Profiling genitourinary injuries in United Arab Emirates

Abstract

Background:

The epidemiology of genitourinary (GU) organ injury following general trauma is not well-studied especially in the Middle East.

Patients and Methods:

All patients with GU injuries from the Trauma Registry of Al-Ain Hospital were studied. The registry data was prospectively collected from March 2003 to March 2006.

Results:

Out of 2573 patients in the registry, 22 had GU injuries (incidence: 0.9%, 2.0 per 100,000 inhabitants per year). Road traffic collision was the most frequent mechanism of injury (50% of all cases). 41% of injuries were renal. In 73% of patients, GU injuries were associated with other organ injuries, the most frequent of which were injuries to the other abdominal and pelvic organs (94%). The mean Injury Severity Score, mean total hospital stay, the percentage of patients who required intensive care unit (ICU) admission were higher in patients with GU injuries compared to non-GU patients (17.1 vs. 5.5 (P 0.001), 15.4 vs. 9.2 days (P 0.040) and 43% vs. 8%, (P 0.0001), respectively.

Conclusions:

The incidence of trauma-related GU injuries in the current study appears to be comparable to those reported from the West. Patients with GU organ injuries tend to have more severe trauma compared to other patients. Road traffic collision was the most common mechanism of injury and the kidney was the most frequently injured organ.

INTRODUCTION

The epidemiology and nature of the genitourinary (GU) trauma have not been well-studied worldwide. In the west, one of the very few studies in this field was the one by Bariol and colleagues who reported a 1.5% incidence of GU trauma in Scotland.[1] In several other countries, this data is not available especially to those working in the emergency services. Middle East is not an exception with very few reports addressing this issue, the majority of which were war-related injuries.[2–5] Furthermore, most of the available data described the GU injuries among soldiers and not among civilians.[2–4] Obviously, the mechanisms of trauma in the Middle East are different from those in the west, and hence it is possible that the epidemiology of genitourinary trauma could be different from those reported from the west. Thus, the aim of this study was to report on the incidence and nature of genitourinary injuries from a high income developing country in the Gulf region using our civilian general trauma registry.

PATIENTS AND METHODS

All patients with genitourinary injuries from the Trauma Registry of Al-Ain Hospital were included in this study. The registry data were prospectively collected over a period of three years (March 2003 to March 2006) and included all patients with trauma who were admitted to the hospital or died in the Emergency Department. During the study period, Al Ain Hospital treated around 80% of the trauma cases at Al Ain city which had a population of 463,000 inhabitants.[6] The data collection was approved by the local ethics committee. The data collected included the patient's age, gender and other personal details. It also included the mechanism of injury, the status of the patient at the scene and at the time of arrival to the emergency room, the injury severity score (ISS), type and management of genitourinary injuries, hospital stay and the final outcome. The ISS was used as a global measure of injury severity. ISS was calculated manually using the abbreviated injury scale handbook.[7] ISS is an anatomical score, which provides a single aggregate number that combines all injuries of the body. It was derived from the Anatomical Injury Score (AIS), which divides the body into six separate anatomical regions and assigns each a severity score that ranges between 1 and 5. The ISS was calculated as the sum squares of the three highest AIS scores from different regions and it ranges between 1 and 75.[8]

Statistical analysis was performed using the predictive analytics softWare (PASW) statistics 18, statistical package for the social sciences (SPSS) Inc, USA. Univariate analysis to compare patients with and without GU was performed using Mann-Whitney test for continuous or ordinal data and Fisher's exact test for categorical data. A P value of <0.05 was considered statistically significant.

RESULTS

Out of 2573 patients in the general trauma registry, 22 patients had GU injuries with an incidence of 0.9%. Since only around 80% of the trauma in Al-Ain City presented to our hospital, the calculated incidence in Al-Ain City was 2.0 per 100,000 (1 per 51,000) inhabitants per year. The mean age was 31 years (range: 8-57 years). Five patients were younger than 18 years old. There were 21 males and one female and there was no gender statistical difference between those with and those without GU injuries (male:female; 21:1 vs. 6:1, P=0.47). Road Traffic Collision was not only the most frequent mechanism of injury encountered in our general trauma registry (41% of all trauma cases; adults: 87%; children: 13%), but was also the commonest mechanism of trauma among patients with GU injuries. Other mechanisms of GU injuries are shown in Table 1. Out of the 11 patients who had road traffic collision-related GU injuries, there were 10 adults (91%) and one child (9%) with no difference between the two age groups in their susceptibility to GU injuries when involved in road traffic collision (P0.31). Table 2 shows the genitourinary organs involved and the type of injuries, and renal injuries accounted for 41% of all injuries. Only two renal injuries (22%) were severe (grade IV and V) for which one patient required nephrectomy. The rest were treated conservatively. Both bladder injuries were extraperitoneal, managed with bladder drainage and were associated with pelvic fractures. Similarly, the three out of the four urethral injuries involved complete disruption of the membranous urethra and were associated with pelvic fractures. The fourth urethral injury was in the anterior part. Two testicular injuries were in the form of hematoma for which one required exploration. In the third case, the testis was totally damaged and required orchiectomy. Three scrotal wall injuries were managed with debridement and primary repair of the skin and the fourth injury was in the form of second degree scrotal skin burn. The single posterior vaginal wall injury was managed with debridement and primary repair.

Table 1.

The mechanisms of trauma encountered in patients with genitourinary organ injuries in the civilian general trauma registry during the study

Table 2.

