Archives of Academic Emergency Medicine. 2019; 7 (1): e63 OR I G I N A L RE S E A RC H Characteristics of Traumatic Urogenital Injuries in Emer- gency Department; a 10-Year Cross-sectional Study Babak Javanmard1, Morteza Fallah-karkan1,2, Mohammadreza Razzaghi2∗, Anahita Ansari Djafari1, Saleh Ghiasy1, Behzad Lotfi1, Reza Vafaee3 1. Urology Department, Shohada e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Laser Application in Medical Science Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: July 2019; Accepted: September 2019; Published online: 9 November 2019 Abstract: Introduction: Urogenital system injuries (UGIs) are seen in 10% of adult cases with multiple trauma. Although UGIs are rarely life threatening, they can cause major long-term morbidities. This study aimed to evaluate the characteristics of traumatic UGIs in patients who were referred to emergency department following multiple traumas. Methods: This retrospective cross-sectional study was conducted on multiple trauma patients who were presented to emergency department during a 10-year period (2008-2017). All patients with kidney, ureter, bladder, urethra, or external genitalia injuries were studied. The patients’ data were extracted from their clinical profiles. Results: Out of the 13598 admitted patients in our trauma center, UGIs were seen in 267 (1.9%) cases. The mean age of patients with UGIs was 27.3 ± 6.1 years (74.15% male). The highest incidence of UGI was seen in those aged between 21 and 30 years (39.7%) and motorcycle accidents (49%) was the most frequent cause of trauma. 221 patients had an unstable situation and were emergently transferred to operation room (13.57% with traumatic kidney injury). The most common injured sites of urogenital system were kidney with 155 (58%) cases, followed by external genitalia with 91 (34.1%) cases. 77.5% of cases were managed conservatively and the rest (22.5%) underwent surgical procedures. Conclusion: UGIs comprise a low percentage (2%) of traumatic injuries, which are mostly caused by blunt trauma due to road traffic accidents. Kidney is the most common injured organ and UGIs mostly happen in young ages. Keywords: Urogenital system; acute kidney injury; wounds and injuries; multiple trauma; epidemiology; mortality Cite this article as: Javanmard B, Fallah-karkan M, Razzaghi M, Ansari Djafari A, Ghiasy S, Lotfi B, Vafaee R. Characteristics of Traumatic Urogenital Injuries in Emergency Department; a 10-Year Cross-sectional Study. Arch Acad Emerg Med. 2019; 7(1): e63. 1. Introduction With economic development, incidence of traffic and industry-related accidents, iatrogenic injury, intoxication and also psychological self-mutilation have been increasing (1-8). Morbidity due to trauma has been one of the most se- rious public health concerns all over the world (9). In most reports, urogenital system injuries (UGIs) are seen in approx- imately 10% of adult traumatic patients and in less than 3% of children with multiple/severe trauma of lower abdomen or pelvis (10-12). Kidney is the most common injured organ in ∗Corresponding Author: Mohammadreza Razzaghi; Laser Application in Medical Science Research Center, Shahid Beheshti University of Medical Sci- ences, Tehran, Iran. Tel: +98 9121482592, Fax: +98 2122712234, Email: M- razaghi@sbmu.ac.ir. genitourinary system while ureteral traumas are rare (1, 13). Although UGIs are rarely life threatening, they can cause sig- nificant long-term morbidities such as renal function impair- ment, sexual dysfunction and urethral stricture (14-16). Finding an ideal management in patients with UGIs re- quires comprehensive epidemiological information in differ- ent populations and times (14, 17). Therefore, this study aimed to evaluate the characteristics of traumatic UGIs in pa- tients who were referred to emergency department following multiple traumas. 2. Methods 2.1. Study design and setting This retrospective cross-sectional study was conducted on multiple trauma patients who were presented to emergency department of Shohada-e-Tajrish Hospital, Tehran, Iran, dur- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Javanmard et al. 2 ing a 10-year period (2008-2017). This hospital is the main referral trauma center in north and northeast of Tehran. The Ethics committee of Shohada-e-Tajrish Hospital approved this study and gave us permission to review patients’ medical data. Considering the retrospective design of the study, the ethical committee ceded the necessity to have patients pro- vide consent for collecting their medical data. The patients’ data were collected confidentially and de-identified. 2.2. Participants All admitted patients for more than 6 hours with any kind of traumatic UGIs such as kidney, ureter, bladder, urethra, external genitalia and adrenal gland injuries, were included using a census sampling method. Patients with incomplete medical profiles or unclear evidence regarding the urogenital tract were excluded. There was not any age or gender limita- tion. 2.3. Data gathering We reviewed all information regarding demographic charac- teristics (age, gender), history, physical examination, mecha- nism of injury, type and severity of UGIs, associated injuries, done procedures, and also type of management (conserva- tive or surgical managements) by referring to the medical records of the cases and filling out a checklist designed for the investigation. The type and mechanism of the injury were adapted according to the International Classification of Dis- eases, 10th revision (ICD-10)(18). Two senior urology resi- dents (MFk and SG) were responsible for data gathering. 