Diagnosis and Management of Pediatric Urethral Injuries

Abstract

Objective: The incidence of urethral injuries in children is rare due to the fact that the urethra is short, mobile and protected by the pubic bone. The management of urethral trauma in childhood remains controversial because of the limited expertise of most urologists. Material and Methods: We performed a literature review by searching the Medline database for articles published between 1975 and 2010 based on clinical relevance. Electronic searches were limited to the keywords ‘pediatric’, ‘urethral injury’, ‘trauma’ and ‘reconstruction’. Results: Retrograde urethrography is considered the gold standard for diagnosis of urethral injuries. The initial management should ensure drainage of the bladder either by suprapubic cystostomy or urethral realignment if possible: in complete anterior urethral disruption as well as in children with life-threatening pelvic and intra-abdominal injuries after posterior urethral injuries, a deferred repair after 3 months is necessary. Immediate primary suturing of disrupted and dislocated urethral ends should be avoided because of high complication rates. Primary repair, however, of the defect is possible in girls avoiding a 2-stage approach. Conclusion: The aim of therapy is minimizing remote damages such as urethrocutaneous fistulae, periurethral diverticulae, strictures, incontinence and impotence with different therapeutic management depending on classification of the injury and the presence of life-threatening injuries.

Pelvic-fracture urethral injury in children

“…A lower incidence of PFUI is reported in girls than in boys [8] . This difference can be explained by the anatomical variation of the two genders, with the female urethra being shorter, more mobile and almost completely protected by the pubic bone.…”

“…The incidence of bulbar urethral trauma after straddle injuries in boys is 0.6–10% [6,9] . In comparison, the posterior urethra is most commonly injured by pelvic-ring fractures causing shearing forces that disrupt the puboprostatic ligaments and prostatomembranous junction [8] . The incidence of posterior urethral injury secondary to pelvic fracture in boys is 0.47–4.2% [2,6] .…”

“…In the acute setting with a stable patient, there is controversy about the choice between suprapubic catheter drainage with delayed repair vs. immediate endoscopic realignment. Some authors suggest that endoscopic realignment can improve urethral mucosa relocation and possibly prevent urethral stricture formation, while others advise against it completely [7,8,14] . Podesta [15] reported a 100% failure rate for primary realignment for posterior urethral injuries in boys, but another study with twice as many patients (22) reported 65% urethral patency after realignment as the only treatment [16] .…”

“…Immediate open repair should not be attempted due to a high risk of bleeding and possible disruption of the tamponade effect created by the pelvic haematoma, unless the injury is penetrating and involves the anterior urethra [8] . In the setting of rectal injury and/or bladder neck laceration, early surgical repair should be considered, to reduce the long-term complications of delayed surgery.…”

Isolated complete bladder neck transaction without pelvic fracture in a child: a rare presentation

“…The goal of primary realignment is to align both ends of the disrupted urethra so that they heal in the correct position as the pelvic hematoma is reabsorbed [3]. success of primary realignment, is not very encouraging as most eventually require repeated instrumentation and /or formal urethroplasty to maintain patency as post procedure chances of urethral narrowing ranges from 14% -100% in pediatric patients Primary surgical repair, urethral catheter drainage without suprapubic cystostomy is recommended [2].…”