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Urethral trauma in children
Article in Pediatric Surgery International · February 2001
DOI: 10.1007/s003830000438 · Source: PubMed
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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 man- There have been few previous reviews of urethral
agement of urethral injuries in nine children, six boys trauma in children [4, 14, 15]. Therefore, we report our
and three girls. The most common mechanisms of injury experience in the management of these injuries over a 12-
were motor vehicle accidents, followed by straddle in- year period and suggest a management protocol based
juries. All the injuries in boys involved the anterior on these results.
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 retro- Materials and methods
grade urethrogram. Four were treated non-operatively
with insertion of a urethral catheter. Of the remaining The Paediatric Trauma Registry maintained since 1987 at West-
®ve, one had drainage of a penile haematoma, one cys- mead Hospital and subsequently the Royal Alexandra Hospital for
tourethroscopy, two insertion of urinary and suprapubic Children was searched for all children who had sustained a urethral
injury between May 1987 and June 1999. Additional searches were
catheters, and one open cystotomy and passage of a performed of the medical record databases over the same time
guide wire with antegrade passage of a urethral catheter. period at both hospitals. A detailed retrospective case note review
Complications included one urinary tract infection, one was performed and data collected on the mechanism of injury
urethral ®stula, one urethrovaginal ®stula, and two (MOI), clinical features, radiological investigations, management,
complications, and long-term outcome.
urethral strictures. Final outcome was satisfactory in all Nine children were identi®ed with urethral injuries, six boys and
nine children. 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 trans-
Keywords Urethral trauma á Pelvic fracture ferred to our institution from a peripheral hospital. The mecha-
nisms 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
Introduction the anterior urethra at the penoscrotal junction following insertion
of a urinary catheter whilst under general anaesthesia prior to
Urethral trauma is an uncommon but possibly serious cardiac surgery.
The most common clinical feature in boys was blood at the
injury in children [4]. The majority of these injuries oc- urethral meatus in ®ve, followed by perineal bruising in three.
cur in peri-pubertal boys as a result of a straddle injury Scrotal haematoma, extravasation of urine, and a palpable bladder
or direct blow, although signi®cant trauma to the ure- were seen in two boys. Blood was seen at the urethral meatus in one
thra may occur in both sexes resulting from a pelvic girl and at the vaginal opening in another, in whom there was
clinical evidence of an associated pelvic fracture. Labial oedema or
fracture [9]. Whilst many urethral injuries appear to be bruising was not documented in any girl, and one girl had neither
minor, optimal investigation and management are re- haematuria nor obvious external clinical features of a urethral in-
quired to avoid signi®cant adverse sequelae [1, 7, 9]. jury.
Plain radiographs of the pelvis revealed a fractured pubic ramus
with diastasis of the pubic symphysis in one girl, and fractures of
A. J. A. Holland á D. T. Cass (&) the acetabulum and both pubic rami in another girl and one boy. A
Department of Surgical Research, The New Children's Hospital, retrograde urethrogram (RUG) was obtained in each case. In males
Royal Alexandra Hospital for Children, PO Box 3515, all injuries involved the bulbar or penile urethra and in females the
Parramatta, NSW, 2124, Australia proximal urethra and bladder neck or mid-urethra (Table 2).
Two girls had computed tomography scans of the abdomen and
R. C. Cohen á K. M. F. McKertich pelvis performed: in one with an incomplete mid-urethral tear this
Department of Paediatric Urology, The New Children's Hospital, con®rmed a displaced acetabular fracture with an associated frac-
Royal Alexandra Hospital for Children, PO Box 3515, ture of the superior and inferior pubic rami and signi®cant diastasis
Parramatta, NSW 2124, Australia of the pubic symphysis. A further undisplaced fracture of the
59
Table 1 Mechanisms of injury
Results
Mechanism No. of patients
Motor vehicle accident
Treatment was non-operative in four cases with inser-
Fall from motor vehicle 2 tion of a urethral catheter by a paediatric surgical reg-
Pedestrian vs motor vehicle 1 istrar under local anaesthesia. One patient subsequently
Cyclist vs motor vehicle 1 developed a urinary tract infection that responded to
Straddle 3 oral antibiotics. There were no late complications in this
Direct blow 1
Iatrogenic group that included two girls with partial ruptures of the
Urinary catheter insertion 1 proximal urethra adjacent to the bladder neck and as-
Total 9 sociated pelvic fractures.
One patient with an associated tibial-shaft fracture
had a penile haematoma drained whilst a pin for skeletal
Table 2 Location of urethral injury traction was inserted during general anaesthesia. A
urethral catheter was not passed. A subsequent urethr-
Location No. of patients ogram revealed a partial tear of the penile urethra. A
Incomplete Complete ®stula that required formal repair on a later admission
complicated this injury.
