Professional Documents
Culture Documents
Genitourinary
Injuries
l
• Introduction
• Basic rules
○ Spleen
○ Liver
○ Stomach
○ Small bowel
○ Colon
○ Rectum
○ Kidney
○ Bladder
Male urethra
○ Perineum
Vulva
• Abdominal wall
Introduction
Gastrointestinal or genitourinary sport trauma is managed identically to gastrointestinal or
genitourinary trauma from any cause. As sport covers most human physical endeavour
from running to extreme forms of augmented transport, from wrestling to football and the
use of firearms, so the potential range and mechanism of sport injury is enormous.
The injured sportsperson can be physically well conditioned, muscular and full of ‘fight or
flight’ adrenaline. The physical conditioning can help protect from injury but at the same
time can hinder diagnosis by masking the physical signs of injury. Most sportspeople do
not conform to this physical ideal, the range of body habitus, physical condition and
underlying medical condition is as broad as the sports people play. A game of rugby
football in an area of endemic malaria for example has special implications for splenic
injury.
Basic rules
Despite these potentially confounding factors basic rules apply.
• In any injured patient the trauma ‘ABC’ applies (Airway, Breathing, Circulation)
• There is no need to make a precise diagnosis ‘in the field’The only decision that
needs to be made is ‘does this person need more attention than I (the sports
medicine physician) can provide here’. If the answer is yes then they must be
transferred rapidly to an emergency room.
• Difficulty breathing
• Abdominal bruising; bruising on the outside may herald bruising (or rupture) of
an internal organ
• Penetrating injury
• Abdominal distension
The body has only so many ways of reacting to trauma. Bleeding is same whether it is
coming from a transected mesentery, the liver or spleen. The urgency of transfer is the
same and the subtleties of managing one or the other are the responsibility of the
admitting surgeon. Do not spend too much time wondering whether the abdominal
distension and pulse of 160 is because of liver damage or a splenic injury...call the
ambulance.
The trauma protocol of the receiving institution will be invoked irrespective of the
mechanism of injury. The subtleties of choosing peritoneal lavage, CT scan or immediate
laparotomy will vary with surgeon, institution and country.
Stand on the right side of the patient. A long midline incision is preferred. Any massive
source of bleeding is dealt with directly. Several packs can be held in place to tamponade
the bleeding while the wound is extended (xiphisternum to pubis). Retraction. Empty
blood by bailing clots and using large packs which absorb blood more rapidly than a
sucker. Take the sucker off and use the suction tube alone, protecting it in your cupped
hand will make an effective ‘sump’ sucker able to deal with clots while the loops of bowel
are kept at bay. Formal exploration of the entire abdomen is mandatory. If you have a
systematic approach, use it. If you need one, start in the upper abdomen where the
gastrointestinal tract enters and use this to guide you systematically. Stomach, spleen
(reaching high up under the left costal margin and cupping it with the palm), liver (all
peritonealised surfaces), duodenum (noting the space lateral to the second part for
staining), right kidney while you have the area exposed, pancreas, remainder of
duodenum having lifted the mass of small bowel to the right, then every inch of small
bowel and its mesentery down to the caecum, around the colon and down into the pelvis,
bladder and rectum. If minor bleeding is encountered, pack the area for later attention;
massive bleeding should be dealt with.
Splenic trauma results from a blow or crush to the left side of the abdomen or lower
chest. The patient complains of abdominal or left shoulder tip pain (from diaphragmatic
irritation). Pallor, tachycardia and hypotension are signs of blood loss and impending
shock. The abdomen will be tender or guarded and may be distended. Sportspeople from
countries where malaria is endemic are especially prone to splenic injury; bear this in
mind as the global sporting community shrinks.
The patient is fasted, intravenous fluids are commenced through a wide bore cannula
and the patient is transferred urgently to a trauma centre. Shock unresponsive to
resuscitation or other evidence of ongoing blood loss (progressive abdominal distension,
falling haemoglobin, persistent tachycardia) requires emergency laparotomy through a
midline incision.
The stable patient can have a CT scan to confirm the diagnosis. The possibility of
delayed secondary haemorrhage demands conservative management in hospital with
intravenous access, frequent observations and crossmatched blood available. Surgery
will be required for clinical deterioration. Contact sport is prohibited for six months to a
year.
