Genitourinary Tract Trauma in the Pediatric Patient
Genitourinary Tract Trauma in the Pediatric Patient
Author: Norman C. Christopher, MD, Director, Pediatric Emergency Medicine, Children’s Hospital Medical Center of Akron, OH; Chairman, Department of Emergency Medicine; Northeastern Ohio Universities College of Medicine, Rootstown.
Peer Reviewer: John P. Santamaria, MD, FAAP, FACEP, Co-Medical Director, After Hours Pediatrics, Inc.; Medical Director, Wound and Hyperbaric Center, St. Joseph’s Hospital; Clinical Associate Professor of Pediatrics, University of South Florida School of Medicine, Tampa, FL.
Nonaccidental injury remains the most frequent cause of death in children older than age 1. Evaluation and management of the injured child in the emergency department (ED) must first focus on stabilizing the airway, ensuring adequate oxygenation and ventilation, and addressing obvious or impending circulatory insufficiency. Because of a variety of anatomic, physiologic, and developmental factors, children who are injured severely often present with multiple organ system involvement.1 Many of these same factors contribute to the high incidence of genitourinary tract injury in multiply injured pediatric patients.2 Depending on the population studied, as many as 10-15% of all injured pediatric patients evaluated in the ED will have an identifiable injury of the genitourinary tract.3 In fact, renal injuries are more common after blunt trauma than splenic rupture. They are four times more common than injury of the liver or intestines and 10 times more common than injuries of the lungs, heart, pancreas, or major vessels in children.4 While, in many cases, identified renal injuries are of little consequence to the child’s overall morbidity and mortality, in some they may be life-threatening if not identified and managed aggressively.
While some authors continue to urge caution,5-9 a more conservative approach to management of children suspected of having an injury of the genitourinary tract is evolving.10-15 This is particularly true in those patients who are otherwise stable and likely to be candidates for nonoperative management. This issue includes a suggested approach to the evaluation, management, and disposition of the child suspected to have an injury of the genitourinary tract. The discussion will progress from the proximal to the distal urinary tract, and will review injuries resulting from blunt and penetrating mechanisms separately.
—The Editor
Hematuria in the Injured Child
Before discussing specific entities, some introductory comments regarding hematuria in the injured child are necessary. Hematuria, the presence of an abnormal number of red blood cells in the urine, is the hallmark of genitourinary tract injury. In the ED, dipstick urine analysis is likely to be the initial screening mechanism for the presence of hematuria in the multiply injured child. Because the indicator reaction for hematuria does not differentiate between myoglobinuria, hemoglobinuria, or true hematuria, a positive dipstick test must ultimately be confirmed by microscopic analysis. Because dipstick urine analysis correlates well with the presence or absence of hematuria in patients after blunt injury, this test may be used to guide initial management decisions in the ED. If the patient is awake and cooperative, a bag specimen may be obtained for analysis. If bladder catheterization is required in an uncooperative or unstable patient, caution must be used to avoid trauma to the urethra, resulting in a potentially false-positive test for hematuria on dipstick analysis. If urethral injury is suspected, urethral catheterization should be attempted only after proper evaluation for this injury is completed.
While the degree of hematuria does not correlate with the severity or extent of renal injury, it is clear that all children with gross hematuria after blunt abdominal injury require radiographic evaluation. The approach to the child with microscopic hematuria is less well defined. In a recent retrospective analysis of more than 400 children undergoing computed tomography (CT) after blunt abdominal trauma, 48 children with renal injuries were identified.16 Of these, 25 had significant renal injury—two-thirds of which had normal blood pressure and microscopic hematuria at presentation. Following guidelines for the management of adult patients with traumatic (microscopic) hematuria, these latter patients would not have undergone radiographic evaluation.17 The adult guidelines probably are not applicable to pediatric patients, in whom previously unrecognized congenital anomalies may exist (see Figure 1), and in whom hypotension is a late sign of significant volume loss.9,16,18-19 Many authors continue to believe that radiographic imaging is required for all pediatric patients with any degree of hematuria after blunt injury, even if they are hemodynamically stable.10,16 The emergency physician should maintain a low threshold for initiating radiographic evaluation of the pediatric patient with traumatic hematuria, particularly in the presence of physical examination findings or a mechanism of injury consistent with renal injury.
