Page 16 - 63 craniocerebral-and-spinal-trauma30-35_opt

Urogenital and Perineal Trauma 205
Diagnosis
Blood at the external urethral meatus, gross haematuria after trauma,
and inability to void after trauma in the presence of the urge to mictur-
ate are physical findings in children with urethral injuries. Other find-
ings that may indicate underlying urethral injury include a sensation of
micturition without passing urine; swelling; or ecchymosis of the penis,
scrotum, and perineum. The urethral tunics include the corpus spongio-
sum, Buck’s fascia, and the outer layer, or Colle’s fascia. Urethral rup-
ture is usually confined by Colle’s fascia, giving the classic finding of
a perineal butterfly haematoma. A digital rectal examination should be
done, and if upward displacement of the prostrate is encountered, one
should suspect urethral disruption. In girls with blood at the introitus,
careful inspection of the vagina should be done. Retrograde urethrogra-
phy should be done in all children suspected of having urethral injury.
This may reveal a filling defect cause by haematoma or contusion or
extravasation of contrast. (A)
Management
If a urethral injury is suspected from the history and physical examina-
tion of a child, no urethral catheterisation should be done until urethral
rupture has been ruled out. An emergency retrograde urethrogram is
done to ascertain the nature (grade) of the injury. If the urethrogram is
not possible on an emergency basis, a suprapubic bladder catheter is
inserted and urethrogram done the following day.
Grade I and II injuries are managed without surgery and without an
indwelling urethral catheter.
For grade III injuries, a suprapubic bladder catheter usually is
inserted. However, if the urethra is not completely transected and
contrast is seen entering the posterior urethra and bladder, a Foley
catheter (especially one with a coude-tip) can be inserted carefully
under fluoroscopic guidance. Another option is to use a cystoscope
to place a wire across the defect and then a council-tip catheter over
the wire into the bladder. After 10–14 days, a cystourethrogram is
performed. If there is no extravasation or stricture, the catheter is (B)
removed. Careful follow-up is necessary because a stricture may occur
months or years later. The best results are obtained by ensuring the
urethral lumen is patent, even if this requires open repair of the urethra
tear within 10–14 days, before the tissues have become rigid.
For grade IV injuries, or complete disruption, a suprapubic catheter
should be inserted. Usually, these patients are severely injured, and
an attempt to reapproximate the disrupted bladder neck and prostatic
urethra to the membranous urethra may provoke further bleeding
from the pelvic haematoma and worsen the child’s condition. The
sooner the ends of the urethra are brought together, however, the
better. This is usually facilitated by accurate reduction and fixation of
the pelvic fractures. Once the child is stabilised, immediate (within
2 days) realignment of the urethra over a catheter can be attempted.
If the child is unstable, delayed repair (2–14 days) can be attempted
by using cystourethrography and limited suprapubic manipulation
and downward displacement of the bladder. If the anterior urethra
is completely blocked, perineal urethroscopy can be performed.
In some situations, late repair (>3 months) must be done and may
require extensive pelvic surgery, including transpubic urethroplasty (C)
or a combined suprapubic and perineal approach with or without Figure 31.5: (A) Scrotal/perineal haematoma with (B) ultrasound showing
pubectomy. 11,12 Long-term complications from complete urethral disruption of the tunica albuginea. (C) Exploration reveals rupture of the inferior
disruption may include erectile dysfunction and incontinence. Urethral pole of the testis.
injuries are rare in girls; however, in the presence of pelvic fracture
and blood at the meatus/introitus, one must carefully inspect the vagina
and retrograde urethrogram or cystoscopy for injury. Urethral injuries
in girls may result in urethral stenosis, urethrovaginal fistula, urinary
incontinence, and vaginal stenosis. Meticulous management is needed
to avoid these serious complications.