Epidemiologic Study of 284 Patients with Urogenital Trauma in Three Trauma Center in Tehran SALIMI J, NIKOOBAKHT MR, ZAREEI MR Trauma and Surgery Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran ABSTRACT Purpose: To perform an epidemiologic study of urogenital injuries in traumatic patients who were referred to three traumatic centers in Tehran during one year. Materials and Methods: This study included a part of data of National Trauma Registries, which was performed within one year. Questionnaires were completed by trained staff in three different geographical regions of Tehran: Shohada-e-Tajrish hos- pital (north of Tehran), Sina hospital (south of Tehran), and Shaheed Faiazbakhsh (west of Tehran). Results: Two hundred and eighty four (5%) out of 57367 patients who were referred to the above mentioned centers had genitourinary trauma, of whom, 145(42%) were hospitalized. Males with a frequency of 92% (258 patients) were the most injured group. Patients mean age was 25±14 years, mostly between 20 and 29 years (33.6%) followed by 10-19 years age group with a frequency of 25.6%. Non-penetrating trauma with a frequency of 96% was the most common type and accident was the most mech- anism of trauma. One hundred and one patients out of the studied population had associated injuries. The most frequent injuries were occurred in extremities (40%) and the less in head and neck (7%). There were 22 (21.7%) intra-abdominal organ injuries. Sixty nine percent of patients developed mild injury (ISS<7), 20% developed severe injury and (ISS>12), and 4.2% of patients died. The most common injured organ was kidney (3.3%) and the least one was ureter, as no ureteral injury was reported. Conclusion: Although a low percentage of traumatic patients develop urogenital injuries, disregarding these injuries may lead to serious complications and it is recom- mended to consider these injuries while dealing with such patients. Considering the fact that these complications which could be preventable, are mostly developed in the youth, making solution for such problem is recommended. KEY WORDS: urogenital system trauma, epidemiology, Tehran, injury severity 47 Urology Journal UNRC/IUA Vol. 2, 47-50 Spring 2004 Printed in IRAN Introduction Trauma is considered as the main reason for mortality in the ages between 1 and 44 years in the United States, and some believe that it is the first reason of mortality for this age group world- wide. The rate of injuries leading to disability is 2.5 times as many as the mortality caused by trau- ma.(1) Urogenital system injuries are seen in 10% of traumatic patients and mostly in patients with multiple trauma and severe trauma of lower parts of abdomen or pelvis. The prevalence of uretrogen- ital injuries has been reported between 10 and 30% in adults and less than 3% in children.(1) Blunt trauma is the cause of more than 90% of such injuries(2,3) and damages caused by sports and accidents are among common causes of such injuries. Penetrating trauma caused by knife and gunshut comprises the highest percentage of injuries factors.(3) Renal injury is the most common injury in ure- trogenital system. Renal trauma in traumatic patients who were referred to hospital comprises 3% and is detected in 8-10% of patients with Accepted for publication in August 2003 EPIDEMIOLOGIC STUDY OF 284 PATIENTS WITH UROGENITAL TRAUMA IN THREE TRAUMA CENTER IN TEHRAN abdominal trauma.(4) Ninety percent of renal injuries are due to blunt trauma. Accidents, falling and being hit are the most fre- quent of non-penetrating injuries, whereas bullet and stab wounds are the most common cause for penetrating injuries.(5) There is no need for surgical exploration in 80% of blunt trauma; while, penetrating trauma mostly needs surgery.(5,6) Etiologically, most ureteral injuries are caused by penetrating trauma which are mostly resulted from stab wound or gunshot.(5,6,7) Bladder injuries are rarely caused by trauma and mostly developed by pelvic fracture. In 5-10% of pelvic fractures, uri- nary tract injuries are seen.(8) Although such trau- mas are not mostly life threatening, they can lead to sexual dysfunction or urinary tract disorders; surely, the study of these organs has a great importance, when patient's vital signs are unsta- ble.