It must be remembered that while most patients with renal injury will have hematuria on dipstick urine analysis, the degree of hematuria found by quantitative microscopy does not correlate well with the severity of underlying renal injury.16 A recent meta-analysis suggests that applying a cutoff of 50 RBCs/HPF would have led to identification of all significant renal injuries in children included for study.19 This finding was not confirmed in a recent retrospective study of 100 consecutive children with blunt renal trauma, in whom three of 11 children with minor injuries and two of eight children with major injuries of the genitourinary tract had microscopic hematuria of less than 20 RBCs/HPF.20
Renal Trauma
Introduction. More than 90% of renal injuries in children follow blunt trauma, and more than 10% of all children with blunt abdominal injuries will have renal injury identified after aggressive radiographic evaluation.7, 21 Children with underlying congenital abnormalities (such as ureteropelvic junction obstruction or other anomalies that result in secondary hydronephrosis) or kidneys in an abnormal location (i.e., ectopic kidney or horseshoe kidney) are more predisposed to injury.22 Other anatomic features that predispose children to renal injury after blunt trauma are listed in Table 1.23 Because of these anatomic features, children are felt to be at greater risk for renal injury than adults with comparable mechanism and overall severity of injury.24,25
| Table 1. Anatomic Factors Predisposing Children to Renal Injury after Blunt Trauma |
| • Flexible thoracic cage |
| • Poorly developed abdominal and thoracic musculature |
| • Renal volume relative to that of the retroperitoneal space |
| • Poorly developed perirenal fat and facial layers |
Evaluation. Renal injury always should be suspected in a child with multiple injuries following blunt trauma. The mechanism of injury, the presence of associated injuries, the child’s age, and the child’s hemodynamic status should each be considered when evaluating a child with traumatic hematuria. In a patient with penetrating injury, information about the caliber of the bullet or the length of the penetrating object should be sought. Rapid deceleration injury resulting from a fall or blunt impact following a high-speed motor vehicle crash are the most common mechanisms of injury. Because of the relative mobility of the kidney in the retroperitoneal space, rapid deceleration may result in stretching of the renal vascular pedicle with subsequent intimal damage, thrombosis formation, development of vascular occlusion, and subsequent renal insufficiency. A direct blow to the flank, as may occur during participation in athletics, also may result in blunt injury of the ipsilateral kidney.
Careful examination may reveal flank pain or tenderness, flank hematoma (Grey Turner sign), periumbilical ecchymosis (Cullen sign), lower posterior rib fractures, lumbosacral spine fracture, abdominal tenderness, or pelvic instability, suggesting the possibility of retroperitoneal hematoma and/or renal injury. An expanding or pulsatile abdominal mass in a hemodynamically unstable patient indicates vascular injury, possibly involving the renal vascular pedicle at its origin with the aorta.
Intravenous pyelography (IVP) has traditionally been the study of first choice when evaluating the urinary tract after blunt trauma, and when used alone, is adequate for staging renal injury. Findings suggesting renal injury include delayed or absent filling of the injured kidney, extravasation of contrast material into the retroperitoneum, and obscuration of the psoas shadow. The most significant shortcoming of IVP is its inability to identify associated intraabdominal injuries. Several studies have shown that intraperitoneal visceral injury is at least as common as renal injury in children with microscopic hematuria.26-27
In the unstable patient requiring urgent abdominal exploration, a single-shot IVP may provide important information aiding rapid and accurate decision-making in the operating room.28 While useful in documenting normal function of the contralateral kidney, a limited IVP may be technically difficult to perform and interpret, and has been shown to have poor sensitivity when identifying the presence and extent of renal injury immediately prior to emergent exploratory laparotomy.29 In the hemodynamically stable patient with hematuria who is at low risk for intra-abdominal injury, a normal intravenous pyelogram provides sufficient information to make decisions about treatment, disposition, and follow-up.
