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Managing Urethral Trauma in Children
urethral injury, female urethral injuries can be classified as urethral incontinence. Discussion of repairs for potential incontinence is
contusion, partial urethral transection, complete urethral transection or beyond the scope of this review (i.e. artificial urinary sphincter,
longitudinal urethral injury. urethral sling); however, these are often needed to achieve a
rehabilitated lower genito-urinary tract.
9
Arguments for immediate repair of acute urethral and vaginal injuries
cite concern for the eventual maturation of the injury into complete
urethral obliteration, high urethrovaginal fistulae and various degrees
The pediatrician and surgeon should
of vaginal stenosis.
8
Indeed, one report found that delayed repair of
paediatric female traumatic urethral injuries was associated with 40/44
not overlook potential urethral injuries
urethrovaginal fistulae at the time of initial referral.
7
In the immediate that may be silent in presentation, as
period after trauma, when tissue is traumatised, the chance of
ignoring their presence can be
successful repair of urethral and vaginal injuries is unlikely; however,
limiting the extent of injury with an initial attempt (even if only minor) associated with serious morbidity.
can make future surgical procedures less daunting. Additionally, in the
presence of concomitant rectal and/or vaginal injuries, bowel repair
with or without colostomy and vaginal tissue re-approximation to Summary
control bleeding and reduce surgical site infections are advised. Paediatric posterior urethral disruption is highly associated with pelvic
Furthermore, placement of a urethral catheter across the injury site fracture in boys and girls. Limited reports that include small numbers
with tacking urethral sutures for tissue approximation can be preclude management strategies that encompass all acute settings.
performed in addition to suprapubic tube placement. Concomitant Primary alignment, immediate repair and delayed repair are all valid
bladder neck lacerations are associated with stress urinary options; however, we favour suprapubic catheter placement with
incontinence, which can be reduced by acute management; however, delayed repair in boys. Identification of possible concomitant and/or
repair should proceed only when the patient has been stabilised from clinically silent urethral, vaginal and rectal injuries after female pelvic
more acute injuries. fracture are crucial and can often be missed, as life-threatening injuries
often take precedence in the acute setting. In contradistinction to male
Some have cautioned against immediate repair when the overall posterior urethral injuries, in females immediate repair after patient
condition of the patient is poor secondary to associated severe soft- stabilisation has a more prominent role (i.e. elimination of
tissue/skeletal injuries. Proponents of this argument instead prefer to urethrovaginal fistula, improved continence if bladder neck injury is
place a suprapubic tube for urinary diversion with repair at a later date present) and may reduce the complexity of future repair.
when the patient’s overall condition has improved. The authors of one
series of eight patients who underwent delayed repair were able to Soft-tissue, vascular and skeletal injuries are highly associated with
achieve successful urethral continuity in all eight patients; however, pelvic fracture urethral disruptions and deserve the full attention of the
two of the females had incontinence.
8
These two girls had an trauma team in the acute setting. However, the pediatrician and
associated bladder neck injury that was not repaired in the acute surgeon should not overlook potential urethral injuries that may be
setting, and one wonders whether an attempt to repair the bladder silent in presentation, as ignoring their presence can be associated
neck injury (even if after initial resuscitation) could have reduced future with serious morbidity. ■
1. Podesta ML, Use of the perineal and perineal-abdominal 11. Musemeche CA, Fischer RP, Cotler HB, et al., Selective 1996;78(3):450–53.
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4. Rourke KF, McCammon KA, Sumfest JM, et al., Open 14. Ismail N, Bellemare JF, Mollitt DL, et al., Death from pelvic management of posterior urethral disruptions due to pelvic
reconstruction of pediatric and adolescent urethral strictures: fracture: children are different, J Pediatr Surg, 1996;31(1): fracture: therapeutic alternatives, J Urol, 1997;157(4):
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EUROPEAN UROLOGICAL REVIEW 121
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