Experience with lower urinary tract disruptions associated with pelvic fractures: implications for emergency room management

Urethral Trauma Following Pelvic Fracture From Horseback Saddle Horn Injury Versus Other Mechanisms of Pelvic Trauma

OBJECTIVE

To examine the rate of urethral trauma and pubic symphysis diastasis in saddle horn injury, which occurs when horseback riders are bucked into the air and land with their perineum striking the rigid saddle horn, compared to pelvic fracture from other mechanisms.

METHODS

A retrospective review was performed of male patients presenting to our level-1 trauma center with pelvic ring fractures between January 1, 2001 and December 30, 2016. Demographics, injury severity score, mechanism of injury (saddle horn vs other), pubic symphysis diastasis, and lower genitourinary (GU) injuries (bladder and urethra) were identified in the trauma registry. Chart review confirmed accuracy of lower GU trauma.

RESULTS

A total of 1195 males presented with pelvic ring fractures, average age 43 years (SD 19 years). Of these, 87 of 1195 (7%) presented with lower GU injuries. Saddle horn injuries had a higher rate of lower GU injuries, 12/60 (20%) versus 75 of 1135 (7%) [P = .001]. In those with lower GU injuries, 47 of 87 (54%) had urethral injury. The rate of urethral injury was significantly higher in the saddle horn cohort, 10 of 12 (83%) versus 37 of 75 (49%) [P = .03]. Furthermore, rate of pubic symphysis diastasis was higher amongst saddle horn injuries, 12 of 12 (100%) versus other mechanisms 39 of 75 (52%) [P = .001].

CONCLUSION

We found that urethral injury and pubic symphysis diastasis were higher in patients with saddle horn injury compared to other mechanisms of pelvic ring disruption. Clinicians should be aware of these associations when treating pelvic fracture following equestrian injuries.

Urotrauma: AUA guideline

PURPOSE

The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries.

MATERIALS AND METHODS

A systematic review of the literature using the MEDLINE® and EMBASE databases (search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria. These publications were used to inform the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

RESULTS

Guideline statements were created to inform clinicians on the initial observation, evaluation and subsequent management of renal, ureteral, bladder, urethral and genital traumatic injuries.

CONCLUSIONS

Genitourinary organ salvage has become increasingly possible as a result of advances in imaging, minimally invasive techniques, and reconstructive surgery. As the field of genitourinary reconstruction continues to evolve, clinicians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes.

SIU/ICUD Consultation on Urethral Strictures: Pelvic fracture urethral injuries

The posterior urethra pierces the perineal diaphragm in close relationship to the pubic arc elements of the bony pelvis to which it is tethered by attachments to the puboprostatic ligaments and the perineal membrane. Because of these relationships, it is not surprising that fracture disruptions of the pelvic ring can be associated with injuries to the urethra at this level. Although the relationship between pelvic fracture and posterior urethral injury has been recognized for >1 century, considerable controversy exists on almost any aspect of these injuries, from the anatomy and classification of the injuries to the strategies for acute management, reconstruction, and treatment of complications, to mention just a few. What it is not controversial and well known is that these injuries can result in significant morbidity in the long run--mainly strictures, erectile dysfunction, and urinary incontinence--which can cause lifelong disability. It also well known that, just as in many other areas of trauma, the severity and duration of the complications can be reduced considerably if the injury is diagnosed and treated promptly and efficiently. This chapter summarizes the most relevant published evidence about the management of pelvic fracture urethral injuries. This comprehensive review, performed by an international panel of experts, will provide valuable information and recommendations to help urologists worldwide improve the treatment and outcomes of their injured patients.

The diagnosis of acute urethral trauma

BACKGROUND

During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury.

METHODS

A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted.

RESULTS

There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0-82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4-100.0) for urethral trauma.

DISCUSSION

Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.

Prospective comparison of microscopic and gross hematuria as predictors of bladder injury in blunt trauma

OBJECTIVES

The evaluation of the genitourinary system in patients with blunt trauma remains controversial. Historically, patients with more than 50 red blood cells on urinalysis underwent additional genitourinary imaging. Retrospective studies have demonstrated that bladder injury is almost always associated with gross hematuria. We have prospectively demonstrated that bladder imaging is required for gross hematuria and unnecessary for microscopic hematuria.

METHODS

Patients sustaining blunt trauma with hematuria were prospectively evaluated during a 3-year period. During the first 18 months of the study (first treatment arm), patients with microscopic hematuria (more than 50 red blood cells on urinalysis) underwent bladder imaging. During the second 18 months, patients underwent bladder imaging only for gross hematuria.

RESULTS

A total of 8026 patients were evaluated. In the first arm, 214 patients underwent cystography for microscopic hematuria, and no bladder injuries were identified; 78 patients underwent cystography for gross hematuria, and 21 bladder injuries were identified. Chi-square analysis revealed no difference in the presence of microscopic hematuria to predict for bladder injury. In the second arm, 308 patients presented with microscopic hematuria, none of whom underwent cystography, and 91 patients underwent cystography for gross hematuria, with 15 bladder injuries identified. The presence of gross hematuria demonstrated 100% sensitivity and 98.5% specificity as a screening test for bladder injury. No bladder injuries were missed.

CONCLUSIONS

The results of our study have shown that the presence of gross hematuria warrants evaluation of the bladder. The presence of gross hematuria demonstrated improved sensitivity, specificity, positive predictive value, negative predictive value, and accuracy over the presence of microscopic hematuria in the detection of bladder injury. Using gross hematuria as an indication for bladder imaging will eliminate unnecessary imaging without compromising the quality of patient care.

Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma

PURPOSE

Precise definition of pelvic fracture location may enable prediction of which subjects are at risk for urethral injury and understanding of the pathophysiological mechanism of injury. We determined the specific anterior pelvic injury locations associated with urethral injury.

MATERIALS AND METHODS

We completed a retrospective, nested case-control study of 119 male patients evaluated at a single large level 1 trauma center between January 1, 1997 and July 15, 2003. We performed detailed measurements of the location, displacement and direction of force of each anterior pelvic fracture from computerized tomography and pelvic radiographs. Multiple logistic regression was used to determine associations between specific fracture locations and urethral injury after controlling for age, injury mechanism, injury severity and direction of force.

RESULTS

Urethral injury was present in 25 patients and all had anterior pelvic fracture (inclusive of pubic symphysis diastasis). There were no urethral injuries in patients with fractures isolated to the acetabulum. Pelvic fractures that were independently associated with urethral injury from multiple regression analysis included displaced fractures of the inferomedial pubic bone, OR 6.4 (95% CI 1.6 to 24.9), and symphysis pubis diastasis, OR 11.8 (95% CI 4.0 to 34.5). Each millimeter of symphysis pubis diastasis or inferomedial pubic bone fracture displacement was associated with an approximately 10% increased risk of urethral injury.

CONCLUSIONS

The location and displacement of anterior pelvic fractures in males predict risk of urethral injury and may be valuable in determining when evaluation of the urethra is appropriate.

Urogenitale Begleitverletzungen bei Beckenringfrakturen

BACKGROUND

Follow-up of patients with pelvic ring fractures and associated injuries of the lower urogenital tract was performed from January 2000 to October 2004. Analysis focused on incidence, fracture type, type of urogenital injury, associated intrapelvic lesions, mortality, and urologic outcome.

METHOD AND RESULTS

The retrospective study included 18 of 111 patients (16.2%). Nine patients had a rupture of the urethra, six a rupture of the bladder, three a rupture of the penile root, and two a gonadal defect. The type of the pelvic ring fracture according to the AO classification was type A in 1, type B in 6, and type C in 11 cases. Fifteen patients (83.3%) were followed up clinically for a mean duration of 26 months (range: 12-66 months) after trauma. Seven patients were asymptomatic concerning the urogenital injury, five had erectile dysfunction, two had urethral stenosis, in one case associated with incontinence, and one patient with bilateral defect of the testicles was under hormone substitution therapy.

CONCLUSION

Urogenital injuries, often associated with intrapelvic lesions in so-called complex pelvic trauma, are typical for high-grade pelvic ring fractures and have an essential prognostic value for the patient's morbidity and quality of life.

Radiographic and clinical predictors of bladder rupture in blunt trauma patients with pelvic fracture

RATIONALE AND OBJECTIVES

Bladder rupture is a potentially serious injury in blunt trauma patients. We determined whether location and displacement of pelvic fractures and the degree of hematuria can accurately predict bladder injury.

MATERIALS AND METHODS

A retrospective database of 721 blunt trauma pelvic fractures that presented to a single large regional level 1 trauma center between January 1, 1997, and July 15, 2003, was expanded to include data on bladder injury and the initial urinalysis. Multiple logistic regression was performed to determine if an association exists between pelvic fracture pattern, degree of hematuria, and bladder injury. A potential clinical prediction rule was then derived using a point system for four independent, significant risk factors identified from the logistic regression results.

RESULTS

There were 37 bladder ruptures (5.0%), all of which presented with hematuria >30 red blood cells per high-powered field (RBC/HPF). Pelvic injuries that were independently associated with bladder injury included diastasis of the pubic symphysis >1 cm, RR = 9.8 (95% CI 4.6-20.9), and fracture of the obturator ring with displacement >1 cm RR = 3.2 (95% CI 1.6-6.5). No patient with isolated acetabular fractures sustained bladder injury. A clinical prediction rule was derived, consisting of a single point for each of the significant pelvic injury sites in patients with hematuria >30 RBC/HPF. Patients with a prediction score of 0 had a 2.3% probability of bladder injury, whereas patients with scores of 1 and 2 had probabilities of bladder injury of 9.2% and 43.7%, respectively.

CONCLUSIONS

Patients with isolated acetabular fractures and patients with <30 RBC/HPF did not sustain bladder injury. In addition to hematuria, specific pelvic injury patterns are associated with bladder rupture. If validated, a clinical prediction rule derived from this data has the potential to guide the care of the blunt trauma patient.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging

PURPOSE

The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome.

METHODS

We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series.

RESULTS

Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates.

CONCLUSION

The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

Urologic injuries in pelvic ring disruptions

Pelvic ring disruptions are the result of high energy blunt trauma and are associated with other significant injuries in greater than 50% of the cases. These injuries may involve neurovascular structures and other organ systems. Lower urinary tract injuries may occur in as much as 25% of patients with pelvic ring disruptions. Coordinated care between the orthopaedist and urologist is required for successful treatment of the urologic and pelvic injury. Of primary importance to the orthopaedist is the potential for infection after open stabilization of the anterior arch. When contaminated urine communicates with the anterior arch, the possibility of infection exists. Early repair of bladder disruptions with simultaneous anterior arch plating minimizes this risk. The treatment of urethral disruptions and the safest method for urinary drainage remain controversial, however.