A CT scan with intravenous contrast enhancement has become the diagnostic study of first choice for the evaluation of the hemodynamically stable child with traumatic hematuria who is at risk for intra-abdominal or retroperitoneal injury.11, 30-31 The clear advantage of CT over other diagnostic modalities is that it provides information about pelvic, peritoneal, and retroperitoneal structures, in addition to its demonstrated sensitivity in identifying renal injuries. (See Figure 2.) CT also has been used to estimate hematoma size and to calculate average bleeding rate, and may be useful in predicting need for immediate surgical intervention.32 CT is the diagnostic test of choice in children with penetrating flank injury without indications for emergent exploratory laparotomy.33
Ultrasound has been applied extensively in the evaluation of adult patients with traumatic hematuria, although its use in children has been limited largely to follow-up study of patients with already staged renal injuries.34 The advantages of ultrasound compared to CT include its portability, cost, speed, lack of need for sedation, ability to identify other associated intra-abdominal and intraperitoneal injuries, and limited radiation exposure. A clear disadvantage is its inability to provide information about function (contrast uptake) in the injured kidney.35 A significant disadvantage of diagnostic ultrasound is that accuracy is influenced by the skill and experience of the operator.
Arteriography provides little information beyond what is learned by contrast-enhanced CT, although it may be useful if CT is not definitive or unavailable.36 Magnetic resonance imaging (MRI) may be used for follow-up of patients with renal injury, but has no role in the initial management of children with traumatic hematuria.37
Staging and Management. Staging and classification of renal parenchymal injury, whether the result of blunt or penetrating trauma, are based on anatomic criteria:
• Grade I = contusion or subcapsular hematoma;
• Grade II = nonexpanding perirenal hematoma or shallow laceration or the renal cortex;
• Grade III = deep laceration of the renal cortex without urinary extravasation;
• Grade IV = laceration through the cortex, medulla, and collecting system, or injury of the renal vascular pedicle; and
• Grade V = shattered kidney or avulsion of the renal vascular pedicle.
In addition to providing common definitions for research, management options are defined by accurate, simple, and reproducible staging of renal injuries. Early consultation with a urologic surgeon is recommended in all but those with simple renal contusions.
Absolute indications for operative management include the presence of an expanding or pulsatile retroperitoneal hematoma, renovascular injury, extensive extravasation of contrast material in a patient with high-grade injury, and hemodynamic instability in a patient with documented or suspected renal injury.38 Shattered kidneys (Grade V) and high-grade renal trauma (Grade IV or V) with associated vascular injury also require exploration. Patients with moderately severe renal parenchymal injury who are managed nonoperatively are subject to delayed complications, including delayed bleeding, continued urinary extravasation, perinephric abscess formation, hypertension, and delayed nephrectomy.39
The majority of blunt renal injuries are minor (Grade I or II) and may be managed nonoperatively. Conservative management of patients with minor renal parenchymal injury includes bed rest until gross hematuria has cleared, usually within 24-48 hours. Complications are unusual in patients with low-grade injuries who are managed conservatively.40
Ureteral Trauma
Introduction. Ureteral injury is uncommon in children, and is usually the result of penetrating injury when it does occur. Significant force is required to cause blunt ureteral injury, and usually involves an acceleration-deceleration mechanism. Sudden and forceful flexion of the thoracic and lumbosacral spine with consequent stretching of the ureter is felt to be an important mechanism of injury resulting in either a ureteral tear or in disruption of the ureteropelvic junction.