Male In one boy with a straddle injury a RUG revealed a
Penile urethra 1 ± longitudinal urethral tear at the penoscrotal junction. A
Bulbar urethra 4 1
urethral catheter was passed and cystourethroscopy
Female performed 24 h after the injury revealed that the tear
Mid urethra 1 ±
Urethro-vesical junction 2 ± involved the mucosal surface of the urethra only. The
urethral catheter was removed with a satisfactory long-
Total 8 1
term 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 cath-
contralateral acetabular rim was identi®ed together with loss of the
soft-tissue planes around the urethra, consistent with extravasion eter (Fig. 1). The rupture healed with no adverse se-
of urine. In the second patient with a partial tear at the junction quelae.
between the bladder neck and urethra, an undisplaced fracture of Another 12-year-old boy who presented 12 h after a
the superior pubic ramus was seen with evidence of free ¯uid straddle injury sustained a complete disruption of the
around the bladder neck.
Associated injuries were present in ®ve patients and consisted of
bulbar urethra. This was treated with insertion of a
three pelvic fractures, one vaginal laceration, and two limb frac- urethral catheter over a guide wire passed via an open
tures, one upper and one lower. cystotomy and suprapubic drainage. The urethral injury
Fig. 1 Retrograde urethrogram
indicating incomplete rupture
of bulbar urethra with extrava-
sation of contrast posteriorly
60
traumatic injuries or 3.4% of children sustaining trauma
to the genitourinary tract [4, 11, 15].
In general, signi®cant urethral injuries are less com-
mon in children than in adults as a result of reduced
exposure to high-speed MVAs and the absence of oc-
cupational 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 pre-
vented both injuries.
The occurrence of a urethral injury following inser-
tion of a urinary catheter demonstrates the delicate na-
ture 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, particu-
Fig. 2 Intraoperative retrograde urethrogram. Note fracture of right larly more minor lesions such as a urethral contusion,
superior and inferior pubic rami and diastasis of symphysis pubis. may be under-diagnosed [10]. Indeed, severe urethral
Urethral catheter is outside bladder; incomplete urethral tear trauma appears to be commoner in girls compared to
indicated by extravasation of contrast at level of middle third of adult women and is almost invariably associated, as in
urethra
our patients, with vaginal lacerations and pelvic frac-
tures [2, 12, 14].
was complicated by a stricture that required formal di- The anatomical distribution and completeness of
latation on ®ve occasions over a 6-month period. Sub- urethral injuries diers between adults and children, and
sequent review has been satisfactory. this is in part a re¯ection of the dierence in the MOI. In
The ®nal patient was a 13-year-old girl with an al- our study all the injuries in boys involved the anterior
most complete disruption of the middle third of the urethra, whereas in adults posterior urethral injuries are
urethra in association with multiple pelvic fractures more common as a result of an MVA or crush injury [2].
following a motor vehicle accident (MVA). A urethral When a male child is involved in major pelvic trauma,
catheter had been inserted at a peripheral hospital and however, the intra-abdominal location of the bladder
was draining urine satisfactorily. In view of her pelvic and the small, relatively high prostate surrounding a
fractures and blood at the introitus, a RUG was per- more delicate posterior urethra and supporting liga-
formed in theatre prior to ®xation of the fractures ments potentially predispose to a signi®cant and often
(Fig. 2). This revealed incorrect placement of the origi- complete posterior urethral disruption [1, 7, 9, 11±13].
nal catheter outside the bladder with an incomplete As our review indicates, many of these children may
urethral tear. The urethral catheter was easily reposi- be managed non-operatively with a normal functional
tioned into the bladder using a catheter introducer: a outcome [3, 4]. The key to this approach appears to be a
suprapubic catheter was also inserted and a laceration to careful assessment of each case to determine those that
the right lateral wall of the vagina documented. This may be safely treated without operative intervention.
injury was complicated by a urethral stricture that was The information obtained from clinical examination did
treated with a urethrotomy approximately 4 weeks fol- not appear to necessarily correlate with the severity of
lowing her injury. Examination at 8 weeks revealed the injury, and therefore cannot be relied upon to safely
development of a low urethrovaginal ®stula (UVF), exclude a urethral injury [10, 12]. RUG, performed in
through which urine was now exclusively draining. The the radiology department or operating theatre, correctly
urinary stream and continence were assessed as normal 6 diagnosed the injury in all cases in our series and allowed
months following the injury. an informed decision to be made regarding further in-
vestigations and management [5, 15].
The treatment of more complex injuries using a
Discussion conservative operative approach resulted in the devel-
opment of urethral strictures requiring further surgical
Urethral injuries in children are uncommon, with an intervention in two of our patients. The ®nal functional
estimated incidence of 1 in 2,000 children admitted with outcome in both cases was satisfactory.
61
In girls, where these injuries are usually associated associated with complex or complete injuries, re¯ecting
with pelvic fractures and vaginal tears, primary repair the greater force of the trauma. It is dicult to make a
has been advocated [3, 14, 15], but is not always associ- clear recommendation of the ideal approach to this
ated with an optimal outcome [3, 12, 14]. There is a small but important subgroup of patients, whose man-
signi®cant incidence of vaginal stenosis and UVF, al- agement will vary depending on the precise nature of the
though these complications may occur independent of injury, time of presentation, and experience of the sur-
the management approach adopted. In addition, there is geon involved.
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 References
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