Abstract We report our 12-year experience in the man- agement of urethral injuries in nine children, six boys and three girls. The most common mechanisms of ...
Pediatr Surg Int (2001) 17: 58±61
Ó Springer-Verlag 2001
ORIGINAL ARTICLE
A. J. A. Holland á R. C. Cohen á K. M. F. McKertich D. T. Cass
Urethral trauma in children
Accepted: 3 February 2000
Abstract We report our 12-year experience in the management of urethral injuries in nine children, six boys and three girls. The most common mechanisms of injury were motor vehicle accidents, followed by straddle injuries. All the injuries in boys involved the anterior urethra, and in girls the proximal or mid-urethra. There were associated injuries in ®ve, including three pelvic fractures. All children were investigated with a retrograde urethrogram. Four were treated non-operatively with insertion of a urethral catheter. Of the remaining ®ve, one had drainage of a penile haematoma, one cystourethroscopy, two insertion of urinary and suprapubic catheters, and one open cystotomy and passage of a guide wire with antegrade passage of a urethral catheter. Complications included one urinary tract infection, one urethral ®stula, one urethrovaginal ®stula, and two urethral strictures. Final outcome was satisfactory in all nine children. Keywords Urethral trauma á Pelvic fracture
Introduction Urethral trauma is an uncommon but possibly serious injury in children [4]. The majority of these injuries occur in peri-pubertal boys as a result of a straddle injury or direct blow, although signi®cant trauma to the urethra may occur in both sexes resulting from a pelvic fracture [9]. Whilst many urethral injuries appear to be minor, optimal investigation and management are required to avoid signi®cant adverse sequelae [1, 7, 9]. A. J. A. Holland á D. T. Cass (&) Department of Surgical Research, The New Children's Hospital, Royal Alexandra Hospital for Children, PO Box 3515, Parramatta, NSW, 2124, Australia R. C. Cohen á K. M. F. McKertich Department of Paediatric Urology, The New Children's Hospital, Royal Alexandra Hospital for Children, PO Box 3515, Parramatta, NSW 2124, Australia
There have been few previous reviews of urethral trauma in children [4, 14, 15]. Therefore, we report our experience in the management of these injuries over a 12year period and suggest a management protocol based on these results.
Materials and methods The Paediatric Trauma Registry maintained since 1987 at Westmead Hospital and subsequently the Royal Alexandra Hospital for Children was searched for all children who had sustained a urethral injury between May 1987 and June 1999. Additional searches were performed of the medical record databases over the same time period at both hospitals. A detailed retrospective case note review was performed and data collected on the mechanism of injury (MOI), clinical features, radiological investigations, management, complications, and long-term outcome. Nine children were identi®ed with urethral injuries, six boys and three girls. The median age was 12 years with a range from 3 to 13 years. Five of the patients who resided in rural areas were transferred to our institution from a peripheral hospital. The mechanisms of injury are shown in Table 1. Five injuries occurred on a dirt track or private land, two on public roads, one in a driveway, and one in hospital. This last patient sustained a partial rupture of the anterior urethra at the penoscrotal junction following insertion of a urinary catheter whilst under general anaesthesia prior to cardiac surgery. The most common clinical feature in boys was blood at the urethral meatus in ®ve, followed by perineal bruising in three. Scrotal haematoma, extravasation of urine, and a palpable bladder were seen in two boys. Blood was seen at the urethral meatus in one girl and at the vaginal opening in another, in whom there was clinical evidence of an associated pelvic fracture. Labial oedema or bruising was not documented in any girl, and one girl had neither haematuria nor obvious external clinical features of a urethral injury. Plain radiographs of the pelvis revealed a fractured pubic ramus with diastasis of the pubic symphysis in one girl, and fractures of the acetabulum and both pubic rami in another girl and one boy. A retrograde urethrogram (RUG) was obtained in each case. In males all injuries involved the bulbar or penile urethra and in females the proximal urethra and bladder neck or mid-urethra (Table 2). Two girls had computed tomography scans of the abdomen and pelvis performed: in one with an incomplete mid-urethral tear this con®rmed a displaced acetabular fracture with an associated fracture of the superior and inferior pubic rami and signi®cant diastasis of the pubic symphysis. A further undisplaced fracture of the
