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206 Urogenital and Perineal Trauma
Genital and Scrotal Injuries Table 31.1: Evidence-based research.
Boys Title Development of a highly accurate nomogram for prediction
Circumcision mishap is the commonest cause of penile injury in boys of the need for exploration in patients with renal trauma
and includes partial glans and/or meatal amputation or skin deglov- Authors Shariat SF, Trinh QD, Morey AF, Stage KH, Roehrborn CG,
ing. 13,14 The penis may also be injured in motor vehicle accidents, falls Valiquette L, Karakiewicz PI
and straddle injuries, and animal or human bites. Penile injuries may Institution Department of Urology, University of Texas Southwestern
also be associated with scrotal and testicular injuries. Medical Center, Dallas, Texas, USA; Cancer Prognostics
Circumcision injuries should be immediately debrided and and Health Outcomes Unit, University of Montreal, Montreal,
Quebec, Canada; Brooke Army Medical Center (AFM), Fort
lacerations repaired. In cases of partial glans amputation, reattachment Sam Houston, Houston, Texas, USA
of the excised segment should be done immediately. Complete Reference J Trauma Injury Infect Crit Care 2008; 64(6):1451–1458
amputation in children is exceedingly rare. If significant skin loss has Problem To develop a highly accurate nomogram for predicting which
occurred, a split-thickness skin graft may be required. patients would need exploration after renal trauma.
Scrotal and testicular injuries occur from mechanisms similar to Comparison/ Logistic regression models were used to develop a
those for penile and urethral injuries. Trauma from sports is perhaps control (quality nomogram for prediction of the need for renal exploration
the most common form of blunt injury to the scrotum. If there is of evidence) after renal trauma. Internal (200 bootstrap resamples) and
significant swelling of the scrotum and one cannot completely or 50% split sample validations were performed.
adequately examine the testes, an ultrasound or CT scan should be Outcome/effect Overall, 89 patients (21.2%) underwent renal exploration,
immediately obtained. Ultrasound documentation of disruption of the from which 60.7% (54 of 89) underwent nephrectomy and
39.3% (35 of the 89) underwent renorrhaphy. Nine percent
tunica albuginea of the testis or the presence of a haematocele should of patients with grade II injury underwent renal exploration,
prompt immediate exploration of the scrotum, given the high likelihood 16% with grade III injuries, 41% with grade IV injuries,
of testicular rupture (Figure 31.5). A drain should be placed into the and 100% of grade V injuries. The kidney injury scale, the
scrotum following exploration and repair of testicular rupture. mechanism of injury, the need for transfusion, blood urea
nitrogen level, and serum creatinine represented the most
Girls informative predictors of the need for renal exploration,
Genital injuries in girls may result from sexual abuse or straddle and were included in the nomogram. The split sample
accuracy of the nomogram for prediction of the need for
15
injuries. Types of injuries include lacerations or contusions of the renal exploration was 96.9%. It significantly (p < 0.001)
perineal body, vagina, and labia. Adequate evaluation for abuse is exceeded the accuracy of each of its components, including
the American Association for the Surgery of Trauma kidney
necessary if this is suspected. Necrotic tissues should be debrided and injury scale (87.7%).
lacerations repaired.
Historical This article gives the scientific basis for predicting which
Evidence-Based Research significance/ patients with renal injury would need exploration, and
Table 31.1 presents a study to develop a prediction model for the need comments whether it could be applied to children with renal injury. The
nomogram generates highly accurate and reproducible
for exploration after renal trauma. 7 predictions of the probability for renal exploration according
to the authors’ decision-making process. It could help
standardise the management of patients with renal trauma
(i.e., inclusion criteria for clinical trials) and serves as a
proof-of-principle that predictive tools can be applied to
the trauma setting. Its use may improve the management
of renal trauma patients at institutions with limited trauma
experience.

Key Summary Points

1. The urogenital tract is involved in up to 12% of children with 4. Due to advances in radiological imaging, evaluation and
injuries. identification of most urological tract injuries in children can be
2. Perineal injuries are quite common in children. made nonoperatively; the operation rate has therefore greatly
decreased.
3. Most urogenital and perineal injuries follow blunt trauma. Road 5. The aim of managing a child with renal trauma is the
traffic accidents are the most common. Child abuse should be preservation of renal function.
suspected in unusual cases.

References

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