OVERVIEW
- Haematuria in trauma may be microscopic (with or without symptoms) or macroscopic
- In general, the greater the degree of hematuria the greater the risk of significant intra-abdominal injury (including non-urinary tract structures)
- About 5% of renal injuries and up to 20% of renovascular injuries lack hematuria — even severe injuries such as renal artery injury or ureteropelvic disruption may present without hematuria
GOALS
- find source of bleeding along urological tract
- treat cause
- support blood volume
- identify associated injuries
ASSESSMENT
Clinical interpretation of haematuria is not diagnostic, however:
- Faint hematuria, primarily shades of pink, is usually associated with renal injury or a bladder contusion
- A moderate amount of darkly bloody urine is frequently associated with extraperitoneal bladder injury
- A small amount of very dark, bloody urine may mean an intraperitoneal bladder injury
- Scant and very dark blood in the catheter suggests a urethral injury or a catheter balloon inflated in the urethra
Microscopic haematuria in blunt trauma
- If the patient is asymptomatic the yield of injuries requiring intervention in this setting is extremely low:
— no further imaging is needed
— arrange repeat urinalysis (e.g. in a week’s time) and close follow up by a GP
— Some experts advocate imaging in pediatric patients with asymptomatic hematuria following blunt abdominal trauma as they are more vulnerable to significant renal injury; cut off values vary, with values from 5 to 50 RBCs/hpf being suggested. - Hematuria with <5 RBCs/hpf can be caused by urinary catheter insertion
- If the patient is significantly symptomatic, they may have associated non-urinary intrabdominal or retroperitoneal injury:
— CT abdomen with IV contrast
Macroscopic haematuria in blunt trauma
- 50% of such patients have renal injuries, and a further 15% have injuries to other intra-abdominal organs:
— CT abdomen with IV contrast and CT cystogram
Haematuria in penetrating trauma
- surgical exploration +/- CT if stable
Perform urethrogram if suspected urethral injury
- displaced fractures of the pelvic ring, particularly ‘butterfly fractures’
- Gross hematuria, difficulty placing a urinary catheter
- Classic clinical features are uncommon:
— blood at the meatus
— perineal / scrotal haematoma
— high riding prostate on examination
Skeletal injuries associated with genitourinary injury:
- Pelvic fractures
— posterior urethrethal injury (above the urogenital diaphragm) and bladder injury - Perineal straddle injury
— anterior urethral injury - Fracture of the lower posterior ribs, lower thoracic or lumbar vertebrae
— renal or ureteral injuries
MANAGEMENT
- ATLS approach
- Urology referral if significant identifiable injury
- Renal injury
— Most renal injuries (Grades I to III, and most Grade IV injuries) can be managed conservatively, as they tend to heal spontaneously
— Surgical repair is needed for urinary extravasation or if ongoing bleeding or hemodynamic instability due to renal injury
— Alternatives to operative repair are interventional radiology to embolise bleeding vessels or to stent dissected renal arteries, and urinary extravasation may be amenable to stenting
— Grade V injuries (avulsed kidneys) need operative intervention and often require nephrectomy - Ureteral injury
— contusions may be conservatively managed
— more significant injuries require operative repair, urinary diversion, or (rarely) nephrectomy - Bladder injury
— Bladder contusion and hematomas can be observed
— Intraperitoneal rupture requires laparotomy and surgical repair
— Extraperitoneal rupture can often be managed with simple catheterisation (usually about 10 days) - Urethral injury
— Suprapubic catheterization may be required initially, followed by operative repair
Reference and Links
LITFL
Journal articles and textbooks
- Legome E, Shockley LW. Trauma: A Comprehensive Emergency Medicine Approach, Cambridge University Press, 2011.
FOAM and web resources
- The Trauma Professional’s Blog — AAST Revises Renal Injury Grading
- The Trauma Professional’s Blog — Evaluation of Hematuria in Blunt Trauma
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