59 Table 1 Mechanisms of injury Mechanism
No. of patients
Motor vehicle accident Fall from motor vehicle Pedestrian vs motor vehicle Cyclist vs motor vehicle Straddle Direct blow Iatrogenic Urinary catheter insertion
2 1 1 3 1 1
Total
9
Table 2 Location of urethral injury Location
No. of patients Incomplete
Complete
Male Penile urethra Bulbar urethra
1 4
± 1
Female Mid urethra Urethro-vesical junction
1 2
± ±
Total
8
1
contralateral acetabular rim was identi®ed together with loss of the soft-tissue planes around the urethra, consistent with extravasion of urine. In the second patient with a partial tear at the junction between the bladder neck and urethra, an undisplaced fracture of the superior pubic ramus was seen with evidence of free ¯uid around the bladder neck. Associated injuries were present in ®ve patients and consisted of three pelvic fractures, one vaginal laceration, and two limb fractures, one upper and one lower. Fig. 1 Retrograde urethrogram indicating incomplete rupture of bulbar urethra with extravasation of contrast posteriorly
Results Treatment was non-operative in four cases with insertion of a urethral catheter by a paediatric surgical registrar under local anaesthesia. One patient subsequently developed a urinary tract infection that responded to oral antibiotics. There were no late complications in this group that included two girls with partial ruptures of the proximal urethra adjacent to the bladder neck and associated pelvic fractures. One patient with an associated tibial-shaft fracture had a penile haematoma drained whilst a pin for skeletal traction was inserted during general anaesthesia. A urethral catheter was not passed. A subsequent urethrogram revealed a partial tear of the penile urethra. A ®stula that required formal repair on a later admission complicated this injury. In one boy with a straddle injury a RUG revealed a longitudinal urethral tear at the penoscrotal junction. A urethral catheter was passed and cystourethroscopy performed 24 h after the injury revealed that the tear involved the mucosal surface of the urethra only. The urethral catheter was removed with a satisfactory longterm clinical outcome. One 13-year-old boy with a rupture of the bulbar urethra secondary to a direct blow from a skateboard was treated with a suprapubic catheter (Fig. 1). The rupture healed with no adverse sequelae. Another 12-year-old boy who presented 12 h after a straddle injury sustained a complete disruption of the bulbar urethra. This was treated with insertion of a urethral catheter over a guide wire passed via an open cystotomy and suprapubic drainage. The urethral injury
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Fig. 2 Intraoperative retrograde urethrogram. Note fracture of right superior and inferior pubic rami and diastasis of symphysis pubis. Urethral catheter is outside bladder; incomplete urethral tear indicated by extravasation of contrast at level of middle third of urethra
was complicated by a stricture that required formal dilatation on ®ve occasions over a 6-month period. Subsequent review has been satisfactory. The ®nal patient was a 13-year-old girl with an almost complete disruption of the middle third of the urethra in association with multiple pelvic fractures following a motor vehicle accident (MVA). A urethral catheter had been inserted at a peripheral hospital and was draining urine satisfactorily. In view of her pelvic fractures and blood at the introitus, a RUG was performed in theatre prior to ®xation of the fractures (Fig. 2). This revealed incorrect placement of the original catheter outside the bladder with an incomplete urethral tear. The urethral catheter was easily repositioned into the bladder using a catheter introducer: a suprapubic catheter was also inserted and a laceration to the right lateral wall of the vagina documented. This injury was complicated by a urethral stricture that was treated with a urethrotomy approximately 4 weeks following her injury. Examination at 8 weeks revealed the development of a low urethrovaginal ®stula (UVF), through which urine was now exclusively draining. The urinary stream and continence were assessed as normal 6 months following the injury.
