Genitourinary Trauma in Disaster Situations:  The  Haitian  Earthquake of January 12, 2010

* Angelo E. Gousse, MD, 2011.

Disasters can be environmental or man-made. Environmental  disasters  include  flooding, hurricanes, tornadoes, landslides and earthquakes. Man-made disasters include industrial accidents, terrorism and warfare.  The Haitian earthquake of January 12, 2010 was an environmental disaster of horrific proportion, accounting for over 230,000 deaths and an estimated 300,000 injuries1. The epicenter of the earthquake was located approximately 25 kilometers west of Port-au-Prince, and while the initial tremor was 7.0 on the Richter scale, there were 59 aftershocks greater than a 4.0 magnitude2.

By far the majority of injuries after this and other similar earthquake disasters are orthopedic; however, the genitourinary system is one of many bodily systems which are susceptible to either blunt or penetrating trauma as a result of disasters and is often overlooked.  It is important to recall the close proximity  of  genitourinary  organs  to  associated bony anatomical structures.   Rib fractures and transverse spinal process fractures with or without flank hematoma are a sign of significant intra- abdominal organ injury in 44% of cases 3.   With regard to bladder injury and associated pelvic fracture, one study found 31 of 32 cases of bladder injury also had pelvic fracture 4.   Genitourinary trauma occurs at a frequent amount enough to warrant  strategies  for  treatment  in  disaster settings.  A similar earthquake to the one in Haiti occurred in Bam, Iran in 2003.   Of 256 patients admitted to the hospitals in the Kerman region after this  earthquake,  28  patients  (11%)  had genitourinary trauma 5. This included pelvic fracture with  urethral  disruption,  urethral  disruption without pelvic fracture, vesicovaginal fistula, renal trauma, and ureteral rupture.

A secondary injury to the genitourinary system can also occur in the case of crush injuries which occur as a result of compression due to entrapment under fallen structures.   This is a notoriously common occurrence after earthquakes in countries with poorly constructed infra-structure.    Entrapment leads to rhabdomyolysis, increased plasma myoglobin, increased filtered load of myoglobin by the kidney, renal injury and failure 6.  This type of secondary injury to the kidney from trauma can commonly lead to the requirement for renal replacement therapy.  In fact, renal failure is the second most common cause of mortality after the direct trauma in crush injury patients 7. It is noted that when preventative treatment strategies are employed and dialysis is available after such disasters, lives can be saved 7.  One of the early- response mobile hospitals in Haiti reported that of 1111 patients triaged at their facility, 126 (11%) had experienced  crush  syndrome  of  varying  severity with the average time a patient was trapped under rubble of 31 hours (median 24, range 2-72) 8.  When renal replacement therapy is unavailable they advocated for conservative treatment for renal failure to be administered which included: volume resuscitation with 5 to 7 liters of normal saline, one ampule of bicarbonate three times per day, high- dose furosemide administration (240 mg/d) and close observation of electrolytes and urine output 8. One potential solution suggested is acute peritoneal dialysis which maybe more readily available and portable after disaster situations that hemodialysis. Unfortunately, even when hemodialysis was available in Port-au-Prince it was under-utilized due to  lack  of  central  communication  coordination  9. The Renal Disaster Relief Task Force (RDRTF) only treated  18  patients  with  hemodialysis  and suggested that better interagency communication and awareness of services was a major lesson learned from this disaster 9.