Type and grade of genitourinary organ injuries in the general trauma registry during the study

Out of the 22 patients with GU injuries, six patients (27%) had ‘isolated’ genitourinary organ injuries. Sixteen patients had other associated injuries. As demonstrated in Table 3, injuries to other abdominal and pelvic organs were the most frequently encountered associated injuries. The mean ISS for the genitourinary patients was 17.1 (median: 18, range: 1-41) compared to 5.5 (median: 4, range: 1-43) for those without GU injuries (P 0.001). Similarly, the total hospital stay was higher in the first group (mean: 15.4 days (median: 10.0, range: 1-93) vs. 9.2 days (median: 5.0, range: 1-150), respectively, P 0.040). In addition, the percentage of patients who required ICU admission was higher in GU patients compared with patients with no such injuries (43% vs. 8%, respectively, P 0.0001).

Table 3.

Incidence of non-genitourinary injuries associated with genitourinary organ injuries during the study

DISCUSSION

The epidemiology of genitourinary trauma is not well-studied and most of the studies in this field report on the incidence of a single organ injury. For instance, Wessells et al. reported on 6231 renal injuries (incidence: 1.2%; 4.89 per 100,000 population) out of 523,870 patients who were hospitalized for trauma in 1998 and 1999 in one of the American series.[9] McAleer and colleagues also reported an incidence of 2.6% for renal injuries among 14,763 children who presented to the emergency department in United States of America.[10] Nevertheless, the incidence of overall genitourinary organ injury in trauma is far less reported. Bariol et al. examined data on patients with severe trauma presenting to all major Scottish hospitals.[1] They studied 24,666 trauma admissions from 1999 to 2002, and 362 patients were found to have genitourinary injuries, comprising 1.5% of the trauma population.

The Middle East is not an exception and adequate data on genitourinary trauma is lacking. Obviously, the socio-demographic factors are different from those in the west and may affect the incidence and nature of genitourinary injuries. In a report from Iran, Salimi and colleagues reported a 0.5% incidence of genitourinary injuries from a general trauma registry.[11] However, the socio-demographic factors differ among various countries of the Middle East. In this report, we studied the epidemiology of civilian genitourinary organ injury in a high income developing country in the Gulf, where such information is lacking.

The incidence of genitourinary trauma in our registry was comparable to those reported from Scotland (1 per 51,000 vs. 1 per 45,000 inhabitants per year, respectively).[1] The similarity between the two series was also associated with a comparable proportion of cases exposed to the most frequent mechanism of injury (road traffic collision; 50% compared to 54% in the Scottish group). In addition, the proportion of the organs involved was comparable between the two series with the kidney injury being the most frequently encountered injury in both series.

From the current study, it is obvious that genitourinary injuries are associated with more severe trauma as indicated by the higher ISS among these patients compared to other patients without genitourinary injuries. Other parameters of severity such as the total hospital stay and the percentage of patients who required ICU admission were also higher in the genitourinary patients.

Interestingly, two out of the 22 (9%) injuries were animal-related injuries and the camel was the animal involved in both cases. The first patient was kicked by the camel which resulted in scrotal wall injury and associated hydrocele. In the second case, the patient fell down from the animal on a hard object leading to a pelvic bone fracture and a posterior urethral injury. This is not surprising as camels have been shown to cause some of the most severe types of injuries[12,13] and more strict regulations are required to be implemented by the camel farms.

Children formed 23% of our patients with genitourinary injuries. This is similar to the proportion of children in our population during the study period (26%, P=1.0).[14] In addition, their susceptibility to road traffic collision-related GU injuries was not different from adults. Collectively, this data might indicate that children are not more susceptible to genitourinary trauma compared to adults, although there is some evidence from the literature to suggest that children are more susceptible to major renal injury following blunt trauma compared with adults.[15] This discrepancy is difficult to explain from the results of the current study. One possible explanation could be that although children are more susceptible to more severe injuries following major trauma, this is not the case when all genitourinary injuries are taken into consideration. Alternatively, the discrepancy could be due to the small numbers in the current study.

One of the limitations of this study is the relatively small number in the registry especially when compared to the one reported by Bariol et al.,[1] which studied only patients between 13-65 years of age. However, in our study, the data was collected prospectively from all age groups with their detailed mechanisms of injury. Furthermore, the data which were collected was verified by an urologist (first author). This also included reviewing the radiological images. Collectively, and despite the relatively small number in the registry, this research would help to increase trauma awareness in the community, stimulate the development of relevant legislations followed by enforcing these laws by the appropriate authorities to implement several safety measures such as the use of seatbelts in an attempt to decrease the incidence of road traffic collisions-related injuries.[16] For instance, currently, there is no national law to enforce child restraints and the seatbelt law applies only to front seat passengers.[17] As a result, the overall seatbelt compliance was found to be 11%. Only 4% of children in front seats and 1% in the rear were found to be restrained.[18] Nevertheless, due to the increased community awareness, it is anticipated that a child safety seatbelt law would be implemented in the near future.[19] Other safety measures include car airbags. Currently, there is no formal data on the presence of airbags in the cars in our area but the majority of cars are relatively modern and hence are expected to have airbags in them.

CONCLUSION

This study represents the first report of the incidence of genitourinary injuries from a civilian general trauma registry in a high-income developing country from the Gulf region. From the available evidence, it appears that the incidence is comparable to those reported from the West. Patients with genitourinary organ injury tend to have more severe trauma compared to other patients. Finally, road traffic collision was the most frequent mechanism of injury and the kidney was the most frequently injured organ.