Discussion Urethral injuries in children are uncommon, with an estimated incidence of 1 in 2,000 children admitted with
traumatic injuries or 3.4% of children sustaining trauma to the genitourinary tract [4, 11, 15]. In general, signi®cant urethral injuries are less common in children than in adults as a result of reduced exposure to high-speed MVAs and the absence of occupational injuries such as falls from signi®cant heights [2]. The MOI in children typically involves a straddle injury or MVA. Two of the injuries in girls in this series occurred on private land and involved low-speed MVAs in which no restraint was used. Given the infrequency of falls from a motor vehicle in children, the clinician should be alerted by this MOI to actively exclude an associated urethral injury. Simple safety measures such as the use of an appropriate restraint would have prevented both injuries. The occurrence of a urethral injury following insertion of a urinary catheter demonstrates the delicate nature of the paediatric male urethra. In the training and supervision of clinical sta in urinary catheterisation, the importance of ensuring that there is drainage of urine from the catheter prior to in¯ation of the balloon should be emphasised. Although uncommon, there is some evidence that urogenital injuries in girls, particularly more minor lesions such as a urethral contusion, may be under-diagnosed [10]. Indeed, severe urethral trauma appears to be commoner in girls compared to adult women and is almost invariably associated, as in our patients, with vaginal lacerations and pelvic fractures [2, 12, 14]. The anatomical distribution and completeness of urethral injuries diers between adults and children, and this is in part a re¯ection of the dierence in the MOI. In our study all the injuries in boys involved the anterior urethra, whereas in adults posterior urethral injuries are more common as a result of an MVA or crush injury [2]. When a male child is involved in major pelvic trauma, however, the intra-abdominal location of the bladder and the small, relatively high prostate surrounding a more delicate posterior urethra and supporting ligaments potentially predispose to a signi®cant and often complete posterior urethral disruption [1, 7, 9, 11±13]. As our review indicates, many of these children may be managed non-operatively with a normal functional outcome [3, 4]. The key to this approach appears to be a careful assessment of each case to determine those that may be safely treated without operative intervention. The information obtained from clinical examination did not appear to necessarily correlate with the severity of injury, and therefore cannot be relied upon to safely exclude a urethral injury [10, 12]. RUG, performed in the radiology department or operating theatre, correctly diagnosed the injury in all cases in our series and allowed an informed decision to be made regarding further investigations and management [5, 15]. The treatment of more complex injuries using a conservative operative approach resulted in the development of urethral strictures requiring further surgical intervention in two of our patients. The ®nal functional outcome in both cases was satisfactory.
61
In girls, where these injuries are usually associated with pelvic fractures and vaginal tears, primary repair has been advocated [3, 14, 15], but is not always associated with an optimal outcome [3, 12, 14]. There is a signi®cant incidence of vaginal stenosis and UVF, although these complications may occur independent of the management approach adopted. In addition, there is some concern that this approach may be associated with a higher incidence of subsequent incontinence [8]. In our series there were three girls with partial urethral tears; two had satisfactory results with insertion of a urethral catheter only. In this single case with subsequent urethral stenosis and UVF, the injury was associated with multiple pelvic fractures and a vaginal laceration. A primary repair was not considered because of the incomplete nature of the urethral injury and the delayed presentation as a result of transfer from a rural centre. None of the boys in this series sustained a posterior urethral injury. Most series in the literature favour a primary repair in this situation, with a lower incidence of subsequent urethral stricture [2±4, 6, 12, 15]. Others favour a non-operative approach, citing a reduced incidence of later impotence and incontinence [5, 11]. Although there is a greater risk of stricture with this method, if one occurs it is usually uncomplicated and may be treated using conventional techniques [5]. Both impotence and incontinence may be related to the severity of the initial injury rather than surgical intervention, however, and an individualised approach based on the anatomy of the injury and the age of the patient would seem to be optimal [1, 8]. Certainly, there seems to be a higher incidence of complications with a complete injury in the younger patient and the more proximal lesions that are usually associated with a greater force of injury [1]. In those children with urethral injuries associated with pelvic fractures, the rare but documented complication of heterotopic bone formation around the traumatised urethra may be prevented by prophylactic use of a non-steroidal anti-in¯ammatory drug given within 48 h of injury [16]. The review indicates that a selective non-operative approach to urethral trauma was associated with satisfactory results in children with incomplete urethral injuries. Signi®cant complications were more commonly
associated with complex or complete injuries, re¯ecting the greater force of the trauma. It is dicult to make a clear recommendation of the ideal approach to this small but important subgroup of patients, whose management will vary depending on the precise nature of the injury, time of presentation, and experience of the surgeon involved.
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