Another secondary injury to the genitourinary system often overlooked is neurogenic bladder as  it  relates  to  orthopedic  trauma  and  spinal cord  injury.     The  immediate  phase  of  spinal injury causes the bladder to become flaccid whereby it is able to act a reservoir for urine but does not empty.   While this is often managed with indwelling urethral catheter, simplifying the acute disaster bladder management, it typically lasts for only 4-6 weeks and following this period a patient specific regimen for bladder drainage should be implemented according to their particular injury and residual function with the goal for continence and reliable drainage.  In a similar   earthquake   in   Rawalpindi,   Pakistan in 2005, it was estimated that there were 650-750 patients with spinal cord injury 10. One group reported on their experience of 187 spinal cord injured patients who were treated at two makeshift spinal cord rehabilitation centers created to manage the problems associated with acute spinal cord injury 10.   They reported that 91.5% of patients were initially treated with an indwelling catheter and that by 10 weeks after the injury 75% were either continent or performing clean intermittent catheterization 10. This experience hallmarks how disasters create new populations of patients with complex dependencies. Spinal cord injured patients with neurogenic bladder will require techniques and instruments for bladder drainage and this will require a new set materials, physician skills, and appropriate monitoring with renal ultrasounds and urodynamics that may or may not be readily available.

Primary  genitourinary  trauma  is  typically grouped by the structure or structures affected and each type of injury has its own grading scale, evaluation and management recommendations. Consensus statements on the evaluation and management of genitourinary trauma have been established for renal, ureteral, bladder, urethral and external genitalia injuries 11-15.

Renal injuries are progressively graded from I to V  according  to  the  type  and  severity  of  the injury.       Whereas  grade  I  injuries  are characterized by non-expanding hematomas (renal contusions), do not require surgery, and can be managed expectantly; grade V injuries are characterized by renal parenchymal shattering or renal  vascular  pedicle  avulsions  and  are associated with life-threatening bleeding and usually require nephrectomy 11.   Most of the debate that exists for management of renal trauma regards grade IV injury.  Grade IV injuries are divided into two categories:  vascular – main renal   artery   or   vein   injury   with   contained hemorrhage and non-vascular – laceration into the renal medulla or collecting system 16. Hematuria while commonly a sign of genitourinary trauma can be absent when significant  renal  injury  has  occurred (ureteropelvic junction disruption or renal artery thrombosis)  and  is  an  imperfect  marker  for triage 11.  Urinary extravasation from renal injury can be managed with minimal intervention and resolves in > 75% of cases 16.  When it does not resolve on follow-up imaging, urinary extravasation can be managed with minimally invasive procedures including percutaneous drainage  of  urinoma  and  cystoscopy  with ureteral stent placement. Renal angiography and embolisation is becoming a modern mainstay of treatment for many significant renal injuries with hemorrhage reducing the need for surgical exploration, however; these capabilities would likely be limited in triage during medical disaster situations 16.

Ureteral injuries are often difficult to diagnose and because of this result in complications such as persistent abdominal pain, ileus, infection, and fistula; therefore the diagnosis of ureteral injury requires a high index-of-suspicion 16.  They are more commonly seen from iatrogenic causes rather than trauma.   They are classified based on location: ureteropelvic junction, abdominal ureter, and pelvic ureter 12.  Ureteropelvic junction avulsion is more common in children as their spine is more mobile during deceleration events (such as a fall from height).     While  a  child’s  spine  may  be  flexible enough to hyperextend, the fixed renal pedicle cannot  and  it  dissociates  12.    The  instrument  of choice for diagnosis of ureteral injuries is a CT scan with delayed (urographic phase) contrast; however in disaster setting this may not be possible.   A retrograde  pyelogram  could  be  more  easily available than a CT scanner or even more so a 10- minute delay, one-shot intravenous pyelogram whereby you give a patient 2mg/kg of ionic contrast intravenously and obtain a single 10-minute plain film of the kidneys, ureters and bladder 16.  Ureteral repair is often impractical in the setting of acute trauma with instability and aims are made for stabilization and drainage with delayed repair.

