Pediatric emergency medicine trisk 834

FIGURE 108.6 Penile zipper injury. A wire cutter may be used to cut the median bar of the
zipper, releasing the two sides of the zipper and freeing the penis.

FIGURE 108.7 Screwdriver technique for the release of foreskin entrapped in the zipper. The
screwdriver should be placed between the two faceplates and twisted toward the median bar.


PERINEUM
The mechanism most commonly associated with trauma to the female perineum
is a straddle-type injury. These injuries may cause vulvar hematomas, which
usually respond to treatment with ice packs and bed rest. Patients experiencing
mild urinary retention may be more comfortable voiding in a tub of warm water.
Massive or expanding hematomas may require surgical exploration and
evacuation.
Superficial lacerations of the perineum can be treated conservatively at home
with sitz baths. Deep lacerations may extend into the rectum or urethra. If the
extent of injury cannot be easily defined, surgical consultation for examination
under anesthesia should be requested. Rectal injury requires a diverting
colostomy. Suprapubic cystostomy or primary repair should be performed if the
urethra is disrupted.
Vaginal lacerations must be suspected in patients with severe trauma to the
external genitalia or penetration by foreign object. If a significant vaginal
laceration is noted, endoscopy with sedation or general anesthesia is necessary for
a full evaluation. The possibility of extension into the urethra, bladder, or rectum
must be investigated. The vaginal laceration is debrided and repaired with fine
absorbable sutures.

SEXUAL ABUSE
When common accidental situations fail to explain certain genitourinary injuries,
the possibility of sexual abuse should be considered. Injuries resulting from
sexual abuse include abrasions and hematomas in the penile shaft, vaginal

lacerations, and perineal hematomas (see also Chapters 79 Vaginal Bleeding and
87 Child Abuse/Assault ).
Suggested Readings and Key References
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injury in fractures of the pelvic ring. BJU Int 2007;100:567–573.
Black PC, Miller EA, Porter JR, et al. Urethral and bladder neck injury associated
with pelvic fracture in 25 female patients. J Urol 2006;175:2140–2145.


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the suprapubic tube necessary? J Trauma 2003;54:431–436.
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Raveenthiran V. Releasing of zipper-entrapped skin: a novel nonsurgical
technique. Pediatr Emerg Care 2007;23:463–464.
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