most likely diagnosis?

FRACTURE of the TUNICA ALBUGINEA (=FRACTURE of the CORPORA CAVERNOSA) NB: A classic description of FRACTURE of the TUNICA ALBUGINEA (FRACTURE of the CORPORA CAVERNOSA)—including the usual cover story given by the patient. These always happen during sexual intercourse, usually with woman on top—but the patient is too embarrassed to explain the true details

A patient involved in a high-speed automobile collision has multiple injuries, including rib fractures and abdominal contusions (but no pelvic fracture). Insertion of a Foley catheter shows that there is gross hematuria. What is the most likely diagnosis?

KIDNEY INJURY NB: The blood has to be coming from the KIDNEYS

In a rollover car accident a 42-year-old woman is thrown out of the car, and subsequently the car lands on her and crushes her. At evaluation in the ER it is determined that she has a pelvic fracture. She arrived hypotensive, but responded promptly to fluid administration. CT scan shows no intraabdominal bleeding, and a pelvic hematoma. What is the best next step in management?

OBSERVATION NB1: An option "EXTERNAL FIXATION of the PELVIC FRACTURE" is also correct NB2: Nonexpanding pelvic hematomas in a patient who has become hemodynamically stable are LEFT ALONE. Depending on the type of fracture, the orthopedic surgeons may eventually do something to STABILIZE the PELVIS, but at this time the main issue is to RULE OUT the potential ASSOCIATED PELVIC INJURIES: RECTUM, BLADDER, and VAGINA. Physical examination and a Foley catheter will do it

A patient involved in a high-speed automobile collision has multiple injuries, including rib fractures and abdominal contusions (but no pelvic fracture). Insertion of a Foley catheter shows that there is gross hematuria. CT scan reveals an injury of the right kidney. What is the best next step in management?

OBSERVATION NB: They will NOT ask you for fine-judgment surgical decisions, but the rule is that traumatic hematuria from blunt trauma to the kidney does NOT need surgery even if the kidney is smashed. They operate ONLY IF the RENAL PEDICLE is AVULSED or the patient is EXSANGUINATING

A 19-year-old man is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood at the meatus, scrotal hematoma, and the sensation that he wants to urinate but cannot. Rectal examination shows a high-riding prostate. What is the most likely diagnosis?

POSTERIOR URETHRAL INJURY NB1: This is a description of a POSTERIOR URETHRAL INJURY NB2: If there is BLOOD at the MEATUS or PERINEAL HEMATOMA, do NOT try to insert a Foley catheter! Start with a RETROGRADE URETHROGRAM

A 22-year-old woman involved in a high-speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter reveals gross hematuria. What is the best next step in management?

RETROGRADE CYSTOGRAM NB: It must be a BLADDER INJURY. Assessment will require RETROGRADE CYSTOGRAM. When done, obvious intraperitoneal extravasation may be seen (rupture at the dome), but if "negative" you need ANOTHER FILM after the bladder is empty. Ruptures at the trigone leak retroperitoneally, and the leak may be obscured by the bladder full of dye

A 22-year-old man involved in a high-speed automobile collision has multiple injuries, including a pelvic fracture. On physical examination there is blood at the meatus. What is the best next step in management?

RETROGRADE URETHROGRAM NB1: The vignette will be longer, but the point is that pelvic fracture plus blood at the meatus in a male means either BLADDER or URETHRAL INJURY, most likely the latter. Evaluation starts with a RETROGRADE URETHROGRAM because urethral injury would be compounded by insertion of a Foley catheter NB2: Once again, if there is BLOOD at the MEATUS or PERINEAL HEMATOMA, do NOT try to insert a Foley catheter! Start with a RETROGRADE URETHROGRAM

A 19-year-old man is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood at the meatus, scrotal hematoma, and the sensation that he wants to urinate but cannot. Rectal examination shows a high-riding prostate. What is the best next step in management?

