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chapter 138Pediatric Genitourinary Trauma

Douglas A.Husmann,MD
Questions
1 Which of the following signs or symptoms noted after a traumatic insult is suggestive of a preexisting
renal abnormality?
a Microscopic hematuria with shock
b Gross hematuria with shock

c Gross hematuria with clot formation

d Hematuria disproportionate to severity of trauma
e Hematuria in the absence of coexisting injuries to the thorax, spine, pelvis/femur, or intra
abdominal organs
2 The radiographic study that is the most sensitive for the presence of a renal injury is:
a intravenous pyelography (IVP).
b magnetic resonance imaging (MRI) of abdomen.

c focused assessment with sonography for trauma (FAST) ultrasonography.

d triphasic abdominal computed tomography (CT).
e monophasic abdominal CT.
3 Following a traumatic injury, a CT of the abdomen reveals a renal laceration that extends into the
collecting system with urinary extravasation. The injury is associated with a devitalized fragment; the
grade of renal injury is:
a 1.
b 2.

c 3.
d 4.
e 5.
4 An 11-year-old boy sustained a renal laceration that extended into the collecting system 2 weeks
previously. He has been at home for the past week with grossly clear urine. He is at home and has the
sudden onset of gross hematuria with clots. The next step is:
a reassurance and continued observation.
b bed rest, force fluids, and follow-up the next day.

c continued observation and arranging for follow-up CT in the morning.

d bringing the patient by car to the office for evaluation.
e transportation to the emergency room by ambulance.
5 A 9-year-old boy sustained a renal laceration associated with a functional renal fragment that was
completely dissociated from the kidney. He has a persistent symptomatic urinary fistula despite combined
treatment with a nephrostomy tube, double-J stent, and urethral catheter. The next step is:
a angiographic embolization of the functional renal fragment.
b radiofrequency ablation (RFA) of functional renal fragment.

c cryotherapy of the functional renal fragment.

d laparoscopic partial nephrectomy.
e open partial nephrectomy.
6

An 8-year-old boy on intravenous (IV) prophylaxis with cephazolin undergoes angiographic embolization
of a traumatic arteriovenous (AV) fistula associated with a grade 4 traumatic renal injury. His urine is

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clear, but, on postembolization day 1 and 2, he has febrile temperature spikes to 40 C. Blood pressure is
stable. Acetaminophen is given for the fever, and blood and urine cultures are obtained. The next step is:
a continued observation.
b a change in antibiotic coverage to piperacillin.
c addition of metronidazole.
d CT of abdomen and aspiration of perinephric hematoma/urinoma.
e percutaneous nephrostomy drainage of urinoma.

7 A 2-year-old boy sustains a major renal laceration with a tear into the collecting system secondary to child
abuse. He has persistent gross hematuria with clots and ileus, 5 days following his injury. CT scan
reveals clot filling the renal pelvis and a significant perinephric urinoma; however, good flow of contrast is
seen into the ipsilateral distal ureter. These findings are essentially unchanged from a CT scan done 48
hours earlier. Vital signs and hemoglobin are normal and stable. The next step is:
a continued observation.

b angiography.
c percutaneous nephrostomy.
d cystoscopy, retrograde pyelogram, and stent placement.
e surgical exploration and renorrhaphy.
8 Follow-up CT imaging for a grade 2 renal injury should be performed:
a only if the patient develops localized signs or symptoms.
b 2 to 3 days post-traumatic injury.

c 3 to 4 weeks post-traumatic injury.

d 3 months post-traumatic injury
e 1 year post-traumatic injury.
9 Retroperitoneal (renal) exploration is recommended when:
a a stab wound to the flank results in a grade 2 renal injury.
b a 38-caliber gunshot wound (GSW) results in a grade 2 renal injury.
c a motor vehicle accident (MVA) results in an isolated grade 4 renal injury.

d a nonhemorrhagic retroperitoneal mass is found on surgical exploration following a GSW.

e an MVA results in the need for emergent laparotomy due to vascular instability, and a

retroperitoneal hemorrhage is found on exploration.

