Pediatric emergency medicine trisk 832

Treatment of intraperitoneal bladder rupture involves surgical exploration and
repair.

Clinical Indications for Discharge or Admission
Children with bladder injuries should be admitted to the hospital for further
operative or nonoperative care.

URETHRA
Goal of Treatment
The goals of the acute management of children with urethral injuries include
identifying the extent and location of the potential urethral injury and, in
consultation with urology, providing safe drainage of the bladder while
minimizing the risk of long-term sequela such as urethral stricture or erectile
dysfunction.

FIGURE 108.4 Sagittal section of male lower urinary tract illustrating levels of urethra.

CLINICAL PEARLS AND PITFALLS


In boys, the urethra is divided by the urogenital diaphragm into an
anterior urethra (pendulous and bulbous) and a posterior urethra
(membranous and prostatic) ( Fig. 108.4 ). Anterior and posterior
urethral injuries differ from each other by mechanism of injury, clinical
presentation, and treatment.
The major sign of acute anterior injury is bleeding from the urethra.
Urethral injury should be suspected when there is blood at the meatus,
hematuria, inability to void, displacement of the prostate on rectal
examination, and/or perineal ecchymosis. Blind placement of a urethral
catheter when urethral injury is suspected is discouraged as it may
theoretically convert a partial tear into a complete transection.

Current Evidence
Blunt trauma, due to motor vehicle accidents, high-velocity falls onto the
perineum, and straddle injuries, accounts for most urethral injuries sustained
during childhood. Injuries due to instrumentation and penetrating injuries, such as
gunshot wounds, are less common. Urethral injuries occur primarily in males.
Anterior urethral injuries result from direct trauma and are often isolated. The
pendulous urethra is well protected from injury when the penis is flaccid, but can
be damaged by blunt or penetrating forces. Bulbar injuries are more common and
most often result from straddle injuries, as the urethra is compressed between the
symphysis pubis and a solid object.
Posterior urethral injuries occur with severe trauma to the body and are usually
associated with other injuries, particularly pelvic fractures. Posterior urethral
injuries in men almost uniformly occur distal to the prostate. In adults, the mature
prostate, puboprostatic ligament, and bladder stabilize the prostatic urethra,
making it less susceptible to trauma. When this occurs, the urethra is usually
sheared at the level of the urogenital diaphragm with separation of the prostate
from the membranous urethra or the bulbar urethra from the membranous urethra.
The mortality rate with fractured pelvis has been reported to be as high as 30%.
Injuries to the prostatic urethra may extend to the bladder neck.
Female urethral injuries are commonly divided into avulsions and longitudinal
tears. These injuries occur most often from blunt abdominal trauma in motor
vehicle accidents and in association with pelvic fractures. Injuries may also occur
after surgical procedures or instrumentation. The diagnosis is missed on initial
assessment in up to 40% of patients, emphasizing the need for careful physical
examination and diagnostic evaluation.


Clinical Considerations
Clinical Recognition

Blood at the meatus has been reported in up to 90% of patients sustaining anterior
urethral injuries. Other findings include hematuria, inability or difficulty voiding,
and periurethral or perineal edema, ballooning and ecchymosis. Perineal
ecchymosis in the shape of a butterfly is typical for these injuries.
Posterior urethral injury may be predicted by the location and displacement of
associated pelvic fractures. There is an association between pubic arch fractures
and urethral injury, with higher risk as the number of broken rami increases. The
classically described “high-riding prostate” is rarely found clinically.
Because the female urethra is relatively mobile and short, trauma to the urethra
is uncommon. It was reported in less than 6% of cases with associated pelvic
fractures in one series of women and girls. When it does occur, it is found more
commonly in girls than in women. In one series, every female patient with a
significant urethral injury had gross hematuria or blood at the introitus and a
pelvic ring fracture. Any female patient with this combination of findings should
be evaluated for a urethral injury. Most serious injuries involve the vesicourethral
junction and extend to the vagina.
Initial Assessment/Diagnostic Testing
Urethral injuries in males can be diagnosed by a retrograde urethrogram (RUG).
The patient is positioned with a bump under one side with the lower leg slightly
bent. A tapered inserter (such as a pediatric Taylor adaptor or angiocatheter) or if
necessary, a Foley catheter appropriate for the size of the patient is inserted into
the urethra to the fossa navicularis. If a Foley is used, the balloon should not be
inflated within the urethra. Contrast material is injected via the catheter to gently
distend the urethra and images are obtained. If a Foley catheter is already in
place, the urethrogram can still be performed via a small feeding tube passed
alongside the catheter. Retrograde urethrography should be performed under
fluoroscopy with minimal pressure. Gross extravasation of the contrast agent at
the site of the injury without visualization of the proximal urethra and bladder is
diagnostic for complete rupture of the urethra. Partial rupture is represented by
localized extravasation at the site of the injury, with some contrast passing into

the proximal urethra and bladder. If no extravasation is noted, a urinary catheter
can be gently advanced into the bladder. CT is not adequate for diagnosing
urethral injuries and is presumptive only if extravasation is detected at the bladder
neck or urethra ( Fig. 108.5 ). US or MRI may provide useful information in


determining need for surgical repair, but these modalities are not especially useful
in the initial evaluation.
It is recommended that, whenever possible, a full speculum examination be
performed in females with gross hematuria and pelvic ring fractures, difficulty
placing a urethral catheter, and anticipated delay until the pelvic fractures are
stabilized as injury often extends to the vagina.

Management
In the acute setting, partial anterior urethral injuries in males can be managed by
7 to 10 days of urethral catheterization. More severe injuries may require urinary
diversion by suprapubic cystostomy. Initial management of anterior urethral
injuries remains controversial. Urologic follow-up is required as the most
common sequelae of anterior urethral injury, urethral stricture, may take months
or longer to manifest and is usually managed definitively in a delayed fashion.
Penetrating wounds of the urethra demand early surgical exploration with
conservative debridement and primary repair. Patients with extensive loss of
urethral tissue can be managed with delayed repair and staged reconstruction.
The acute management of posterior urethral injuries also remains controversial.
The comparative effectiveness and benefits of immediate exploration and
realigning the urethra over an indwelling urethral catheter versus placement of a
suprapubic tube and delayed urethroplasty are debated by experts. Primary repair
of posterior urethral injuries is generally discouraged.
For urethral injuries in females, most authors recommend some form of
primary operative repair of the urethral rupture with closure of associated vaginal

tears. Placement of a suprapubic tube and delayed repair are reserved for unstable
patients, as placement has been associated with scarring, strictures, urethral
obliteration, and fistulas. Long-term complications of this injury include
urethrovaginal fistula, vaginal stenosis, incontinence, sexual dysfunction, and
urethral stricture.

Clinical Indications for Discharge or Admission
For children with isolated straddle injuries that do not result in urethral rupture, it
is necessary to ensure that the child can void and empty their bladder prior to
discharge. Occasionally, a catheter may need to be placed for 5 to 7 days to allow
bladder drainage while the urethral edema resolves. Follow-up with a urologist is
essential as urethral stricture formation is a common long-term consequence of
these injuries. More severe urethral injuries, including those that result in urethral
rupture, require admission. All patients with posterior urethral injuries are to be
admitted given the severity of the associated pelvic injuries.