Treatment of intraperitoneal bladder rupture involves surgical exploration and repair Clinical Indications for Discharge or Admission Children with bladder injuries should be admitted to the hospital for further operative or nonoperative care URETHRA Goal of Treatment The goals of the acute management of children with urethral injuries include identifying the extent and location of the potential urethral injury and, in consultation with urology, providing safe drainage of the bladder while minimizing the risk of long-term sequela such as urethral stricture or erectile dysfunction FIGURE 108.4 Sagittal section of male lower urinary tract illustrating levels of urethra CLINICAL PEARLS AND PITFALLS In boys, the urethra is divided by the urogenital diaphragm into an anterior urethra (pendulous and bulbous) and a posterior urethra (membranous and prostatic) ( Fig 108.4 ) Anterior and posterior urethral injuries differ from each other by mechanism of injury, clinical presentation, and treatment The major sign of acute anterior injury is bleeding from the urethra Urethral injury should be suspected when there is blood at the meatus, hematuria, inability to void, displacement of the prostate on rectal examination, and/or perineal ecchymosis Blind placement of a urethral catheter when urethral injury is suspected is discouraged as it may theoretically convert a partial tear into a complete transection Current Evidence Blunt trauma, due to motor vehicle accidents, high-velocity falls onto the perineum, and straddle injuries, accounts for most urethral injuries sustained during childhood Injuries due to instrumentation and penetrating injuries, such as gunshot wounds, are less common Urethral injuries occur primarily in males Anterior urethral injuries result from direct trauma and are often isolated The pendulous urethra is well protected from injury when the penis is flaccid, but can be damaged by blunt or penetrating forces Bulbar injuries are more common and most often result from straddle injuries, as the urethra is compressed between the symphysis pubis and a solid object Posterior urethral injuries occur with severe trauma to the body and are usually associated with other injuries, particularly pelvic fractures Posterior urethral injuries in men almost uniformly occur distal to the prostate In adults, the mature prostate, puboprostatic ligament, and bladder stabilize the prostatic urethra, making it less susceptible to trauma When this occurs, the urethra is usually sheared at the level of the urogenital diaphragm with separation of the prostate from the membranous urethra or the bulbar urethra from the membranous urethra The mortality rate with fractured pelvis has been reported to be as high as 30% Injuries to the prostatic urethra may extend to the bladder neck Female urethral injuries are commonly divided into avulsions and longitudinal tears These injuries occur most often from blunt abdominal trauma in motor vehicle accidents and in association with pelvic fractures Injuries may also occur after surgical procedures or instrumentation The diagnosis is missed on initial assessment in up to 40% of patients, emphasizing the need for careful physical examination and diagnostic evaluation Clinical Considerations Clinical Recognition Blood at the meatus has been reported in up to 90% of patients sustaining anterior urethral injuries Other findings include hematuria, inability or difficulty voiding, and periurethral or perineal edema, ballooning and ecchymosis Perineal ecchymosis in the shape of a butterfly is typical for these injuries Posterior urethral injury may be predicted by the location and displacement of associated pelvic fractures There is an association between pubic arch fractures and urethral injury, with higher risk as the number of broken rami increases The classically described “high-riding prostate” is rarely found clinically Because the female urethra is relatively mobile and short, trauma to the urethra is uncommon It was reported in less than 6% of cases with associated pelvic fractures in one series of women and girls When it does occur, it is found more commonly in girls than in women In one series, every female patient with a significant urethral injury had gross hematuria or blood at the introitus and a pelvic ring fracture Any female patient with this combination of findings should be evaluated for a urethral injury Most serious injuries involve the vesicourethral junction and extend to the vagina Initial Assessment/Diagnostic Testing Urethral injuries in males can be diagnosed by a retrograde urethrogram (RUG) The patient is positioned with a bump under one side with the lower leg slightly bent A tapered inserter (such as a pediatric Taylor adaptor or angiocatheter) or if necessary, a Foley catheter appropriate for the size of the patient is inserted into the urethra to the fossa navicularis If a Foley is used, the balloon should not be inflated within the urethra Contrast material is injected via the catheter to gently distend the urethra and images are obtained If a Foley catheter is already in place, the urethrogram can still be performed via a small feeding tube passed alongside the catheter Retrograde urethrography should be performed under fluoroscopy with minimal pressure Gross extravasation of the contrast agent at the site of the injury without visualization of the proximal urethra and bladder is diagnostic for complete rupture of the urethra Partial rupture is represented by localized extravasation at the site of the injury, with some contrast passing into the proximal urethra and bladder If no extravasation is noted, a urinary catheter can be gently advanced into the bladder CT is not adequate for diagnosing urethral injuries and is presumptive only if extravasation is detected at the bladder neck or urethra ( Fig 108.5 ) US or MRI may provide useful information in determining need for surgical repair, but these modalities are not especially useful in the initial evaluation It is recommended that, whenever possible, a full speculum examination be performed in females with gross hematuria and pelvic ring fractures, difficulty placing a urethral catheter, and anticipated delay until the pelvic fractures are stabilized as injury often extends to the vagina Management In the acute setting, partial anterior urethral injuries in males can be managed by to 10 days of urethral catheterization More severe injuries may require urinary diversion by suprapubic cystostomy Initial management of anterior urethral injuries remains controversial Urologic follow-up is required as the most common sequelae of anterior urethral injury, urethral stricture, may take months or longer to manifest and is usually managed definitively in a delayed fashion Penetrating wounds of the urethra demand early surgical exploration with conservative debridement and primary repair Patients with extensive loss of urethral tissue can be managed with delayed repair and staged reconstruction The acute management of posterior urethral injuries also remains controversial The comparative effectiveness and benefits of immediate exploration and realigning the urethra over an indwelling urethral catheter versus placement of a suprapubic tube and delayed urethroplasty are debated by experts Primary repair of posterior urethral injuries is generally discouraged For urethral injuries in females, most authors recommend some form of primary operative repair of the urethral rupture with closure of associated vaginal tears Placement of a suprapubic tube and delayed repair are reserved for unstable patients, as placement has been associated with scarring, strictures, urethral obliteration, and fistulas Long-term complications of this injury include urethrovaginal fistula, vaginal stenosis, incontinence, sexual dysfunction, and urethral stricture Clinical Indications for Discharge or Admission For children with isolated straddle injuries that not result in urethral rupture, it is necessary to ensure that the child can void and empty their bladder prior to discharge Occasionally, a catheter may need to be placed for to days to allow bladder drainage while the urethral edema resolves Follow-up with a urologist is essential as urethral stricture formation is a common long-term consequence of these injuries More severe urethral injuries, including those that result in urethral rupture, require admission All patients with posterior urethral injuries are to be admitted given the severity of the associated pelvic injuries ... positioned with a bump under one side with the lower leg slightly bent A tapered inserter (such as a pediatric Taylor adaptor or angiocatheter) or if necessary, a Foley catheter appropriate for the