10 A 12-year-old girl is involved in a bicycle MVA. A CT scan taken 2 hours following trauma reveals an
isolated renal injury with no perfusion and, subsequently, no function of the left kidney. The right kidney is
within normal limits. Vital signs are stable and hemoglobin is normal. The next step is:
a observation.
b angiography with stenting of left renal artery.

c angiographic infusion of streptokinase into left renal artery.

d systemic heparinization.
e surgical exploration.
11 In a patient with a preexisting ureteropelvic junction (UPJ) obstruction, gross hematuria following trauma
is usually due to:
a coexisting renal lithiasis.
b renal contusion.

c laceration through the thinned renal cortex.

d rupture of the renal pelvis.
e UPJ disruption.
12 The following is an absolute indication for CT cystography following blunt trauma:
a gross hematuria.
b abdominal wall bruising.

c pelvic fracture.
d lumbar spinal fracture.

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e inability to void.
13 In the presence of an extraperitoneal bladder injury, consideration for open surgical intervention should
be given if:
a gross hematuria with clots is present.
b the pubic ramus is fractured.

c a vaginal laceration is present.

d a coexisting rectal injury is present.
e the bladder neck appears incompetent.
14 While assessing bladder function for a delayed urethroplasty, a static cystogram reveals contrast in the
posterior urethra. The next step is:
a video urodynamics.
b a pudendal nerve electromyogram (EMG).

c MRI of the pelvis and perineum.

d MRI of the lumbosacral spinal cord.
e combined cystoscopy per suprapubic (SP) tube tract and urethroscopy per meatus.
15 A newborn has excess skin excised during circumcision, leaving a 7-mm gap between the residual penile
shaft skin and the mucosal collar. The next step is:
a wet-to-dry dressings and antibiotic ointment.
b to mobilize and suture the penile shaft skin to mucosal collar.

c to bury the phallus in scrotal skin with planned second-stage release.

d a split-thickness skin graft from thigh.
e a full-thickness skin graft from thigh.

Answers
1 d.Hematuria disproportionate to severity of trauma. The classic patient history that should make the
physician think of a preexisting renal anomaly is that the degree of hematuria present is disproportionate

to the severity of trauma. None of the other distracters have been found to be related to the presence of a
preexisting renal abnormality during the evaluation of trauma.
2 d.triphasic abdominal computed tomography (CT). A triphasic CT studya precontrast study,
followed by a study immediately following injection, and then a 15 to 20 minute delayed studyis the
most sensitive method for diagnosis and classification of renal trauma. A single-phase CT study is
beneficial in determining renal perfusion and major renal fractures but may, on occasion, miss the

presence of urinary extravasation and will miss the vast majority of ureteral injuries. Focused assessment
with sonography for trauma (FAST) evaluations are operator and experience dependent and will miss 5%
to 10% of clinically significant renal injuries. It is noteworthy, however, that a normal FAST sonographic
evaluation coupled with serial normal physical examinations over 24 hours will reliably detect all clinically
significant genitourinary (GU) injuries.
3 d.grade 4. A grade 4 renal injury is a laceration extending into the collecting system with urinary

extravasation, with viable or devitalized renal fragments, or is an injury to the main renal vasculature with
contained hemorrhage. (See Table 1382 in Campbell-Walsh Urology, 10th Edition.)
4 e.transportation to the emergency room by ambulance. Approximately 25% of patients with grade 3
to 4 renal trauma managed in a nonoperative fashion will have persistent or delayed hemorrhage.
Classically, delayed hemorrhage will present 10 to 14 days postinjury, but may occur up to 1 month after
the insult. Delayed hemorrhage arises from the development of arteriovenous fistulas, will not

spontaneously resolve, and may be associated with life-threatening hemorrhage. Management should be
by ambulance transportation, remembering that shock in a child may be one of the later signs of severe
bleeding. Intravenous access should be obtained by emergency medical technicians and the patient
immediately returned to the hospital for angiographic evaluation and embolization of the bleeding site.
5 a.angiographic embolization of the functional renal fragment. Urinary fistulas associated with a
viable renal fragment that is separate from the remaining portions of a traumatically injured kidney are

initially managed with percutaneous nephrostomy tube drainage and double-J stent placement. If
persistent fistula drainage continues, it may be managed by angiographic infarction of the isolated
functional segment, which will prevent the need for open surgical excision of the functional segment.
6 a.continued observation. Postembolization syndrome is well recognized and self-limiting. It is

