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泌尿生殖系统钝挫伤：初步评估和治疗

Author
Michael S Runyon, MD, MPH
Section Editors
Maria E Moreira, MD
Richard G Bachur, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM
Translators
杜岳峰, 副教授

引言

及时发现和处理泌尿生殖系统(genitourinary, GU)的钝性损伤，可使相关的并发症减至最少，并发症可能包括尿失禁和性功能障碍。快速发现损伤取决于系统性评估，评估内容包括：损伤的机制、相关的体格检查发现、尿液分析以及适当的诊断性影像学检查，这些评估要按正确顺序进行。

除在罕见情况下，可发生肾粉碎伤或肾脏大血管撕裂伴大出血外，泌尿生殖系统损伤很少危及生命。一旦危及生命的病情已经稳定，应以一种逆向的方式检查泌尿生殖系统损伤，首先评估外生殖器和尿道，然后评估膀胱。在排除下泌尿生殖道损伤后，或对明确的下泌尿生殖道损伤开始进行适当的急诊处理之后，对输尿管和肾脏进行评估。

本专题将讨论钝挫伤导致的泌尿生殖系统损伤的诊断及处理。关于一般创伤和其他特定损伤的处理，将在别处讨论。 (参见“成人创伤的早期处理”和“成人腹部钝挫伤的初始评估和处理”和“骨盆创伤：初步评估与处理”)

流行病学

在严重受伤以致于需入院接受创伤治疗的患者中，10%的患者存在泌尿生殖系统损伤。这些损伤大多(约80%)是由钝挫伤导致的。常见的损伤机制包括：机动车辆碰撞(motor vehicle collisions, MVC)、高处坠落、以及躯干或外生殖器受到直接打击。女性生殖器损伤经常伴有骨盆骨折。

其他重要的机制包括：身体攻击或性侵犯、双方自愿的性行为、以及穿通伤。对于成人患者，单纯的外阴钝性损伤少见，当出现这种情况时，提示医生应筛查人际暴力。在男性中，多达85%的睾丸损伤是由钝挫伤导致的。所导致的损伤包括血肿、破裂、移位和扭转。阴茎折断是一种不常见的损伤，是由白膜破裂导致的，在高达20%的病例中，同时伴有尿道损伤[1-4]。总体而言，骨盆骨折伴尿道损伤的比例在女性中约为5%，在男性中高达25%；其风险随骨折程度的不同而不同[5,6]。钝性损伤占膀胱创伤的大部分，多数膀胱破裂的病例伴有骨盆骨折[1,7]。 (参见“骨盆创伤：初步评估与处理”)

                     

