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Urogenital and Perineal Trauma 201

noted when examining a child with suspected urogenital tract injuries: Imaging Studies
1. Abdominal flank tenderness or bruising and lower rib fractures may Abdominal and pelvic plain film x-ray
suggest renal injury (Figure 31.1), although one-quarter of children A plain film x-ray is done routinely for all abdominal and pelvic trauma,
with severe renal injuries may not have abdominal examination especially if intravenous contrast is to be given. This film should iden-
findings; therefore, a high index of suspicion and further evaluation are tify the presence and nature of bony injury, foreign bodies, and stones,
1,2
needed to make an accurate diagnosis. and should strengthen the suspicion of bladder and urethral injury.
Abdominal/pelvic ultrasound
Ultrasound is readily available in many centres in Africa, is less expen-
sive than many other imaging modalities, and can be readily used by the
consulting surgeon. This can be done to evaluate injuries to the retro-
peritoneal organs, such as the kidney and bladder. It can also be a useful
tool in assessing injuries to other organs in the abdomen and pelvis.
Urethrocystography
Urethrocystography is a very useful investigation, especially in Africa,
because most radiological services are able to obtain plain film radio-
graphs necessary for this investigation. It is done by the passage of a
small-size catheter into the urethral meatus and held in place by inflat-
ing the balloon by with 1–2 ml of sterile water.
The patient is placed in the oblique position, and, if the patient is
a male, the penis is placed on stretch. A water-soluble contrast is then
injected and the retrograde urethrogram is done. This outlines the
urethra, giving a diagnosis of the type of urethral trauma, if present. If
the urethra is uninjured but a bladder injury is suspected, the catheter is
advanced into the bladder and then filled with a water-soluble contrast.
In children, the bladder should be filled to at least 50% of expected
bladder capacity, calculated by
Figure 31.1: Patient with flank haematoma found to have fractured kidney.
EBC (ml) = (age + 2) × 30.
In adolescents or older children, fill with at least 350 to 400 ml for
2. Swelling or ecchymosis in the perineum as well as lacerations or
bleeding are suggestive of urinary tract injuries, so a patient with any an adequate study to be done. If possible, have the patient void and
or a combination of the above should be further evaluated to determine capture an antegrade voiding view of the urethra. To be complete, a
the exact part of the urinary tract that is injured. postvoid view of the bladder must be obtained. If the patient is unable
to void, drain the bladder and take a second film.
3. The presence of blood at the external urethral meatus may be the
only indicator of a urethral injury. Another sinister sign is upward Urethrocystoscopy
displacement of the prostate in boys on digital rectal examination. This Paediatric-sized fibre-optic cystoscopes are becoming increasingly
physical finding may be very difficult to interpret in a child, but must available in most tertiary centres in Africa, and these scopes can be used
be investigated further due to the risk of posterior urethral disruption. to diagnose and manage some urethral and bladder injuries. In certain
types of urethral injuries, this may enable the surgeon to pass a wire
Investigations beyond the injury and then place a catheter over the wire.
The suspicion of urinary tract injury on history and physical examina- Intravenous urography
tion warrants additional investigations to accurately determine the site In intravenous urography (IVU), urografin, or other water-soluble
and extent of the injury for proper treatment and good outcome. These contrast is given intravenously and serial abdominal films are taken at
investigations are divided into laboratory studies and imaging studies.
30 seconds, and at 1, 5, and 10 minutes. If there is delay in uptake of
Laboratory Studies the contrast by the kidneys, then delayed images should be obtained at
Laboratory studies supplement clinical history, good physical exami- 30, 60, 120, or 180 minutes, if necessary. In an urgent scenario, where
nation, and imaging techniques. The results of these studies, when the child is taken to the operating theater for exploratory laparotomy,
interpreted well, would be very helpful to surgeons practicing in Africa an “on-the-table”, two-shot IVU can be done by obtaining a plain film,
because most of the advanced imaging techniques are unavailable in followed by a 2-ml/kg bolus of intravenous contrast, and then imaging
many centres, or even unaffordable in places where they are available. at 10 minutes. This evaluates renal and ureteral injuries. Bladder inju-
These investigations include a complete blood count; urinalysis; serum ries also can be evaluated on the cystogram phase (although imprecise).
levels of electrolytes and urea, creatinine, and amylase; and liver func- Computed tomography scan
tion tests. The results of these laboratory investigations must be inter-
Computed tomography (CT) is rapidly becoming available in most
preted in line with the general condition of the patient. For instance, in
tertiary centres throughout Africa and is extremely useful in evaluat-
a patient with intraperitoneal bladder rupture, the serum urea may be
ing urinary tract injuries. Cost is a major drawback of this investiga-
markedly elevated, whereas the creatinine may be normal due to the
tion, but as medical insurance becomes readily available to patients,
absorption of urea by the peritoneum.
CT scans are becoming more widely used. Another limitation of the
Urethral catheterisation may be required to obtain an accurate
use of CT in the paediatric population is the large amount of ionising
urinalysis, and a clean, appropriate-sized urethral catheter should be
radiation children receive if they require serial scanning. CT is the most
passed gently into the bladder under aseptic conditions. This is done
accurate imaging modality for the evaluation of renal trauma and has
only when there is no blood at the urethral meatus, or gross haematuria.
several advantages over IVU by virtue of its three-dimensional imaging
The presence of blood in the urine after passing the urethral catheter
capability and exceptional anatomical clarity. CT cystography is a very
indicates urinary tract injury.