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manifested by pyrexia up to 40 C, flank pain, and adynamic ileus. Symptoms should resolve in 96 hours
after the embolization. When pyrexia develops, blood and urine cultures are necessary to rule out

bacterial seeding of the necrotic tissue. Consideration for a repeat CT scan with possible aspiration,
culture, and drainage of a perinephric hematoma/urinoma should be given if febrile response persists for
greater than 96 hours or if a patient's clinical course deteriorates.
7 c.percutaneous nephrostomy. Post-traumatic urinomas are asymptomatic and have a spontaneous
resolution rate approaching 85%; they will occasionally persist and be associated with continued flank
pain, adynamic ileus, and/or low-grade temperature. Frequently, the authors will manage these patients
by endoscopic intervention, with cystoscopy, retrograde pyelography, and placement of a ureteral stent. It
should be noted that both percutaneous nephrostomy drainage and internal stenting are equally
efficacious. The advantage of an internal stent is that it prevents possible dislodgment of the draining tube

and the need for external drainage devices. The two major disadvantages of internal drainage are that
both stent placement and removal, in the pediatric patient population, require general anesthesia. In
addition, the small-size ureteral stents (4 to 5Fr) placed in young children may become blocked with
blood clots from the dissolving hematoma, resulting in persistence of the urinoma. In this young infant
with large perinephric clots, the best way to manage the problem is with a percutaneous nephrostomy.
This will allow external irrigation of the system, if the tube becomes blocked with clots.
8 a.only if the patient develops localized signs or symptoms. Follow-up renal imaging is not
recommended for grade 1 to 2 renal injuries and for grade 3 lacerations where all fragments are viable. In
patients with grade 3 renal lacerations associated with devitalized fragments and grade 4 and salvaged
grade 5 renal injuries, a repeat CT scan with delayed images should be obtained 2 to 3 days following the
traumatic insult. This study serves the purpose of assessing the extent of the hematoma/urinoma and will
serve as a baseline evaluation in case secondary hemorrhage or infection occurs. Irrespective of the

grade of the injury, repeat imaging with a triphasic CT scan is recommended for patients with a history of
renal trauma who have a persistent and/or increased fever, worsening flank pain, or persistent gross
hematuria greater than 72 hours following the traumatic insult. The authors recommend a 3-month followup triphasic CT scan in all grade 3 renal lacerations associated with a devitalized fragment and grade 4
and salvaged grade 5 renal injuries. This latter study is obtained to verify resolution of any perinephric
urinoma and to define the anatomic configuration of the residual functioning renal parenchyma.
9 e.an MVA results in the need for emergent laparotomy due to vascular instability, and a
retroperitoneal hemorrhage is found on exploration. An MVA results in an isolated grade 4 renal
injury. Retroperitoneal exploration is recommended in the setting of blunt trauma when abdominal

exploration is performed for vascular instability and retroperitoneal hemorrhage is identified, even when
there has not been adequate preoperative imaging. In these cases, assessment of contralateral function
is necessary as well. (See Table 1383 in Campbell-Walsh Urology, 10th Edition.)
10 a.observation. In a patient sustaining renal arterial trauma, the clinical triad of hemodynamic instability,
inadequate collateral blood flow, and warm ischemic time almost invariably results in the inability to
salvage renal function. Because of these facts, no attempt to repair injuries to segmental renal vessels
should be considered, and repair of the traumatically injured main renal artery is seldom, if ever, indicated
when a normal contralateral kidney is present. In essence, reconstruction of the main renal artery

following trauma is only a primary consideration in patients who are hemodynamically stable, with an
injury to a solitary kidney, or in patients with bilateral renal arterial injuries. The infrequent exception to
this rule is the presence of an incomplete arterial injury where perfusion to the kidney has been
maintained by flow of blood through either the partially occluded main renal artery or through collateral
vessels.
11 b.renal contusion. Although it has been reported that preexisting hydronephrosis or a congenital
ureteropelvic junction obstruction renders the patient more susceptible to a UPJ disruption, this is
controversial. The vast majority of patients with a history of trauma and preexisting UPJ or

