Urinary Tract Trauma

DRG Category:	659
Mean LOS:	10.8 days
Description:	SURGICAL: Kidney and Ureter Procedures for Non-Neoplasm with Major CC
DRG Category:	663
Mean LOS:	5.2 days
Description:	SURGICAL: Minor Bladder Procedures With CC
DRG Category:	699
Mean LOS:	4.5 days
Description:	MEDICAL: Other Kidney and Urinary Tract Diagnoses With CC

Urinary tract trauma includes injury to the kidneys, ureters, urinary bladder, and urethra. Although these injuries occur in fewer than 3% of patients admitted to the hospital for trauma, the damage can threaten life and lead to lifelong impaired genitourinary (GU) dysfunction. Most urinary tract trauma affects the kidneys (80%). Blunt renal injury is classified as minor, major, and critical trauma. Minor renal trauma occurs when organ tissue is bruised or when superficial lacerations of the renal cortex occur without disruption of the renal capsule. Major renal trauma occurs with major lacerations that extend through the renal cortex, medulla, and renal capsule. Critical renal trauma occurs when the kidney is shattered or when the renal pedicle (stem that contains the renal artery and vein) is injured.

Bladder injury occurs in 8% of GU trauma, usually involves bladder rupture, and can be either intraperitoneal or extraperitoneal. Intraperitoneal bladder rupture occurs with blunt trauma to the lower portion of the abdomen, usually when the bladder is full. The bladder ruptures at the dome (the point of least resistance), and blood and urine collect in the peritoneal cavity. Extraperitoneal bladder rupture usually occurs in conjunction with a pelvic fracture when a sharp bone fragment perforates the bladder at its base. Blood and urine then collect in the space surrounding the bladder base. Urethral injury occurs in 8% of cases of GU tract trauma, whereas ureteral trauma is rare.

Although renal trauma is unusual, it is associated with a 6% to 12% mortality rate, possibly because of the kidneys’ high vascularity. Complications of urinary tract trauma include hemorrhage and exsanguination, hypovolemic shock, peritonitis, septic shock, acute renal failure, urinary incontinence, pyelonephritis, and impotence.

Causes

Urinary tract trauma is caused by either blunt or penetrating trauma. Motor vehicle crashes are the most common cause of blunt trauma. Other causes include falls, assaults, occupational (crush) injuries, and sports injuries. The energy of the trauma is dissipated throughout the cavity, which frequently causes rupturing of the bladder or kidney or tearing of the urethra. Penetrating trauma to the urinary tract is frequently the result of a gunshot wound or a stabbing injury. The degree and severity of the damage from a gunshot wound depend on the velocity and trajectory of the bullet. The result is usually localized tissue damage and potential hemorrhage in the highly vascular kidney or the distended bladder.

Genetic considerations

No clear genetic contributions to susceptibility have been defined.

Gender, ethnic/racial, and life span considerations

Trauma is the leading cause of death and disability in individuals from ages 1 to 44. Although trauma to the urinary tract is relatively rare, young men remain the largest group of individuals admitted to the hospital for the management of multiple trauma. Because urinary tract trauma is not usually an isolated injury, young men are the population at highest risk for this type of trauma. There are no known racial or ethnic considerations.

Global health considerations

Falls and motor vehicle crashes occur around the world and may lead to urinary tract trauma. Internationally, falls from heights of less than 5 meters are the leading cause of injury overall, and automobile crashes are the next most frequent cause. Regions of the world with war or civil unrest may have increased incidence of penetrating injury because of penetrating injuries from guns and knives. When rape is used as a weapon of war, urinary tract trauma may occur.

Assessment

History

Obtain a relevant history from the patient or significant others. If the patient is critically injured, note that the history, assessment, and early management merge in the primary survey. Determine as much as you can from witnesses to the trauma or the life squad.

If the patient’s condition is stable enough to warrant a separate history, ask questions about allergies, current medications, preexisting medical conditions, and factors surrounding the injury. Take a sexual history from women to rule out rape. Note that patients with preexisting renal diseases such as polycystic kidney disease and pyelonephritis are at higher risk for renal injury than those with normal kidneys. If you suspect a lower urinary tract injury, ask if the patient has experienced suprapubic tenderness, the inability to void spontaneously, or bloody urine. If you suspect kidney injury, ask the patient if he or she is experiencing flank pain, pain at the costovertebral angle, back tenderness, colicky pain with the passage of blood clots, or bloody urine. Note that if the patient has a positive blood alcohol level, the patient may not be sensitive to painful stimuli even if he or she has experienced a severe injury.