Bladder injuries are classified as either extra peritoneal or intra peritoneal which describes the location of abnormal urine leakage due to injury. These are commonly due to blunt trauma with extra peritoneal injuries occurring more commonly than intra peritoneal injuries 4.  While bladder injury is commonly  associated  with  pelvic  fracture  from blunt trauma only about 5% of pelvic fractures are associated with bladder injuries 18.   Retrograde cystogram with oblique and post-drainage views are a key diagnostic test and may be more available in a disaster setting, but CT cystogram is the gold- standard for diagnosis 18.  Of key importance is that the bladder be distended to capacity with contrast otherwise the exam maybe falsely negative. Additional information is gained with the retrograde study with regard to establishing a urethral injury (see below).   In trauma settings in an unstable patient, the diagnosis of a bladder injury can be made by direct inspection during laparotomy, creation of a cystotomy, or by cystoscopy in the operating room 13.   Other signs of a bladder injury are inability to void, suprapubic tenderness, and lower abdominal guarding.  Extra peritoneal injuries can heal with adequate catheter drainage while intraperitoneal injuries are usually closed intra- operatively with two to three layers of absorbable suture.     Adequate bladder drainage with a catheter(s) is necessary for either type of bladder injury and cystogram is typically performed prior to catheter removal but not always necessary 13.

Urethral injuries are categorized into posterior or anterior injuries based on the location of the injury with respect to the genitourinary diaphragm.  Only 2% of urethral injuries occur in women, but 10-17% of urethral injuries are associated with bladder injuries (18).    Like bladder injuries, almost all posterior urethral disruptions occur with pelvic fracture, while only 10% of pelvic fractures have associated urethral injuries 14.  Signs of a urethral injury include blood at the urethral meatus, perineal hematoma  or  penile  ecchymosis,  and  a  “high- riding”  prostate  on  rectal  examination  14. Retrograde urethrogram is again the test of choice and the exam should be performed at an oblique angle.  If there is no available imaging equipment, gentle attempt at placement of a urethral catheter may be attempted, but placement of the catheter into a pelvic hematoma with large bloody fluid drainage  may  be  mistaken  as  intravesical placement.   Posterior urethral injuries have a high risk of incontinence and erectile dysfunction which can be made worse with acute repair 17.  In general posterior urethral disruptions are best treated with urinary  diversion  with  a  suprapubic  bladder drainage followed by delayed reconstruction.  This simplifies  the  initial  approach  to  urethral  trauma and simplifies the tools and instruments needed immediately following a disaster.  Anterior injuries are associated with caused by straddle injuries or a direct perineal injury or penetrating trauma.   They are treated with bladder drainage (urethral catheter or a suprapubic tube) and delayed reconstruction 14.

External  genitalia  injuries  are  more  uncommon than renal, urethral and bladder injuries.  Vaginal lacerations can be seen with pelvic fractures and are commonly associated with bladder and urethral injuries in women 16.  Penile fractures are typically associated with faux-pa-du-coitus and would be uncommon in a disaster situation.   Penetrating trauma  to  the  penis  is  also  rare  but  must  be explored unless superficial or trivial 16.  Scrotal and testicular injuries are more commonly a result of blunt trauma. Testicular rupture is a tear in the tunica albuginea often resulting in extrusion of seminiferous tubules and hematocele (blood within the tunica vaginalis).      If testicular rupture is suspected the scrotum and testicles should be explored 14.   In many cases exposed yet viable seminiferous tubules may be salvaged to help to preserve endocrine and exocrine function 16.

While the exact number of genitourinary injuries following  the  Haitian  earthquake  of  January  12, 2010 is unknown, similar disasters have shown that they occur at about a 10% rate.  Considering the greater than 300,000 injured in this disaster there would be almost 30,000 cases of genitourinary trauma.  Better coordinated efforts to implement rapid, mobile disaster-specific medical units with tools  to  help  disaster  specific  injuries  –  such  as crush syndrome and spinal cord injury after earthquake – are paramount to improved patient survival.    Also relevant is the fallout of an environmental disaster and that it creates a new society  with  specific  medical  and  social  needs. While consensus guidelines for evaluation and management of genitourinary injuries are key tools which can be helpful in disaster scenarios, pragmatism prevails in catastrophe.  These lessons and many more are the legacy of the 2010 earthquake in Haiti.