The spleen is an important immunological organ and should be preserved if possible. The
splenectomized individual is vulnerable to infection from encapsulated organisms and
should be immunized against pneumococcal, meningococcal and haemophilus
organisms.
Liver
A direct blow to the right upper quadrant, epigastrium or right chest can produce liver
trauma although it is uncommon. Crush can produce a more extensive injury.
As with splenic trauma the patient complains of abdominal or shoulder tip pain (from
diaphragmatic irritation). Pallor, tachycardia and hypotension are signs of blood loss and
impending shock. The abdomen will be tender or guarded and may be distended.
The patient is fasted, intravenous fluids are commenced through a wide bore cannula
and the patient is transferred urgently to a trauma centre. Shock unresponsive to
resuscitation or other evidence of ongoing blood loss (progressive abdominal distension,
falling haemoglobin, persistent tachycardia) requires emergency laparotomy through a
midline incision.
The stable patient can have a CT scan to confirm the diagnosis. Capsular tears,
superficial lacerations and deep haematomas (smaller than three cm) can usually be
managed conservatively (as long as the patient remains stable) however extensive
lacerations, devascularized segments and large haematomas (greater than three cm) will
usually require surgery. The liver can be expeditiously mobilized by dividing the falciform,
and if necessary the diaphragmatic ligaments. Severe injuries may need to be packed;
do not put the packs into the rent as this will keep the vessels open, place the packs
above and below the liver so as to force the rent closed and apply pressure. This may be
an opportunity to transfer the patient to a specialized liver unit. Abscess and bile leak are
longer term complications.
Requiring a direct epigastric blow (e.g. the kick of a horse) to compress the pancreas and
or duodenum against the spine, this deep, often retroperitoneal injury can remain hidden.
Duodenal injuries are usually hard to recognize as the leak can be contained by the
retroperitoneum and there need not be any signs until sepsis supervenes. Blunt duodenal
injury (the invariable case in sporting accidents) is even harder to recognize. Remain
suspicious, delays in diagnosis increase morbidity and any patient with persistent
epigastric pain, usually but not always radiating through the back or shoulders must have
pancreatic duodenal injury excluded. Duodenal haematoma will present with symptoms
of gastric outlet obstruction.
The serum amylase may be elevated with duodenal perforation. The plain abdominal x-
ray may have an absent psoas shadow, retroperitoneal air or a scoliosis. Oral contrast
enhanced CT scan may demonstrate a leak and peripancreaticoduodenal oedema.
The duodenum is approached through a long midline incision. Haematoma or bile stained
fluid at any of the lateral margins of the duodenum suggests perforation. The right side of
the duodenum is exposed by Kocherising the second part and carrying this dissection
toward the midline in the retropancreatic duodenal plane. Further exposure requires
mobilization of the viscera supplied by the superior mesenteric artery which overlies the
third part of the duodenum; small bowel, caecum and right and transverse parts of the
colon. The caecum and right colon are mobilized on their primitive mesentery along with
the base of the small bowel mesentery (which represents the left edge of this
embryological plane); this plane is carried up to and over the third part of the duodenum.
Simple perforations are debrided and sutured. Segmental resection and anastomosis
may be necessary. Patching with a jejunal loop or Roux-en-Y may be used if primary
repair is not possible. Duodenal diversion with closure of the pylorus, gastroenterostomy,
and decompression for the duodenal loop may be required for rupture. Severe cobined
duodenal and pancreatic trauma could require a Whipple procedure.
Stomach
The stomach is usually resistant to injury from blunt trauma. The important exception is
the full stomach that can burst with a direct blow or crush.
Do not be sidetracked into repairing the stomach until the laparotomy has been
completed and the full extent of the injuries determined. If the stomach is leaking gastric
contents place a clamp or quick suture to control the contamination before moving on.
The injury is debrided if necessary. If the laceration crosses into the origin of the greater
or lesser omentum, clear this meticulously (in the manner of a highly selective vagotomy)
to allow seromuscular apposition with the repair. stomach is repaired with large
interrupted absorbable sutures. A two layer continuous repair is acceptable. Take a larger
bite of the seromuscular than the mucosal layer. The repair should be inverted.
Decompress the stomach with a nasogastric tube.
Small bowel
Small bowel injury includes serosal tear, full thickness rupture and mesenteric injury
(haematoma or laceration). Physical signs are indistinguishable from those above.
