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CHAPTER 31

Urogenital and Perineal Trauma

Lohfa B. Chirdan
Ronald S. Sutherland

Introduction body insertion into the urethra. Medical procedure–related penetrating
1,2
Trauma is a leading cause of death in children in developed countries. injuries include catheter trauma (i.e., urethral disruption from balloon
In Africa, as in many developing countries where malnutrition and inflation inside the urethra or creation of a false passage), penile sur-
infectious diseases are leading causes of death in children, trauma may gery (especially circumcision), and surgeries of the retroperitoneum,
not be encountered as often by the surgeon. As developing countries pelvis, and anorectal area (e.g., posterior sagittal anorectoplasty).
improve the general health care of children with better nutrition and With increasing violence in many parts of urban Africa, urogenital
control of infectious disease vectors, however, trauma is becoming a tract trauma from high-velocity gunshot wounds and use of sharp
leading cause of death in children in Africa. This is largely due to the objects in children are likely to increase. The ability to provide early
rise of high-speed motor vehicle travel and increasing traffic congestion and rapid treatment to victims in war-torn regions may be severely
along poorly developed transportation routes. Most areas lack emer- limited due to the remote locations and transportation difficulties.
gency response systems with trained personnel, adequate emergency Domestic violence also must be remembered as a significant cause of
transport vehicles, and avenues for medical evacuation to higher ech- paediatric trauma, which may be from sexual abuse (usually penetrating
elons of care, which are critical to the survival and decreased morbidity. injury) or use of blunt force.
Dilapidated vehicles traveling on these roads often add to the burden Evaluation
of trauma in these regions. Many of these young trauma victims arrive To avoid serious long-term complications, significant urogenital tract
3
to the surgeon a long time after injury, so the surgeon operating in injuries in children must be appropriately and promptly managed.
developing countries must be prepared to quickly and accurately evalu- Improper or inadequate treatment may have a long-term disabling effect
ate and manage these youngsters in order to save lives and decrease on these children and condemn a child to lifelong urological disability.
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morbidity from urinary tract injuries. The initial approach to the child with any urogenital tract injury is
The urogenital tract is involved in up to 12% of children with identifying life-threatening conditions and applying the ABCDE’s of
abdominal and pelvic trauma. The same mechanisms causing injury resuscitation. These include identification and control of any airway
1
to the urinary and genital systems also frequently involve the perineum obstruction, breathing problems, control of the circulatory system,
and challenge the surgeon who is attempting to evaluate the extent of management of other life-threatening (usually neurological) disabili-
injury. After conducting the primary survey and instituting resuscitative ties, and control of potentially lethal environmental threats (exposure).
measures, the surgeon will need to employ diagnostic imaging studies Once these priorities are addressed, then the assessment and subsequent
to evaluate and identify the urological injuries that can be managed management of the urogenital tract injuries follows.
nonoperatively. Advances in radiological imaging have led to a greatly
decreased number of unwarranted exploratory operations because History
some of these patients can be managed nonoperatively. In settings A detailed history after resuscitation includes the description of the
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with limited facilities, the use of a simple protocol in children with accident scene and mechanism of injury. One should strongly suspect
blunt abdominal trauma could lead to a reduction in laparotomy and urogenital tract involvement in any sudden deceleration accident with
mortality rates. 3 anuria, penetrating flank injury, urethral bleeding, or gross haematuria.
In penetrating injuries, the type and calibre of the missile or weapon
Aetiology and Mechanism of Injury must be determined. It should be noted that, due to the kinetic proper-
Injury to the urogenital tract results from either blunt or penetrating ties of high-velocity injuries, one must suspect a much more extensive
trauma. Blunt trauma accounts for more than 98% of injuries to the injury than appears on the surface.
urogenital tract, and penetrating trauma occurs in less than 2%. There The paediatric patient’s medical history must also be known. Certain
1,2
are many different mechanisms of injury to the urinary tract; in Africa, congenital or acquired conditions of the urinary tract are predisposed to
the majority of these injuries occur as a result of motor vehicular acci- injury. Congenital hydronephrosis from pelvi-ureteric or uretero-vesical
dents. Most accidents occur on poorly maintained roads with minimal junction obstruction may cause the kidney to rupture with a sudden
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emergency response capability. The aetiology of urogenital trauma can deceleration accident. Urethral obstruction from posterior urethral valves
be divided into blunt and penetrating causes and regions of involvement or urethral stricture may result in bladder distention and increase the risk
(renal, ureteral, bladder, urethral, genital, and gonadal). of bladder rupture after blunt force trauma. Other conditions, such as
Blunt urinary tract calculi or a history of urinary infections (e.g., schistosomiasis/
Blunt injuries in Africa commonly are caused by motor vehicle and bilharziasis), may complicate the management of these patients.
traffic accidents, falls from heights, and direct blows to the abdomen Physical Findings
or perineum from child abuse, sports injuries, and straddle accidents. After the initial quick primary general assessment, the abdomen and
Penetrating genitalia are examined, looking for evidence of contusion or subcuta-
Penetrating injuries in Africa are commonly due to gunshots, stab neous haematoma, which may point to serious internal injuries to the
wounds from a knife or other sharp object, machete hacking, or foreign retroperitoneum or pelvic fractures. Several important points should be