2.4. Statistical Analysis Statistical analyses were performed by the Statistical Package of Social Science System software, version 20. Findings were presented using descriptive statistics as mean ± standard de- viation or frequency (%). 3. Results 3.1. Baseline characteristics of studied patients Out of 13598 admitted patients in our trauma center dur- ing the study period, UGIs were seen in 267 (1.9%) patients (92.5% blunt and 7.5% penetrating trauma). Table 1 shows the baseline characteristics of studied patients. The mean age of patients with UGIs was 27.3 ± 6.1 (3 - 82) years (74.15% male). The highest incidence of UGI was seen in those aged between 21 and 30 years (39.7%) followed by 11-20 years (25.07%) and 3 -10 years (19.1%) age groups. Motorcycle ac- cidents (49%) followed by falling down (26%) were the most frequent causes of trauma. 221 patients had unstable sit- uation and were emergently transferred to operation room (13.57% with traumatic kidney injury). 7 (2.8%) cases died due to severity of associated injuries (5 patients had renal Table 1: Baseline characteristics of studied patients Variables Number (%) Gender Male 198 (74.15) Female 69 (25.8) Age (year) 3 – 10 51 (19.1) 11 –20 67 (25.07) 21 –30 106 (39.7) 30 – 60 31 (11.4) >60 12 (4.73) Trauma mechanism Motorcycle accident 131(49) Falling down 69 (26) Car accident 58 (21.6) Sports accident 9 (3.3) Hemodynamics Stable 238 (89.2) Unstable 29 (10.8) Associated injuries Abdominopelvic 104 (38.8 ) Extremities 85 (31.9) Thoracic 46 (17.1) Head and neck 32(12.2) Presenting sign and symptom Hematuria 169 (63.2) Flank pain 50 (19.1) Flank or genital abrasion 19 (7.1) Obstruction 15 (5.6) Other 14 (5.2) and 2 cases had bladder injuries). The most common injured sites of urogenital system were kidney with 155 (58%) cases, followed by external genitalia with 91 (34.1%) cases (table 2). The common associated injuries were extremity (52.8%) and abdominopelvic (41.9%) injuries. 3.2. Management strategies Table 3 summarizes different types of treatment strategies used for management of injured patients. Upper urinary tract Conservative management was applied for 51.8% of patients with renal injury and 2 patients with grade IV renal injury underwent angiographic embolization. Two patients with adrenal trauma were managed conservatively. Lower urinary tract Nineteen cases out of 27 patients with extra peritoneal blad- der rupture were managed conservatively, by foley catheter insertion for two weeks. In one case with extra peritoneal bladder rupture, during orthopedic surgery bladder was in- jured intra peritoneally so cystoraphy was done intraopera- tively. Fourteen of 25 patients with testis trauma had intact tunica albuginea and underwent conservative management. Three patients needed dermal flap to reform scrota because This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7 (1): e63 Table 2: Distribution of urogenital injuries among the studied sub- jects Injured organ Number (%) Upper urinary tract Renal 155 (58.1) Ureter 3 (1.1) Adrenal 2 (0.7) Lower urinary tract Scrotum 43 (16.1) Testis 25(9.3) Urethra 15(5.6) Bladder 34 (12.7) Genitalia 25 (9.9) Severity of renal injury Grade 1 103 (38.5) Grade 2 34 (12.7) Grade 3 10 (3.7) Grade 4 5 (1.8) Grade 5 3 (1.1) Type of bladder injury Intra peritoneal injury 7 (2.6) Extra peritoneal injury 27 (10.1) Type of ureteral injuries Partial rupture of urethra 10(3.7) Complete rupture of urethra 5(1.8) Table 3: Management strategies of studied patients Variables Number (%) Type of management Conservative management 207(77.5) Operative management 52(19.4) Type of procedures Nephrectomy 7(2.6) Bladder repair 8(2.9) Immediate endoscopic realignment 10(3.7) Renoraphy 10(3.7) Ureter repair 2(0.7) Partial orchiectomy 5(1.8) Male genital organ repair 8(2.9) Female genital organ repair 2(0.7) of extensive external genitalia injuries. Nine men and one girl with external genitalia injuries were managed conserva- tively. Ten of fifteen patients with urethral injuries underwent primary realignment (seven cases had complete urethral in- juries). For five patients cystostomy was performed and they became candidates for delayed treatment. 4. Discussion According to our results, the frequency of UGIs in this series of cases was 1.9%. The most common injured sites of uro- genital system were kidney with 155 (58%) cases, followed by external genitalia with 91 (34.1%) cases. 