Physical examination

Common symptoms include urethral bleeding, bruising along the flank, urinary retention, lower abdominal distention and pain, and swelling and edema of the genitalia. If the patient is stable enough for you to perform a complete head-to-toe assessment, determine if there are any physical signs indicating kidney injury. Note, however, that physical signs may be masked because of the protection of the kidneys by the abdominal organs, muscles of the back, and bony structures. Inspect the area over the 11th and 12th ribs and flank area for obvious hematomas, wounds, contusions, or abrasions. Inspect the lower back and flank for Grey-Turner’s sign or bruising because of a retroperitoneal hemorrhage. Note any abdominal distention. To identify lower urinary tract trauma, inspect the urinary meatus to determine the presence of blood. Note any bruising, edema, or discoloration of the genitalia or tracking of urine into the tissues of the thigh or abdominal wall.

Auscultate for the presence of bowel sounds in all quadrants. Although the absence of bowel sounds does not indicate urinary tract injury for certain, increase your index of suspicion when bowel sounds are absent because abdominal injury often accompanies urinary tract injury. If you note a bruit near the renal artery, notify the physician at once because an intimal tear may have occurred in the renal artery. Percussion may reveal excessive dullness in the lower abdomen or flank. When you palpate the flank, upper abdomen, lumbar vertebrae, and lower rib cage, the patient may experience pain. Other signs of urinary tract trauma include crepitus and a flank mass. Bladder rupture leads to severe pain in the hypogastrium on palpation or swelling from extravasation of blood and urine in the suprapubic area. Signs of peritoneal irritation (abdominal rigidity, rebound tenderness, and voluntary guarding) may also be present because of extravasation of blood or urine into the peritoneal cavity.

Psychosocial

The patient with urinary tract trauma requires immediate emotional support because of the nature of any sudden traumatic injury. The sudden alteration in comfort, potential body image changes, and possible impaired functioning of vital organ systems can often be overwhelming and can lead to maladaptive coping. Determine the patient’s and family’s level of anxiety and their ability to cope with stressors.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Retrograde urethrogram	Normal structure of urethra	Transected or torn urethra	Urethra irrigated with contrast media to determine location and extent of injury
Kidney-ureter-bladder x-ray and radionuclide imaging	Normal structures of urinary tract	Location and extent of injury	Contrast media and radiography used to identify areas of injury
Renal and lower urinary tract computed tomography	Normal structures of urinary tract	Location and extent of injury	Identifies radiographic slices with or without contrast

Other Tests: Complete blood count, urinalysis, renal ultrasound, excretory urogram (intravenous pyelogram)

Primary nursing diagnosis

Diagnosis

Pain (acute) related to tissue damage and swelling

Outcomes

Comfort level; Pain control behavior; Pain: Disruptive effects; Pain level

Interventions

Pain management; Analgesic administration; Positioning; Teaching: Prescribed activity/exercise; Teaching: Procedure/treatment; Teaching: Prescribed medication

Planning and implementation

Collaborative

medical.

The initial care of the patient with urinary tract trauma involves airway, breathing, and circulation. Measures to ensure adequate oxygenation and tissue perfusion include establishing an effective airway and supplemental oxygen source, supporting breathing, controlling the source of blood loss, and replacing intravascular volume. As with any traumatic injury, treatment and stabilization of any life-threatening injuries are completed immediately.

surgical.

Patients with renal trauma may need urinary diversion with a nephrostomy tube, depending on the location of injury or in situations in which pancreatic and duodenal injury coexist with renal trauma. If the patient is unable to void, the trauma team considers urinary catheterization. If the patient has blood at the urinary meatus or if there is any resistance to catheter insertion, a retrograde urethrogram is performed to evaluate the integrity of the urethra. In the presence of urethral injury, an improperly placed catheter can cause long-term complications, such as incontinence, impotence, and urethral strictures. A suprapubic catheter may be used to manage severe urethral lacerations and urethral disruption. Extraperitoneal bladder rupture is usually managed not with surgery but with urethral or suprapubic catheter drainage. Ongoing monitoring of the amount, character, and color of the patient’s urine is important during treatment and recovery. In a patient without renal impairment, the physician usually maintains the urine output at 1 mL/kg per hour. Note any blood clots in the urine and report an obstructed urinary drainage system immediately.

The indications for surgery depend on the severity of injury. Patients with major renal trauma who are hemodynamically unstable and patients with critical trauma need surgical exploration. Patients with urethral disruption and severe lacerations may have surgery delayed for several weeks or even months, or the surgeon may choose to perform surgical reconstruction immediately. Patients with an intraperitoneal bladder rupture have the bladder surgically repaired, with the extravasated blood and urine evacuated during the procedure. Usually, suprapubic drainage is used during recovery. Laceration of the ureter is immediately repaired surgically or the patient risks loss of a kidney.

Minor renal trauma is usually managed with bedrest and observation. Minor extraperitoneal bladder tears can be managed with insertion of a Foley catheter for drainage, along with antibiotic therapy. Many urethral tears can be managed with insertion of a suprapubic catheter and delayed surgical repair or plasty, provided that bleeding can be controlled. The patient needs to be monitored for complications throughout the hospital stay, such as infection (dysuria, low back pain, suprapubic pain, and foul or cloudy urine), impaired wound healing (seepage of urine from repair sites, flank or abdominal mass from pockets of urine, and crepitus from urine seepage into tissues), and impaired renal function (nausea, irritability, edema, hypertension, oliguria, and anuria).