Ureteral injury is associated with microscopic hematuria in between 40% and 90% of patients.41 Other specific evidence of ureteral injury often is lacking at the time of the patient’s initial assessment in the ED, making delayed diagnosis more the rule than the exception.42 A high index of suspicion should be maintained in a patient with penetrating injury of the abdomen, flank, or pelvis, or in a patient sustaining significant blunt injury who develops fever, prolonged ileus, and flank pain several days after the initial injury.
Evaluation. IVP or contrast-enhanced CT should be performed in all patients in whom ureteral injury is suspected. In either case, ureteral injury is evidenced by extravasation of contrast dye into the surrounding soft tissues and into the peritoneal cavity. Failure to visualize the entire length of the ureter using either of these approaches suggests the need for further evaluation, such as a retrograde pyelogram or a delayed CT image, to document the integrity of the entire length of the ureters. In patients with operative indications, finding a hematoma adjacent to the anticipated track of the ureter or in the perinephric soft tissues should prompt aggressive intraoperative evaluation by either IVP or a retrograde urethrogram.
Management. Initial management of the patient with ureteral injury must focus on identification and management of associated life-threatening injuries. Surgical management after either partial or complete ureteral transection is required, and includes reimplantation to the bladder for distal injury and repair and/or autotransplantation for more proximal injuries.
Bladder Injury
Introduction. Injury of the urinary bladder is rarely isolated, being associated with other significant visceral or bony injury in more than 90% of patients.43 Fracture of the pelvis is the most common associated injury and is found in more than 75% of all patients with bladder injury.44 While largely a pelvic organ in adults, the bladder extends well into the abdominal cavity in children, making the distended bladder much more susceptible to injury after blunt impact. A classification scheme based on extent and location of bladder injury is outlined in Table 2.
| Table 2. Radiologic Classification of Bladder Injuries48 | ||
| Type I | Bladder contusion | Incomplete bladder mucosal tear. Normal cystography. |
| Type II | Intraperitoneal rupture | Rupture of the bladder dome with extrava- sation into the adjacent peritoneal cavity. |
| Type III | Interstitial rupture | Uncommon. Incomplete perforation of the bladder wall without frank rupture. Mural defect on cystography represents intramural hematoma. |
| Type IV | Extraperitoneal rupture | 60% of major bladder injuries |
| Simple | Extravasation of contrast is limited to the pelvic extraperitoneal space. |
|
| Complex | Extravasation of contrast extends to ante- rior abdominal wall and perineal structures. Implies disruption of pelvic fascial support. |
|
| Type V | Combined bladder injury | Injury of both the intraperitoneal and extraperitoneal bladder are noted. |
Evaluation. While more than 95% of patients with bladder tear or rupture have gross hematuria, other specific findings are often absent. Patients will report symptoms of bladder irritability (urinary frequency and hesitancy), suprapubic or generalized abdominal pain and tenderness, or signs and symptoms consistent with an acute surgical abdomen. A patient with grossly clear urine and without a pelvic fracture has virtually no chance of having a significant injury of the bladder.45
Routine abdominal/pelvic CT is an insensitive test in patients with bladder injury because inadequate distension of the bladder occurs in most patients. A properly performed retrograde cystogram or retrograde CT cystography are the preferred diagnostic tests in patients with suspected bladder injury.
Care should be taken when placing a urinary catheter in a patient with gross hematuria, or in particular, a patient with frank blood at the urethral meatus, as urethral injury also may be present. If resistance is met when advancing the catheter, installation of a small volume of contrast dye with the catheter’s saline-filled balloon obstructing the distal urethra should be performed (retrograde urethrogram). After demonstrating an intact urethra with this approach, the catheter may be carefully advanced into the urinary bladder. A baseline scout film of the abdomen should be taken before contrast is instilled. Antero-posterior films of the abdomen should be taken after distending the bladder with iodinated contrast (by gravity) and clamping the distal end of the catheter, and should be repeated after complete spontaneous evacuation of the bladder. Care should be taken not to spill contrast material when emptying the bladder of contrast dye, introducing artifact onto the post-void film. Intraperitoneal bladder rupture is indicated by extravasation of contrast material in the lateral gutters, around loops of bowel, or around the liver and spleen; extraperitoneal rupture is suggested by the appearance of flame-shaped extravasation of contrast into the pelvis and by tracking of the dye into the obturator region and in the area of the pubic symphysis and pelvic outlet. The volume of extravasated dye does not correlate well with the degree of bladder injury, and should not influence management decisions.46 False-negative tests are the result of inadequate filling and distension of the urinary bladder during testing.