77.5% of cases were managed conservatively. Appropriate data are needed to assess clinical presentation, therapeutic procedure, trauma systems issues, and quality of care for this health problem (19). According to burden of disease and injuries, 28% of years of life lost in Iran is attributed to accidents (20). This issue may point out that Emergency Medical Service is not able to provide trauma patients with efficient and perfect pre-hospital care (21). The condition of trauma possibly de- pends on the space from hospital to high ways, socioeco- nomic status, grade of hospital as trauma center, and public health infrastructure mainly in prehospital trauma care (22, 23). Abundance of construction projects may be the reason that falling down is the second most common cause of in- juries. According to the obtained results from this study, UGIs com- prise a low proportion of injuries in trauma patients (267 of 24742 patients, about 2 %). This is similar to the find- ings of other studies (10, 14, 24-26). Presentations of in- jured patients were similar to those in the literature. Regard- ing gender, the males enrolled were four times the females, and mainly prevalent in the 3rd decade of life (14, 17, 27- 29). This may owe to men working in more risky jobs, be- ing more involved in violent behavior and also number of male drivers being more than females (30). Most traffic ac- cidents involved middle-aged victims, while the pedestrian accidents involved older age patients. Road traffic accidents are the cause of the majority of UGIs; trauma had a blunt nature in 92.5% of patients, which is almost similar to other studies (13, 31-34). Moreover, kid- ney was the most common injured organ and kidney re- pair was the most common surgical treatment in this study. The haemodynamic condition is the point of reference for the diagnostic and therapeutic approach in trauma patients. Haemodynamically unstable patients need urgent laparo- tomy (35). Initial treatment of patients with posterior urethral injuries (PUI) is one of the most challenging and technically difficult problems in urology (36). The controversy in treatment of PUI is surrounding two basically different approaches; one is the insertion of suprapubic cystostomy followed by a de- layed urethroplasty; and the other approach is concomitant one stage suprapubic cystostomy and urethral realignment (37, 38). Advances in endoscopic techniques have facilitated early realignment and transurethral catheterization as a new treatment approach. In the present study, two thirds of the urethral injury cases underwent primary realignment and the rest became delayed urethroplasty candidates after cys- tostomy. Skin and tissue defects are another problem in pa- tients with trauma. Grafts can be utilized for extended skin and tissue defects (39, 40). Complete avulsion of the scrotum and penis skin, creates a very serious life-threatening prob- lem. Also, there is a serious problem in saving the testes, cov- ering the penis and rehabilitation of area function. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Javanmard et al. 4 There are two types of bladder ruptures: intraperitoneal and extraperitoneal. The extraperitoneal ruptures are often as- sociated with pelvic fractures. Intraperitoneal ruptures often happen as a result of frontal impact, with unexpected decel- eration while having a full bladder (24). The two most com- mon symptoms of bladder injuries are macroscopic hema- turia and abdominal tenderness. Other findings consist of inability to void, bruising of the supra-pubic region, and con- trast extravasations in computed tomography (CT) urogra- phy. Pelvic fractures, which are associated with multiple or- gan injures, including bladder, have a considerable mortal- ity rate (20–40 %) (11, 41). According to our findings, due to the low rate of positive imaging findings in stable trauma pa- tients with microscopic hematuria, it seems that there is no need to routinely perform abdominopelvic CT scan with in- travenous contrast in these patients. Since most cases with urogenital trauma have multiple in- juries, they need a multidisciplinary approach; disregard- ing these injuries may cause severe complications. We pro- pose establishing an integrated trauma system in Iran to im- prove the quality of trauma care. Also, preventive programs aimed at behavioral modifications in the society should be performed to decrease the health and economic burdens im- posed by accidents. 5. Limitation The first limitation of this investigation is the retrospective nature of the study, which caused some missing medical his- tory and physical examination data. The second limitation is the lack of follow up assessments of disease adjusted life years. 6. Conclusion UGIs mostly result from blunt trauma due to road traffic acci- dents. Renal injuries are the most common; and UGI mostly develops in youth. Conservative management can be the treatment of choice for renal trauma patients who are hemo- dynamically stable. 7. Appendix 7.1. Acknowledgements We would like to show our appreciation towards urology and emergency ward staff for their invaluable help throughout this study. We gratefully appreciate medical record depart- ment staff of Shohada e Tajrish hospital for their kind coop- eration. We would like to express our sincere gratitude to Dr. Saeed Montazeri for his valuable assistance in English editing of the manuscript. 7.2. Author contribution Study concept and design: All Authors. Acquisition of data: Dr. Fallah-karkan, Dr. Ghiasi Statistical analysis: Dr. Ghiasy, Dr. Vafaee. Drafting of the manuscript: Dr. Fallah-karkan, Dr. Ghiasi and Dr. Ansari. Critical revision of the manuscript: All Authors. 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Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitation Conclusion Appendix References