Resuscitation and Stabilization A General Approach to the Ill or Injured Child: Chapter Signs and Symptoms Inguinal Masses: Chapter 39 Pain: Scrotal: Chapter 61 Vaginal Bleeding: Chapter 79 Vaginal Discharge: Chapter 80 Medical, Surgical, and Trauma Emergencies Genitourinary Emergencies: Chapter 119 GOALS OF EMERGENCY THERAPY The goal of emergency therapy for genitourinary injury is to maximize organ preservation and minimize future morbidity To achieve these goals, the initial management of children with genitourinary injury in the ED centers on prompt recognition and staging of injuries, followed by appropriate urologic consultation for management and potential surgical intervention The recognition and treatment of children with genitourinary injury requires an understanding of the mechanism of injury as well as signs and symptoms associated with genitourinary injury along with appropriate use of diagnostic imaging To provide a comprehensive and accessible guide for management of children with genitourinary injury, we discuss trauma of each genitourinary organ separately yet emphasize the potential for concomitant extrarenal injury and need for maintaining a high level of suspicion for these associated injuries KIDNEY Goal of Treatment The principle underlying the management of pediatric renal trauma is preservation of renal tissue and function while minimizing morbidity and mortality Patients who are hemodynamically unstable or have sustained severe penetrating trauma to the kidney require immediate surgical intervention Management of hemodynamically stable children proceeds on the basis of radiographic staging of the traumatic injury CLINICAL PEARLS AND PITFALLS In the adult population, radiographic evaluation is required in patients with hypotension, penetrating injuries in the vicinity of urologic organs, associated abdominal injuries, or the presence of any degree of hematuria Criteria regarding the imaging of children with penetrating trauma are less well established Hypotension is not a reliable indicator of significant renal injury in children and therefore is not used to guide management; however, most patients with multisystem trauma and hypotension undergo an abdominal computed tomographic (CT) scan screening that elucidates both nonurologic and urologic injuries Radiographic evaluation of the pediatric genitourinary tract is necessary in cases with clinical signs indicative of renal injury, gross hematuria, major associated injuries, or history of significant deceleration forces For blunt abdominal trauma, imaging is considered in any stable child with gross hematuria or significant microscopic hematuria (>50 red blood cells per high power field) associated with shock (systolic blood pressure 50 red blood cells with or without shock Additionally, any child with a significant associated injury or a suspicious mechanism of injury such as a rapid deceleration, high velocity strike, fall from >15 ft, or a direct blow to the abdomen or flank should be imaged regardless of the presence of hematuria All clinically stable children with penetrating abdominal or pelvic trauma should undergo radiographic assessment Stable blunt trauma patients with microscopic hematuria may be observed without imaging, unless they suffered a major acceleration or deceleration injury such as a fall from a great height or high-speed MVC FIGURE 108.1 Algorithm for the evaluation of the pediatric patient with genitourinary trauma IVP, intravenous pyelogram; CT, computed tomography; RBC, red blood cell; HPF, highpowered field; UAs, urinalyses Current Evidence Approximately half of all genitourinary injuries involve the kidney Most pediatric renal trauma is minor, requiring no intervention Children are more likely than adults to sustain renal injuries for the following reasons: The pediatric kidney is larger in proportion to the size of the abdomen than in adults; the child’s kidney may retain fetal lobations which allow for easier parenchymal disruption; the pediatric kidney has inadequate protection due to weaker abdominal musculature, a less well-ossified thoracic cage, and less developed perirenal fat and fascia than in adults Blunt trauma accounts for more than 90% of renal injuries in children The majority result from motor vehicle accidents; falls, sports-related incidents, and direct blows are also common mechanisms of injury In these scenarios, the kidneys are crushed against the ribs or vertebral column from their relatively fixed position within Gerota fascia Injuries include contusions, renal lacerations, and rarely stretching of the vascular pedicle causing renal vein or artery injuries Penetrating trauma accounts for the 10% of remaining cases Approximately 10% of penetrating abdominal injuries involve the kidney Minor renal injuries account for 85% of total injuries, lacerations in 10%, and severe kidney ruptures, fractures of pedicle injuries in less than 5% of cases Associated extrarenal injuries often occur, with head injuries being the most common Associated intraperitoneal injuries occur in 80% of patients with penetrating renal trauma and 20% of patients with blunt renal trauma In general, the hospital length of stay is determined by the associated injuries and not the renal injuries Historically, pre-existing anomalies have been believed to increase the risk and severity of injury to the kidney Coincidental congenital renal anomalies and intrarenal tumors have been reported in up to 20% of children with renal injuries However, it appears that in most patients, congenital genitourinary anomalies associated with renal injury are incidental findings and not increase morbidity More accurate recent reviews show that the incidence rate is closer to 1% Nevertheless, a high index of suspicion should be maintained in any child who presents with gross hematuria after a relatively minor trauma Other patients may present with an acute abdomen due to intraperitoneal rupture of a hydronephrotic kidney Clinical Considerations Clinical Recognition Children who sustain significant renal injuries usually present with localized signs such as flank tenderness, hematoma, palpable mass, or ecchymosis However, since kidney injuries are often associated with injuries to other organs, generalized abdominal tenderness, rigidity of the abdominal wall, paralytic ileus, and hypovolemic shock may all be part of the clinical picture Penetrating injuries to the chest, abdomen, flank, and lumbar regions should alert the clinician to the possibility of a renal injury Hematuria has long been considered the cardinal marker of renal injury and 98% of pediatric patients suffering a renal injury will have some degree of hematuria However, the degree of hematuria does not correlate with the severity ... involve the kidney Most pediatric renal trauma is minor, requiring no intervention Children are more likely than adults to sustain renal injuries for the following reasons: The pediatric kidney is... a fall from a great height or high-speed MVC FIGURE 108.1 Algorithm for the evaluation of the pediatric patient with genitourinary trauma IVP, intravenous pyelogram; CT, computed tomography;... screening that elucidates both nonurologic and urologic injuries Radiographic evaluation of the pediatric genitourinary tract is necessary in cases with clinical signs indicative of renal injury,