IMAGING OF

GENITOURINARY
TRAUMA

PRESENTED BY : RAISA MAHMUDAH

L E C T U R E D B Y : D R . L E N I S A N T I A N A , S P. R A D ( K )
OUTLINE
Adrenal Renal

Urinary
Ureteral
Bladder

Urethral Testicular

Penile
Fracture
INTRODUCTION

• Blunt and penetrating trauma  Injury to the

Objective genitourinary organs  Radiology imaging
plays a critical role

• Imaging  evaluation of the genitourinary

tract in a patient who has trauma.
• Contrast-enhanced CT is the primary
technique used to evaluate the upper and
Conclusion
lower UT.
• Cystography and urethrography  initial
evaluation and follow-up of trauma to the
urinary bladder and urethra.
 Blunt Motor
Abdominal vehicle
Trauma crashes
Closed
Injuries
of UG
organs

0.46 % 64% 80-95%

- Road - Motor - Multiorgan
traffic crash vehicle injury
- GU organs crashes
- GU organs
(testicular
and renal
injury)
ADRENAL TRAUMA

• Unusual
• Incidence 0.15-4%
• Patients with adrenal gland trauma have a higher mortality rate than do
trauma patients without adrenal injury.
• The right adrenal gland is more vulnerable to injury for several reasons
 RENAL TRAUMA
MDCT IVU
Evaluate UT (Renal vasculature,
CT may be not available
parenchyma, collecting system)

• Primary role :
Look for excretion and
– Asses the severity and extent of injury extravasation
– Evaluate the injured kidney for underlying
disorders
– Evaluate the anatomy and function of the
opposite kidney
– Assess for other associated injury
 RENAL TRAUMA
Renal contusions • Areas of ill-defined decreased enhancement

• Irregular or linear parenchymal defects that may

Renal lacerations
contain clot

• Round or elliptical high-attenuation (40-7-HU)

Subcapsular hematomas
collections of clotted blood
• Detected on CT, 10 minutes delayed Assess the
Renal Laceration collecting system and evaluate for urinary
extravasation
• Segmental infaction, pseudoaneurysms, or
Segemental arteries injury
arteriovenous fistulae

• Renal artery avulsion, in which case a

Global infarction
perinephric hematoma should be present

• Rare, usually occur in association with arterial

Venous injuries
pedicle injuries and severe parenchymal injuries
Renal contusion Superficial cortical Deeper lacerations, Lacerations that Shattering of the
without a lacerations that are >1cm deep, that do extend into the kidney and
parenchymal <1cm deep (and thus not extend into the collecting system dispersion of the
laceration, and a do not involve the collecting system, and injury to the avulsed portions,
non expanding collecting system) and non expanding main and segmental avulsion,
subcapsular and a nonexpanding perinephric renal vessels. laceration or
hematoma. perinephric hematoma. thrombosis of the
hematoma. main renal vessels,
hilar injury, and
ureteropelvic
junction (UPJ)
avulsion.
Renal Contusion and segmental arterial injury in two patients with blunt trauma.
A. Renal contusions (arrows), perinephric hematoma (arrowheads)
B. Retroperitoneal hematoma (arrow)

Deep parenchymal injuries.

A. Enchanced CT in nephrographic phase  Renal lacerations and perinephric hematoma
B. Densities hematoma (black arrows), small locules of gas in right paraspinal muscles (white arrows)
Collecting system injury
A. Severely lacerated right kidney and large surrounding fluid collection
of hematoma and urinoma
B. Exctretory phase shows extravasation of urine from right kidney
(black arrows) in CT urogram
C. Numerous lacerations (arrows) in right kidney as well as extravasated
urine (arrowheads)
A. Renal lacerations and perinephric fluid
B. Perinephric fluid is combination of hematoma and extravasated urine

A. Total absence of enhancement in left kidney, left renal artery (arrow) terminates abruptly
B. Large filling defect (white arrows) in left renal vein, contrast excretion into collecting system (black arrow)
 RENAL TRAUMA MANAGEMENT
Minor Grades 1, 2 & 3
injuries (hemodynamica Delayed or
lly stable and secondary Surgical
Grade 4
show no hemorrhage (2- Management
Nonoperative devitalized 38 days later)
management fragments

Follow-up CT at Renal pedicle

36-72 hours  Standard injury or
No follow-up Monitor
angiographic severely
imaging extravasation
from the techniques damaged and
collecting system shattered kidney

Sequelae of Renal Trauma

- Minor renal injuries heal completely and Treat
leave no residual change in the kidney on complications
follow-up CT detected on CT
- Higher grade injuries can cause permanent
scars in the affected kidney.
 URETERAL TRAUMA
Ureteral injuries from external trauma are unusual but when they occur are
usually related to penetrating trauma, primarily gunshot wounds.

Iatrogenic ureteral injuries can occur during gynecologic, obstetric, urologic,

colorectal, general, or vascular surgery.

Hematuria is an unreliable indicator of ureteral trauma and may be absent in

many patients.

CT delayed phase  contrast extravasarion, urinary ascites or urinoma.

UPJ injury  perirenal contrast extravasation.

 URETERAL TRAUMA
(AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA)
GRADE IMAGING FINDINGS

1 Ureteral contusion

2 Less than 50% partial transection

3 More than 50% partial transection

Right Ureteral injury as a complication of hysterectomy in 51yo woman. 4 Complete transection

Arrow show contrast material extending from injured right ureter.