hydronephrosis will be found to have a renal contusion or grade 1 renal injury on evaluation. When
urinary extravasation is seen, rupture of the renal pelvis or a major laceration extending through a thinned
renal cortex into the collecting system (grade 3 renal injury) is the most common finding, not a UPJ
disruption.
12 e.inability to void. Absolute indications for bladder imaging following blunt abdominal trauma are
currently limited to two indications: (1) the presence of gross hematuria coexisting with a pelvic fracture or
(2) inability to void. Neither gross hematuria alone or pelvic fracture alone are absolute indications for

screening. Relative indications for bladder imaging following blunt abdominal trauma are urinary clot
retention, perineal hematoma, and history of a prior bladder augmentation. Bladder imaging following
penetrating trauma should be performed any time concern exists that the missile could have penetrated
the bladder.
13
e.the bladder neck appears incompetent. If concern for a bladder neck injury is present, the patient
should undergo surgical exploration with opening of the bladder at the dome. Repair of the bladder neck

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should be performed by an intravesical approach with a multilayered closure. Great care should be given
not to dislodge the pelvic hematoma to help prevent blood loss. The surgeon should be aware that
anterior bladder neck lacerations are frequently associated with urethral injuries, and retrograde

urethrography or cystoscopy to rule out this possibility should be considered. If a bladder neck laceration
is repaired, a voiding cystourethrogram (VCUG) is necessary at the time of catheter removal to
adequately visualize the bladder neck and confirm healing.
14 a.video urodynamics. If the posterior urethra fills with contrast on the static cystogram, this could be
due to either a poorly felt or described detrusor contraction or to an incompetent bladder neck. Because
of the significant impact the latter has on the surgical prognosis, if contrast is seen in the posterior
urethra, a video urodynamic study (UDS) is necessary. If the video UDS documents an incompetent
bladder neck, or if the patient was unable to open up the bladder neck to allow visualization of the

posterior urethra during the VCUG, we perform a simultaneous flexible cystoscopy and urethroscopy. On
occasion, the physician may need to use flexible ureteroscopes for this procedure in small children. If
cystoscopy and video urodynamics demonstrate an incompetent bladder neck, we discuss with the
patient and his or her family the options of urethral reconstruction with the possible result of chronic
incontinence or, alternatively, the performance of a continent abdominal stoma, appendicovesicostomy as
first-line therapy.
15 a.wet-to-dry dressings and antibiotic ointment. Penile trauma in the pediatric patient population is
most commonly iatrogenic and caused by circumcision. If excess penile skin is excised during
circumcision, the majority of patients can be treated by wet-to-dry dressings and antibiotic ointment.

Healing by secondary intention usually results in an excellent cosmetic appearance. If the penis is totally
degloved, the penile shaft skin, if salvaged, can be defatted and replaced on the penis as a full-thickness
skin graft.
Additional Study Points
1 Preexisting renal anomalies are commonly found in children who present with traumatic injuries of the
kidney.
2 In children, there is a poor correlation between the presence of hematuria and a renal injury.
3 A single-shot IVP intraoperatively is only useful in determining the presence of a contralateral kidney when

an ipsilateral nephrectomy is anticipated.

4 The vast majority of AV fistulas that occur after trauma will not spontaneously resolve, unlike AV fistulas

following a renal biopsy, where spontaneous resolution is the rule.

5 Most post-traumatic urinomas are asymptomatic and will resolve spontaneously.
6 When there is a coexistence of an intra-abdominal injury adjacent to the urinary tract injury, the two should

be separated by interposing tissue, often omentum.

7 Post-traumatic hypertension in children is usually due to a small poorly functioning kidney; it is renin

mediated, and nephrectomy is generally the best option.

8 CT findings associated with UPJ disruption include medial extravasation, absence of parenchyma

lacerations, and no visualization of the distal ureter. Immediate surgical repair is preferred.
9 Traumatic bladder lacerations in children are likely to extend through the bladder neck and require surgical

exploration and repair.

10 When a urethral injury is found with a pelvic fracture, a concurrent rectal injury is present in 15%; in

females, urethral injuries associated with pelvic fractures are associated 75% of the time with vaginal
lacerations and 30% of the time with rectal injury.
11 A diverting colostomy is appropriate in traumatic injuries of the urethra associated with rectal injuries.
12 Penile strangulation caused by hair should be suspected when circumferential edema and/or necrosis is

noted from a circumferential point distally.

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