Pelvic Trauma and Genitourinary Injury

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Chapter 60 Pelvic Trauma and Genitourinary Injury

Javier A. Gonzalez del Rey, MD, MEd

1 Why are children more likely to sustain renal injuries than adults?

ce:anchor id=”p0010″/>A child’s kidneys are disproportionately larger in relation to body size and have less perinephric fat, more lobulations, and a more intra-abdominal location. Because children have a weaker anterior abdominal wall and a less well-ossified thoracic cage with a more flexible thoracolumbar spine, the kidneys and other genitourinary structures are more susceptible to blunt trauma. Preexisting congenital renal abnormalities have been documented in 10–15% of patients evaluated for renal trauma. Approximately 10% of trauma patients have urogenital injuries. Common associated injuries include head injuries, fractures (extremities, pelvis, ribs, spine, and skull), spinal cord injuries, and liver or spleen injuries. Blunt trauma accounts for up to 90% of renal injuries.

Abou-Jaoude WA, Sugarman JM, Fallat ME, et al: Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pediatr Surg 31:86–90, 1996.

2 Describe the immediate and delayed complications of renal trauma

Contusions and minor cortical lacerations usually heal without sequelae. More severe injuries may be associated with delayed bleeding, renal failure, abscess formation, urinary extravasation with sepsis, and ureteral obstruction secondary to clot formation. Late complications include hypertension, arteriovenous fistulas, hydronephrosis, pseudocyst formation, and renal calculi. Children with renal trauma (radiologically or operatively confirmed) should be followed closely with serial scans for at least 1 year after injury to evaluate renal anatomy and to ensure prompt diagnosis and treatment of possible complications.

Gotschall CS, Eichelberger MR: Predictors of abdominal injury in children with pelvic fracture. J Trauma 31:1169–1173, 1991.

McAleer IM, Kaplan GW: Pediatric genitourinary trauma. Urol Clin North Am 22:177–188, 1995.

3 Which is the cardinal laboratory marker of renal injury?

Hematuria is the most important laboratory evidence of renal injury. Gross hematuria is the hallmark sign of severe injury. However, this finding may be absent in up to 50% of patients with vascular pedicle injuries and in 29% of patients with penetrating injuries. Radiographic evaluation is needed for children with gross hematuria, hematuria of more than 20 red blood cells/high-powered field, microscopic hematuria with shock, or clinical findings indicative of renal trauma.

Garcia CT: Genitourinary trauma. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006.

4 How are renal injuries classified?

The Organ Injury Scaling Committee of the American Association for Surgery of Trauma developed a new scaling system that unifies previous classifications for research purposes:

Grade I: Contusions or nonexpanding subcapsular hematomas with associated hematuria

Grade II: Hematomas confined to the retroperitoneum or laceration < 1 cm in depth without urinary extravasation

Grade III: Lacerations extending into the perinephric fat > 1 cm in depth without involvement of the collecting system or extravasation

Grade IV: Deep lacerations into the collecting system and vascular injuries with contained hemorrhage

Grade V: Fractured or completely shattered kidneys and avulsion of the renal pedicle with organ devascularization

Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: Spleen, liver, and kidney. J Trauma 29:1664–1666, 1989.

5 Which imaging modality is considered the diagnostic test of choice for evaluation of renal injuries in stable pediatric patients?

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