Pediatric Urethral Injury
Treatment of urethral trauma in boys
1 Posterior urethral trauma Fan Dengxin, Department of Pediatric Urology, Anhui Provincial Children’s Hospital
Causes of injury: car accident, fall injury, smash injury, penetrating injury, medical origin
Pediatric characteristics: membranous urethral rupture is common, while urethral rupture on the prostatic urethra and prostate is almost unique to pediatrics
Special mechanism: The mechanism of membrane urethral injury is the same as that of adults, while the pediatric bladder is basically an intra-abdominal organ, the prostate is immature, small and weak, not large and strong enough to protect the prostatic urethra, and the pubic prostatic ligament is weak. Different traumatic forces cause different proximal urethral trauma
Clinical manifestations: fracture of the pelvis, bleeding from the urethral orifice, hematuria of the meatus, painful urination, urinary retention, butterfly-shaped hematoma of the perineum, scrotal bulge, local hematoma or and urinary extravasation.
Diagnosis: pelvic fracture seen on plain film
Urethrography with extensive spillage of contrast medium
cystocentesis with significant upward displacement of the bladder and intact wall
Complete posterior urethral rupture is considered when the contrast agent injected through the urethral orifice is completely spilled and cannot enter the bladder, while partial spillage of the contrast agent can also enter the bladder is considered as incomplete posterior urethral rupture
Treatment: partial rupture of the posterior urethra can be treated with a simple cystostomy
There are generally three treatment options for complete posterior urethral rupture
1. emergency suprapubic cystostomy only and second stage repair
2. Urethral end-to-end anastomosis through the perineal approach in acute cases
3. delayed stage I surgery followed by urethral repair
Traditional urethral convergence surgery has great limitations in the treatment of pediatric posterior urethral trauma due to the small size of the pediatric urethra, which makes it difficult to ensure that the two urethral break ends are aligned and may also cause new injuries, leading to increased complications such as urinary incontinence, urethral stricture and impotence.
Advantages and disadvantages of simple cystostomy
Simple and rapid surgery, facilitating the management of other combined traumas
Partial rupture of the posterior urethra, mostly avoiding reoperation
avoids repeated trial catheterization in the urethra
No exposure of retropubic hematoma, less chance of secondary infection
No posterior pubic bone exploration, avoiding cephalic stretching of the bladder and prostate, reducing the chance of impotence and urinary incontinence after surgery
Complete posterior urethral rupture with scarring between the two urethral sections causes urethral stricture or atresia, and the upwardly displaced bladder and posterior urethra are not reset
Treatment is more difficult if the stenosis or atresia segment is long, or if it is combined with urethrorectal fistula or urethroperineal fistula
Indications and basic conditions for acute posterior urethral anastomosis
Complete posterior urethral rupture
The child is stable and other co-injuries have been effectively managed
Specialized and experienced pediatric urologist
The management of a complete posterior urethral anastomosis is determined on a case-by-case basis and is difficult to standardize. If one of the two basic conditions, injury and surgeon skill, is lacking, simple cystostomy is preferred to avoid life-threatening aggravation and further damage to the vesicourethra and its function due to inappropriate surgery
Delayed one-stage surgical repair is an option when basic conditions are not available
Principles of emergency management of complete posterior urethral rupture
The management of complete urethral rupture emergencies is determined on a case-by-case basis and does not need to be standardized
If both the basic conditions of the child and the surgeon’s skill level are present, a one-stage surgical anastomosis of the urethra via the perineum should be advocated for emergencies
If there is a deficiency, simple cystostomy is preferred to avoid life-threatening aggravation or further damage to the bladder urethra and its function due to improper surgical operation, while conditions can be actively created to choose delayed surgery for one-stage urethral repair
2 Anterior urethral trauma
Anterior urethral trauma is most commonly seen in straddling injuries, occasionally in stab wounds, gunshot wounds or animal bites and medical trauma.
Clinical manifestations: acute – inability to urinate
Obsolete – difficulty in urination
Treatment: Incomplete urethral rupture with indwelling catheter
complete urethral rupture acute trans-perineal anastomosis
Scar stricture trans-perineal surgical end-to-end anastomosis