5 Complete transection and extensive

devascularization
 URINARY BLADDER TRAUMA
• 90% patients with bladder injuries
due to blunt trauma have Extraperitoneal
associated pelvic fracture.
• 30% with pelvic fractures will
Ruptures
have some bladder injury,
including bladder contusion.
Simplex : Contrast extravasation
• Bladder injury  Direct is confined to the pelvic
extraperitoneal space
laceration by sharp bony spicules
of pelvic fractures.
• Bladder injury  Contra-coup Complex : Extravasation contrast
mechanism ec ligments injury can disperse widely into the
anterior wabdominal wall,penis,
scrotum, and perineum
• Indications for imaging :
Hematuria with pelvic fracture
 URINARY BLADDER TRAUMA
(AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA)
GRAD
IMAGING FINDINGS
E
Includes contusion, intramural
1 hematoma, and thickness partial
laceration.

Extraperitoneal wall lacerations

2
<2cm

Extraperitoneal wall lacerations

3 >2cm, intraperitoneal lacerations
<2cm

4 Intraperitoneal laceration> 2cm Extraperitoneal Bladder Rupture

A. Excreted contrast material as well as small amount of surrounding fluid (arrows), but no
extraluminal contrast material is detected (delayed axial image from contrast enhanced CT shows)
B-D CT cystograms show extraperitoneal rupture and large amount of contrast material in prevesical
Intraperitoneal or extraperitoneal space and extending into superficial soft tissue.

5 lacerations that extend into the

bladderneck or trigone.
URINARY BLADDER TRAUMA
(SOCIETE INTERNATIONAL D’UROLOGIE)
DO NOT TAKE INTO ACCOUNT THE LENGTH OR EXTENT OF THE BLADDER WALL LACERATION

GRADE IMAGING FINDINGS

1 Bladder contusion

2 Intraperitoneal Rupture

3 Extraperitoneal Rupture

4 Combined injury
 Characterizing
Bladder Injury
Conventional
(sensitivity 95% CT Cystography
Cystography
and specificity
100%)

A. Intraperitoneal Bladder Rupture B. Extraperitoneal Bladder Rupture

 URETHRAL TRAUMA

Male urethral injuries Female urethral injuries  uncommon

 Short size and absence of firm
(depend on cause of trauma) : attachment to the pubic zone

Associated with a fracture of

the anterior pelvic arch :
Involve the membranous Often accompanied by
urethra and rupturing the vaginal and rectal injury
puboprostatic ligaments

Straddle injury : Directly

injures the bulbous urethra
URETHRAL TRAUMA

Pelvic trauma Blood at the Retrograde

CT Scan
patient urethral meatus Urethrography
URETHRAL TRAUMA
Posterior Urethral Injuries associated with a
pelvic fracture :

GRADE IMAGING FINDINGS

1 Posterior urethra stretched but
intact
2 Urethra disrupted at the
membranoprostatic junction above
the urogenital diaphragm
3 Membranous urethra disrupted,
with extension to the proximal
bulbous urethra or disruption of the
urogenital diaphragm

4 Bladder neck inury with extension

into the urethra.

5 Partial or complete pure anterior

urethral injury

A. VCUG shows partial urethral transection and extravasation at bulbar urethra (type 5)
B. VCUG shows leakage of urine above urogenital diaphragm (type 2)
C. Enhanced CT shows ballon of Folley catheter positioned anterior to prostate and lateral to urethra (arrow)
URETHRAL TRAUMA

- Obscuration of the
urogenital diaphragmatic fat - Assessing posttraumatic
plane pelvic anatomy
- Hematoma of the - Determining the position
ischiocavernosus and of the prostate and the
obturator internus muscles amount of pelvic fibrosis
- Obscuration of the - Estimating the length of
prostatic contour, and the prostatomembraneous
- Obscuration of the defect
bulbocavernosus muscle.
TESTICULAR TRAUMA

Imaging is useful in triage of patients for

surgical or nonsurgical management

Imaging  High frequency sonography with

a linear transducer, and MRI
TESTICULAR TRAUMA

• US findings
– Heterogenous echotexture in the testis
– Testicular contour abnormality due to extrusion of the testes
– Testicular hematomas  echotexture to be heterogeneous
– Hematomas  varies with their age, show no internal vascularity
PENILE FRACTURE
Occurs Thrusting against
Excessive bending
exclusively with the pubic
of the erect penis
an erection symphisis

Rapid
Cracking sound Immediate pain
detumesence

Defect in tunica
albuginea 
US or MRI
surrounding
hematoma
PENILE FRACTURE

A. Transverse sonogram of penis shows defect in tunica albuginea of left corpus cavernosum (arrows) and large surrounding hematoma.
B. Photograph of penis shows ecchymosis, “eggplant” appearance to penis.
THANK YOU
PERTANYAAN

• Pada trauma testis, kapan kita menggunakan us dan kapan

menggunakan MRI? Bagaimana sensitivitas dan spesifisitasnya?
• Pada trauma adrenal, mengapa kejadian trauma adrenal kanan lebih
sering terjadi?
• Bagaimana gambaran trauma adrenal dari modalitas imaging yang
lain?