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Phenazopyridine hydrochloride (Pyridium)	200 mg PO tid	Urinary analgesic	Decreases burning, urgency, and frequency

Other Drugs: Antibiotics for patients with penetrating injuries or suspected contamination of wounds, analgesia; antispasmodics may be needed for bladder spasm.

Independent

The most important priority is to ensure the maintenance of an adequate airway, oxygen supply, breathing patterns, and circulatory status. If the patient is stable, apply ice to the perineal area, the scrotum, or the penis to help relieve pain and swelling. Use care to avoid cold burns from ice packs that are in contact with the skin for a prolonged period of time. For severe scrotal swelling, some experts recommend a scrotal support to reduce pain. Use either a commercially available support or a handmade support using an elastic wrap as a sling.

Patients may or may not have residual problems with urinary incontinence or sexual functioning. Loss of urinary continence leads to self-esteem and body image disturbances. Provide the patient with information on reconstructive techniques and methods to manage incontinence. Listen to the patient and offer support and understanding. Patients often view injury to the urinary tract system as a threat to their sexuality. Reassure patients who are not at risk for sexual dysfunction that their sexuality is not impaired. Sexual concerns should not be ignored during the acute phase of recovery. Be alert to questions about sexuality, which may be phrased in terms that are familiar in the patient’s culture. Answer questions honestly and listen to the patient’s questions and responses carefully to understand the full meaning.

Note that the inability to function sexually is an enormous loss to patients of both sexes. It may occur with posterior urethral injury in men when nerve damage occurs in the area. Urinary tract injury in men is often associated with injury to the penis and testes as well. Sexual dysfunction may also occur in women if the ovaries, uterus, vagina, or external genitalia are damaged along with urinary tract structures or the pelvis. Provide specific answers to the patient’s questions, such as alternative techniques to intercourse (oral sex, use of a vibrator, massage, or masturbation). Give the patient information about the feasibility and safety of resuming sexual activity and include the partner in all discussions.

Emotional support of the patient and family is also a key intervention. Patients and their families are often frightened and anxious. If the patient is awake as you implement strategies to manage the airway, breathing, and circulation, provide a running explanation of the procedures to reassure the patient. Explain to the family the treatment alternatives and keep them updated as to the patient’s response to therapy.

Evidence-Based Practice and Health Policy

Siram, S.M., Gerald, S.Z., Greene, W.R., Hughes, K., Oyetunji, T.A., Chrouser, K., …Chang, D.C. (2010). Ureteral trauma: Patterns and mechanisms of injury of an uncommon condition. American Journal of Surgery, 199(4), 566–570.

In a retrospective population study, investigators identified 22,706 cases of genitourinary trauma, 582 of which were cases of ureteral injury. Among patients with ureteral injury, 38.5% had blunt trauma, and 61.5% had penetrating trauma.
The primary causes of blunt ureteral trauma were motor vehicle collision (49.1%) and falls (10.3%), and the primary causes of penetrating ureteral trauma were firearm injury (88.3%) and stabbing (8.1%).
Patients with blunt ureteral trauma had a higher incidence of bony pelvic injuries, whereas patients with penetrating ureteral trauma had a higher incidence of bowel and vascular injuries (p < 0.001).
The mean length of hospital stay was decreased by 3.7 days among patients with blunt ureteral trauma compared to patients with penetrating ureteral trauma. However, mortality rates over the 5-year follow-up period were similar among patients with blunt and penetrating ureteral traumas (9% and 6%, respectively).

Documentation guidelines

Urinary tract assessment: Urinary drainage system (patency, color of urine, presence of bloody urine or clots, amount of urine, appearance of catheter insertion site); fluid balance (intake and output, patency of intravenous catheters, speed of fluid resuscitation); wound healing (wound drainage, extravasation of urine from wound, tracts of urine extending beneath the skin)
Assessment of level of anxiety, degree of understanding, adjustment, family or partner’s response, and coping skills
Concern over sexual dysfunction, content of conversations, and content taught

Discharge and home healthcare guidelines

Provide a complete explanation of all emergency treatments and answer the patient’s and family’s questions. Explain the possibility of complications to recovery, such as poor wound healing, infection, and anemia. As needed, provide information about any follow-up laboratory procedures that might be required after discharge from the hospital. Provide the dates and times that the patient is to receive follow-up care with the primary healthcare provider or the trauma clinic. Give the patient a phone number to call with questions or concerns. Provide information on how to manage urinary drainage systems if the patient is discharged with them in place. Demonstrate catheter care, emptying the bag, and the need for frequent hand washing. Explain when the patient can resume sexual activity. If the patient has sexual dysfunction, provide the patient with information about alternatives to intercourse; refer the patient to a support group if she or he is interested.