(2,3) At the evaluation of patients with multiple traumas, the probability of urogenital injuries should be considered in all cases, so that they could be detected at early stages.(5) In this article the frequency of urogenital injuries and their eti- ologies were studied in three medical centers. Materials and Methods The data of this article are based on the approved National Proposal of Demographic Study and Evaluation of Injury Severity in Traumatic Patients according to ISS (Injury Severity Score) and general success rate of medical measures which were carried out multicenterally at Tehran. This prospective cross-sectional study was per- formed at three medical centers: Shohada-e- Tajrish, Sina, and Faiazbakhsh hospitals in 1996 in accordance with Trauma and Registry of American College of Surgeons (TRACS) and National Trauma Data Bank (NTDB). The reason for choosing these three centers was the pattern of patients referral in Tehran, as patients at the north of Tehran are referred to Shohada-e-Tajrish hospital, at the south are referred to Sina hospital and at the west are referred to Faiazbakhsh hospital. Data collection was carried out according to a designed questionnaire form and by trained physi- cians who filled in the forms of whole referred traumatic patients to the above mentioned cen- ters, 24 hours a day. Direct observation and inter- view were the method of data collection. The trained physicians became familiar with data col- lection process during several sections. A total of 57367 patients were referred to these centers with- in one year, 4497 of whom were hospitalized. Those traumatic patients whose urogenital injury was detected by paraclinical investigations and physical examinations, were enrolled in this study and those whose urogenital injury was not proved definitely, were excluded from the study. Finally, 284(5%) patients with urogenital injury entered the study. The collected data included demographic charac- teristics, trauma mechanism, type of injury, sever- ity of injury and associated injuries. These data were collected in a designed data bank and were analysed with SPSS 10.01. t test was used to com- pare the means of constant quantitative variables and Chi-Square test or Fisher's exact test were used to compare qualitative variables. Results From a total of 57363 traumatic patients who were referred to the above mentioned hospitals, 4497(7%) patients were hospitalized and 52780(93%) were followed outpatiently. Genital injury was seen in 284(5%) patients, 125(44%) of whom were hospitalized, which consisted of 2.8% of the total hospitalized traumatic patients. Two hundred sixty one (92%) patients were males and 23(8%) were females (P<0.01). Patients mean age was 25±14 years. The highest incidence (33.6%) was seen in 20-29 years age group followed by 25.6% in 10-19 age group and 13.4% in 30-39 age group (fig. 1). The frequency of blunt trauma was 96% and penetrating was 4%. Non-penetrating trauma, the most common mechanism of trauma, was observed in 139 (48.9%) of cases, vehicle accidents in 75(26.5%) the most common of which were passenger accidents (39%), and falling from a high level in 39 (12.9%) (table 1). Of the patients, 43.1% were injured of street and 25.4% at their work. (table 2). 48 FIG. 1. The distribution of age group in the studied urogenital injured patients 0 20 40 60 80 100 10 20 30 40 50 60 70 Age group F r e q u e n c y EPIDEMIOLOGIC STUDY OF 284 PATIENTS WITH UROGENITAL TRAUMA IN THREE TRAUMA CENTER IN TEHRAN Mean ISS was 7±3.1. Mild injury (ISS<7) was seen in 69%, moderate injury (712) in 20% of patients. One hundred and one (35.5%) patients had asso- ciated injuries, as well. Extremities injuries were seen in 41(40%) patients, organs and abdominal viscera injuries in 22(21.7%), chest injury in 18(17.8%), vertebral column injury in 13(12.8%) and head injury in 7(6.9%). The cause of injury was accident in 84(29.6%) patients and conflict and hitting others in 51(81%) (fig. 2). Renal traumas was reported in 94(33%) of patients, scrotal trauma in 91(32%) and urethral trauma in 16(5.6%), 2 of whom developed complete urethral rupture (table 3). Twelve (4.2%) patients died (ISS>R) in whom renal injury was the most common genital injury, reported in 7(40%). Discussion According to the obtained results from this study, urogenital injuries develop in a little por- tion of traumatic patients. This is similar to the findings of other studies. The considering point is that 20-30 years age group was the most common age group was the most common age group includ- ed in this study, may be because of trauma pattern which mostly affects the youth, though no differ- ence is seen in the outcome of disease. However, since these injuries may lead to urogenital dys- function, neglecting them could cause serious sequelae.