Management. Superficial mucosal lacerations, bladder contusions, and bladder hematomas may be treated expectantly with or without catheter drainage. Extraperitoneal bladder injuries may be managed conservatively by bed rest and catheter drainage for 10 days, followed by cystography to document healing.46 In either case, care must be taken to ensure that the catheter remains patent throughout the course of therapy. Intraperitoneal rupture is usually more extensive and is unlikely to heal with simple conservative management. In the latter case, operative repair and placement of a suprapubic tube or a large-bore urethral catheter are indicated, although attention to associated life-threatening injuries takes precedence.47
Urethral Injury
Introduction. Blood at the urethral meatus in the presence of a pelvic fracture is the hallmark of blunt urethral injury. Other commonly associated clinical findings include inability to void spontaneously, the presence of a palpable urinary bladder, or a scrotal hematoma.48 Injury of the urethra is very uncommon in females, and when found, almost always is associated with a major pelvic ring disruption.49 Concomitant vaginal or perineal injury should alert the emergency physician to the potential for this injury in girls.
The most common mechanism of injury in either male or female patients is a direct blow to the perineum, usually due to a "straddle" injury. In such a patient, a urethral injury is more likely to occur in the absence of a pelvic fracture. Penetrating injury of the anterior or posterior urethra also may occur, but is rare.
Evaluation. The inability to pass a urethral catheter was once felt to be diagnostic of urethral injury, although liberal use of retrograde urethrography in patients at risk for posterior urethral injury is clearly preferred. With the patient in an oblique position and with the penis under slight tension, approximately 1 mL/kg of contrast dye is injected over approximately 30 seconds. A radiograph is taken after the dye is placed—absence of contrast in the bladder and extravasation of dye either above or below the urogenital diaphragm is evidence of a complete Type I or Type II injury. (See Figure 3.) A recently proposed classification scheme for urethral injuries, based on anatomic details evidenced by retrograde urethrography, is outlined in Table 3.50 Type V injuries are the result of straddle injury, and in children are usually incomplete.
| Table 3. Goldman Classification of Urethral Injuries50 |
|
| Type I | Posterior urethra intact (stretching of the membranous urethra is associated with ruptured puboprostatic ligaments). |
| Type II | Pure posterior injury with tear of the membra- nous urogenital diaphragm (partial or com- plete). Contrast extravasates into the pelvic peritoneum above the urogenital diaphragm. |
| Type III | Combined anterior and posterior urethral injury with disruption of the urogenital diaphragm (partial or complete). Contrast extravasates into the perineum below the urogenital diaphragm. |
| Type IV | Bladder neck injury with extension into the urethra. |
| Type V | Anterior urethral injury, partial or complete. |
Management. Anterior urethral injury may be repaired primarily, although delayed repair with interim bladder drainage is the preferred approach for these and for injuries of the posterior urethra.51 If a urethral catheter is inserted, it should be left in place. If passage if a urethral catheter is not possible and bladder drainage is required, suprapubic drainage is indicated.
Conclusion
The approach to the child at risk for blunt injury of the genitourinary tract is evolving. A conservative approach to diagnosis, management, and follow-up is prudent. Liberal application of diagnostic studies to delineate anatomic and functional details is indicated after major and life-threatening injuries are identified and managed during the primary survey. A high index of suspicion is required to make an accurate and timely diagnosis.
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