RETROGRADE URETHROGRAM NB1: This is a description of a POSTERIOR URETHRAL INJURY NB2: If there is BLOOD at the MEATUS or PERINEAL HEMATOMA, do NOT try to insert a Foley catheter! Start with a RETROGRADE URETHROGRAM

A 41-year-old man presents to the ER reporting that he slipped in the shower and injured his penis. Examination reveals a large penile shaft hematoma with normal appearing glans. What is the best next step in management?

RETROGRADE URETHROGRAM followed by PROMPT SURGICAL REPAIR NB: A classic description of FRACTURE of the TUNICA ALBUGINEA (FRACTURE of the CORPORA CAVERNOSA)—including the usual cover story given by the patient. These always happen during sexual intercourse, usually with woman on top—but the patient is too embarrassed to explain the true details. This is a UROLOGIC EMERGENCY. RETROGRADE URETHROGRAM to rule out urethral injury, followed by PROMPT SURGICAL REPAIR, is needed

A 14-year-old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes to the ER with a scrotal hematoma the size of a grapefruit. He can urinate normally, and there is no blood in the urine. What is the most likely diagnosis?

SCROTAL HEMATOMA with or without RUPTURE of a TESTICLE NB: The issue in SCROTAL HEMATOMAS is whether the TESTICLE is RUPTURED or NOT

A 14-year-old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes to the ER with a scrotal hematoma the size of a grapefruit. He can urinate normally, and there is no blood in the urine. What is the best next step in management?

SCROTAL ULTRASOUND NB: The issue in SCROTAL HEMATOMAS is whether the TESTICLE is RUPTURED or NOT. SONOGRAM will tell

A 14-year-old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes to the ER with a scrotal hematoma the size of a grapefruit. He can urinate normally, and there is no blood in the urine. Sonogram reveals rupture of the right testicle. What is the best next step in management?

SURGICAL REPAIR NB1: The issue in SCROTAL HEMATOMAS is whether the TESTICLE is RUPTURED or NOT NB2: If testicle is ruptured, SURGERY will be needed. If intact, only symptomatic treatment

A woman is shot in the flank, and when a Foley catheter was inserted in ER, the urine was found to be grossly bloody. What is the best next step in management?

SURGICAL REPAIR NB: The hallmark of urologic injuries is BLOOD in the URINE after trauma. This is a clear-cut. The therapy is also clear. Penetrating urologic injuries are like most penetrating injuries elsewhere: they need SURGICAL REPAIR

A young man is shot point blank in the lower abdomen, just above the pubis. He has blood in the urine, and no evidence of rectal injury. What is the best next step in management?

SURGICAL REPAIR NB: The hallmark of urologic injuries is BLOOD in the URINE after trauma. This is a clear-cut. The therapy is also clear. Penetrating urologic injuries are like most penetrating injuries elsewhere: they need SURGICAL REPAIR

A 14-year-old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes to the ER with a scrotal hematoma the size of a grapefruit. He can urinate normally, and there is no blood in the urine. Sonogram does not reveal rupture of the testicles. What is the best next step in management?

SYMPTOMATIC TREATMENT NB1: The issue in SCROTAL HEMATOMAS is whether the TESTICLE is RUPTURED or NOT NB2: If testicle is ruptured, SURGERY will be needed. If intact, only symptomatic treatment

A patient involved in a high-speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is hematuria, and retrograde cystogram is normal. CT scan shows renal injuries that do not require surgery. Six weeks later the patient develops acute shortness of breath and a flank bruit. What is the most likely diagnosis?

TRAUMATIC ARTERIOVENOUS FISTULA This is a weird one, but so fascinating that some medical school professor may not be able to resist the temptation to include it. The patient developed a TRAUMATIC ARTERIOVENOUS FISTULA at the renal pedicle, and subsequent heart failure. Management is ARTERIOGRAM and SURGICAL CORRECTION

A 4-year-old falls off his tricycle. In the ensuing evaluation he is found to have microscopic hematuria. What is the best next step in management?

ULTRASOUND of KIDNEYS and BLADDER NB: In CHILDREN, TRAUMATIC MICROHEMATURIA needs to be investigated as it often signifies CONGENITAL ANOMALIES—particularly if the magnitude of the trauma does NOT justify the bleeding. Start by performing a SONOGRAM