(2) Regarding gender, males were enrolled 11 times more than females in this study which might be because of socio-cultural condition of the patients, as females mostly spend their time at home. Statistically, the rate of mortality and temporary disability in the studied patients in different age groups was not statistically different. Trauma was blunt in 96% of patients which is almost similar to other studies;(3,4) moreover, kid- ney was the most common injured organ. According to the type of trauma in renal and scro- tal injuries, there was a significant difference between injured organs and the reason of trauma, injuries were mostly caused by blunt trauma (p<0.05). Moreover, ureteral injuries were the less 49 TABLE 1. The distribution of frequency of trauma mechanism in the studied patients with urogenital injuries Trauma mechanism No. Percentage Accident Falling from high level Non-penetrating objects Penetrating objects Bullet Others 75 36 139 10 1 20 26.5 13.8 48.9 3.5 0.4 7 Total 284 100 FIG. 2. The distribution of Frequency of Urogenital injury according to the cause of accident in the studied traumatic patients 0 5 10 15 20 25 30 Kidney Scrotum Bladder Urethra Uterus Testis Penis Others Accident Conflict Type of injury Cause of trauma N u m b e r TABLE 2. The distribution of place of accident frequency according to the gender of the studied urogenital injured patients Gender Place of Accident Male Frequency (%) Female Frequency (%) Total Frequency (%) Home Street Place of work General places Others 51(20.1%) 109(42.9%) 70(27.6%) 3(1.2%) 21(8.3%) 9(40.9%) 10(45.5%) --- --- 5(22.5%) 60(21.7%) 119(43.1%) 70(27.6%) 3(1.2%) 26(8.7%) Total 254(100%) 24(100%) 278(100%) TABLE 3. The distribution of urogenital injuries frequency in the studied traumatic patients Place of injury Frequency (%) Renal injury - Renal contusion with hematuria - Subcapsular hematoma without laceration - Renal parenchymal laceration 94(33.1) 81 6 7 Bladder injury - Contusion and hematoma - Bladder laceration 9(3.2) 3 6 Scrotum - Contusion, scratching, superficial cutting - Vast rupture 91(32) 89 2 Urethra - Contusion Superficial injury without extravasation - Superficial rupture with extravasation - Complete rapture of urethra 16(5.6) 10 2 2 2 Testis 19(6.7) Male genital organ - Contusion - Superficial laceration - Vast and deep laceration 26(9.2) 14 6 6 Female genital organ 5(1.8) Others 24(8.5) Total 284(100) EPIDEMIOLOGIC STUDY OF 284 PATIENTS WITH UROGENITAL TRAUMA IN THREE TRAUMA CENTER IN TEHRAN common injuries caused by blunt traumas, this was similar to foreign studies results (5,6). Injury of external genitalia in scrotum had a considerable incidence and there was a significant difference between accident and hitting others according to the reason of trauma (p<0.05). Due to unavailability of gunshot and heavy punishment for illegal use of them, penetrating injury rate is low and gunshot consists of the lowest mechanism of trauma. Only 20% of patients developed severe injury (ISS>12), low percentage out of whom needed sur- gical exploration, this finding was similar to the findings of other studies.(5,6) Conclusion Although according to the conclusion of our and other studies, urogenital injuries comprise a low percentage of injuries of traumatic patients, disre- garding these injuries may lead to serious compli- cations and it is recommended to consider these injuries while dealing with such patients. In regard to the fact that these complications are mostly developed in youth and they could be pre- ventable, making solution for this problem is rec- ommended. 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