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Literature review current through: 2017-06 . | This topic last updated: 2017-03-02.
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References
Top
  1. Lynch TH, Martínez-Piñeiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol 2005; 47:1.
  2. Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: external genitalia. BJU Int 2004; 94:507.
  3. Mydlo JH, Harris CF, Brown JG. Blunt, penetrating and ischemic injuries to the penis. J Urol 2002; 168:1433.
  4. Swanson DE, Polackwich AS, Helfand BT, et al. Penile fracture: outcomes of early surgical intervention. Urology 2014; 84:1117.
  5. Chapple CR, Png D. Contemporary management of urethral trauma and the post-traumatic stricture. Curr Opin Urol 1999; 9:253.
  6. Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999; 161:1433.
  7. Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int 2004; 94:27.
  8. Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radiographics 2000; 20:1373.
  9. Siram SM, Gerald SZ, Greene WR, et al. Ureteral trauma: patterns and mechanisms of injury of an uncommon condition. Am J Surg 2010; 199:566.
  10. Koifman L, Barros R, Júnior RA, et al. Penile fracture: diagnosis, treatment and outcomes of 150 patients. Urology 2010; 76:1488.
  11. Andrich DE, Mundy AR. The nature of urethral injury in cases of pelvic fracture urethral trauma. J Urol 2001; 165:1492.
  12. Dorschner W, Biesold M, Schmidt F, Stolzenburg JU. The dispute about the external sphincter and the urogenital diaphragm. J Urol 1999; 162:1942.
  13. Gerstenbluth RE, Spirnak JP, Elder JS. Sports participation and high grade renal injuries in children. J Urol 2002; 168:2575.
  14. Gottenger EE, Wagner JR. Penile fracture with complete urethral disruption. J Trauma 2000; 49:339.
  15. Goldman HB, Idom CB Jr, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol 1998; 159:956.
  16. Lev RY, Mor Y, Golomb J, et al. Missed female urethral injury complicated by myonecrosis of the thigh. J Urol 2001; 165:1216.
  17. Lowe MA, Mason JT, Luna GK, et al. Risk factors for urethral injuries in men with traumatic pelvic fractures. J Urol 1988; 140:506.
  18. Basta AM, Blackmore CC, Wessells H. Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma. J Urol 2007; 177:571.
  19. Aihara R, Blansfield JS, Millham FH, et al. Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures. J Trauma 2002; 52:205.
  20. Watnik NF, Coburn M, Goldberger M. Urologic injuries in pelvic ring disruptions. Clin Orthop Relat Res 1996; :37.
  21. Pokorny M, Pontes JE, Pierce JM Jr. Urological injuries associated with pelvic trauma. J Urol 1979; 121:455.
  22. Avey G, Blackmore CC, Wessells H, et al. Radiographic and clinical predictors of bladder rupture in blunt trauma patients with pelvic fracture. Acad Radiol 2006; 13:573.
  23. Morey AF, Iverson AJ, Swan A, et al. Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma 2001; 51:683.
  24. Morgan DE, Nallamala LK, Kenney PJ, et al. CT cystography: radiographic and clinical predictors of bladder rupture. AJR Am J Roentgenol 2000; 174:89.
  25. Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol 2003; 170:1213.
  26. Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med 2007; 50:25.
  27. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma 2005; 59:1314.
  28. Ball CG, Jafri SM, Kirkpatrick AW, et al. Traumatic urethral injuries: does the digital rectal examination really help us? Injury 2009; 40:984.
  29. Johnson MH, Chang A, Brandes SB. The value of digital rectal examination in assessing for pelvic fracture-associated urethral injury: what defines a high-riding or nonpalpable prostate? J Trauma Acute Care Surg 2013; 75:913.
  30. Shlamovitz GZ, McCullough L. Blind urethral catheterization in trauma patients suffering from lower urinary tract injuries. J Trauma 2007; 62:330.
  31. Spencer Netto FA, Hamilton P, Kodama R, et al. Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury. J Am Coll Surg 2008; 206:322.
  32. Mee SL, McAninch JW, Robinson AL, et al. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. J Urol 1989; 141:1095.
  33. Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol 2014; 192:327.
  34. Haas CA, Brown SL, Spirnak JP. Limitations of routine spiral computerized tomography in the evaluation of bladder trauma. J Urol 1999; 162:51.
  35. Hsieh CH, Chen RJ, Fang JF, et al. Diagnosis and management of bladder injury by trauma surgeons. Am J Surg 2002; 184:143.
  36. Morey AF, McAninch JW, Tiller BK, et al. Single shot intraoperative excretory urography for the immediate evaluation of renal trauma. J Urol 1999; 161:1088.
  37. Bandi G, Santucci RA. Controversies in the management of male external genitourinary trauma. J Trauma 2004; 56:1362.
  38. Jones AE, Mason PE, Tayal VS, Gibbs MA. Sonographic intraperitoneal fluid in patients with pelvic fracture: two cases of traumatic intraperitoneal bladder rupture. J Emerg Med 2003; 25:373.
  39. Fraser JD, Aguayo P, Ostlie DJ, St Peter SD. Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int 2009; 25:125.
  40. Santucci RA, Langenburg SE, Zachareas MJ. Traumatic hematuria in children can be evaluated as in adults. J Urol 2004; 171:822.
  41. Santucci RA, McAninch JW, Safir M, et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma 2001; 50:195.
  42. Sangthong B, Demetriades D, Martin M, et al. Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank. J Am Coll Surg 2006; 203:612.