Development of signs can be delayed by days, especially in the case of an isolated small
bowel rupture. Developing ileus, progressive distension and tenderness with a low grade
fever are important signs.
Abdominal X-ray may show free air or thickened bowel loops. CT scan will reveal free
intra-abdominal fluid or thickening of bowel wall or planes.
When repairing an injury consider the lumen of the small bowel and place a suture line
transversely across the bowel where possible. The principles of the successful
anastomosis apply to the repair as well as to the formal resection and anastomosis; good
blood supply, no tension, no distal obstruction.
Colon
Give broad spectrum antibiotics to cover the range of colonic organisms. The colon
adjacent to the injury is mobilized on its embryological mesentery. Colon may be repaired
primarily if there is no risk of subsequent breakdown of the repair. The injury must be less
than 12 hours old, there can be no intraperitoneal contamination, the wall of the colon
must be viable with a good blood supply. A diaphragmatic defect is a contraindication to
primary repair.
If primary repair is not considered safe the suture line can be exteriorized for early return
to the abdomen once sound healing has been confirmed (5-10 days). The defect itself
can be brought out as a stoma. Both of these procedures can require extensive
mobilization to allow the colon to reach the skin and lie over a colostomy rod without
tension. An exteriorized repair must lie free of the skin edge so that a breakdown will
result in a colostomy rather than a subcutaneous leak.
Rectum
Rare in sport accidents a rectal injury is suspected with a pelvic crush or penetrating
wound in the region of the pelvis (buttocks, hips, perineum). Blood may be found on the
examining finger after rectal examination during the secondary survey in the emergency
room. The principles of management of rectal injury are well established and require
thorough cleansing of the rectum to decrease its potential as a source of contamination
during subsequent management;
• Drainage of the perirectal fascial planes. The drain is placed in the presacral
plane and brought out between anus and coccyx
Kidney
Suspected with flank bruising, bony injury (lower rib or lumbar vertebrae) and
haematuria. Note that the absence of haematuria does not exclude renal injury; a
devascularized kidney will not cause haematuria, nor will an injury that does not involve
the collecting system. A thrombosed and occluded renal artery must be repaired within
three hours to save the kidney from acute tubular necrosis.
• Explore a haematoma in the region of the bladder to rule out bladder injury.
Bladder
More easily injured when full, bladder injury is suspected with haematuria, urinary
retention, suprapubic pain or peritonitis. The rupture may be confined to the
retroperitoneum or be free into the peritoneal cavity. Diagnosed by contrast study a
simple tear may be managed with foley catheter drainage alone.
In most cases the bladder should be opened at laparotomy, the trigone, urethral and
ureteric orifices are confirmed to be clear of injury and the injury and operative cystotomy
are repaired with two layers of absorbable 2/0 or 3/0 suture. The bladder is drained with a
catheter (transurethral or suprapubic) and the extravesical space is drained with penrose
drains.
Male urethra
Caused by a fall astride or severe pelvic fracture. Do not attempt to pass a urinary
catheter if blood is seen at the urethral meatus or there is oedema and bruising of the
penis or perineum, suspect urethral injury and do a urethrogram. Discourage the patient
from voiding to minimize extravasation. Passage of a catheter could convert a partial tear
to a complete disruption.
Suprapubic catheterization and specialist urological referral are required. If the patient
requires urgent laparotomy the suprapubic catheter can be placed with the abdomen
open, otherwise a percutaneous technique can be used.
Posterior urethra extends from urogenital diaphragm to bladder neck. The prostate will be
displaced on digital rectal exam, replaced by a soft boggy mass of haematoma. This
injury is invariably associated with a major pelvic fracture.
Perineum
Perineal, urethral and vaginal injury in the female is best treated with catheterization
(suprapubic if necessary) and surgical repair of lacerations to control haemorrhage.
Vulva
Caused by falls astride and the classical water skiing accident this injury is becoming less
common as the role of protective clothing is appreciated.
Abdominal Wall
• groin strain
• hernia
• hip pointer
• ‘stitch’
• Visceral pain
• peptic ulceration
• cholelithiasis
• diverticulitis
• Heartburn
• reflux
• peptic ulceration
• Nausea
• bowel obstruction
• Vomiting
• gastroenteritis
• Diarrhoea
• infectious diarrhoea
• runners diarrhoea