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FIGURE 108.6 Penile zipper injury A wire cutter may be used to cut the median bar of the zipper, releasing the two sides of the zipper and freeing the penis FIGURE 108.7 Screwdriver technique for the release of foreskin entrapped in the zipper The screwdriver should be placed between the two faceplates and twisted toward the median bar PERINEUM The mechanism most commonly associated with trauma to the female perineum is a straddle-type injury These injuries may cause vulvar hematomas, which usually respond to treatment with ice packs and bed rest Patients experiencing mild urinary retention may be more comfortable voiding in a tub of warm water Massive or expanding hematomas may require surgical exploration and evacuation Superficial lacerations of the perineum can be treated conservatively at home with sitz baths Deep lacerations may extend into the rectum or urethra If the extent of injury cannot be easily defined, surgical consultation for examination under anesthesia should be requested Rectal injury requires a diverting colostomy Suprapubic cystostomy or primary repair should be performed if the urethra is disrupted Vaginal lacerations must be suspected in patients with severe trauma to the external genitalia or penetration by foreign object If a significant vaginal laceration is noted, endoscopy with sedation or general anesthesia is necessary for a full evaluation The possibility of extension into the urethra, bladder, or rectum must be investigated The vaginal laceration is debrided and repaired with fine absorbable sutures SEXUAL ABUSE When common accidental situations fail to explain certain genitourinary injuries, the possibility of sexual abuse should be considered Injuries resulting from sexual abuse include abrasions and hematomas in the penile shaft, vaginal lacerations, and perineal hematomas (see also Chapters 79 Vaginal Bleeding and 87 Child Abuse/Assault ) Suggested Readings and Key References Aihara R, Blansfield J, Millham FH, et al Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures J Trauma 2002;52:205–209 Alli MO, Singh B, Moodley J, et al Prospective evaluation of combined suprapubic and urethral catheterization to urethral drainage alone for intraperitoneal bladder injuries J Trauma 2003;55:1152–1154 Andrich D, Day AC, Mundy AR Proposed mechanisms of lower urinary tract injury in fractures of the pelvic ring BJU Int 2007;100:567–573 Black PC, Miller EA, Porter JR, et al Urethral and bladder neck injury associated with pelvic fracture in 25 female patients J Urol 2006;175:2140–2145 Brandes S, Borrelli J Jr Pelvic fracture and associated urologic injuries World J Surg 2001;25:1578–1587 Broghammer JA, Langenburg SE, Smith SJ, et al Pediatric blunt renal trauma: its conservative management and patterns of associated injuries Urology 2006;67:823–827 Brown SL, Haas C, Dinchman KH, et al Radiologic evaluation of pediatric blunt trauma in patients with microscopic hematuria World J Surg 2001;25:1557– 1560 Buckely JC, McAninch JW The diagnosis, management, and outcomes of pediatric renal injuries Urol Clin North Am 2006;33:33–40 Chandra RV, Dowling RJ, Ulubasoglu M, et al Rational approach to diagnosis and management of blunt scrotal trauma Urology 2007;70:230–234 Guichard G, El Ammari J, Del Coro C, et al Accuracy of ultrasonography in diagnosis of testicular rupture after blunt scrotal trauma Urology 2008;71:52– 56 Hagedorn JC, Voelzke BB Pelvic-fracture urethral injury in children Arab J Urol 2015;13(1):37–42 Henderson CG, Sedberry-Ross S, Pickard R, et al Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center J Urol 2006;178:246–250 Ko SF, Ng SH, Wan YL, et al Testicular dislocation: an uncommon and easily overlooked complication of blunt abdominal trauma Ann Emerg Med 2004;43:371–375 LeeVan E, Zmora O, Cazzulino F, et al Management of pediatric blunt renal trauma: a systemic review J Trauma Acute Care Surg 2016;80(3):519–528 Lynch TH, Martinez-Pineiro L, Plas E, et al EAU guidelines on urologic trauma Eur Urol 2005;47(1):1–15 Morey AF, Brandes S, Dugi DD 3rd, et al Urotrauma: AUA guideline J Urol 2014;192(2):327–335 Nguyen MM, Das S Pediatric renal trauma Urology 2002;59:762–766 Osman Y, El-Tabey N, Mohsen T, et al Nonoperative treatment of isolated posttraumatic intraperitoneal bladder rupture in children—is it justified? J Urol 2005;173:955–957 Parry NG, Rozycki GS, Feliciano DV, et al Traumatic rupture of the bladder: is the suprapubic tube necessary? J Trauma 2003;54:431–436 Quagliano PV, Delair SM, Malhotra AK Diagnosis of blunt bladder injury; a prospective comparative study of computed tomography cystography and conventional retrograde cystography J Trauma 2006;61:410–422 Raveenthiran V Releasing of zipper-entrapped skin: a novel nonsurgical technique Pediatr Emerg Care 2007;23:463–464 Rogers CG, Knight V, Macura KJ, et al High-grade renal injuries in children—is conservative management possible? Urology 2004;64:574–579 Santucci RA, Langenburg SE, Zachareas MJ Traumatic hematuria in children can be evaluated as in adults J Urol 2004;171:822–825 Tarman GJ, Kaplan GW, Lerman SL, et al Lower genitourinary injury and pelvic fractures in pediatric patients Urology 2002;59:123–126 Tasian GE, Bagga HS, Fisher PB, et al Pediatric genitourinary injuries in the United States from 2002 to 2010 J Urol 2013;189(1):288–293  ... et al Pediatric blunt renal trauma: its conservative management and patterns of associated injuries Urology 2006;67:823–827 Brown SL, Haas C, Dinchman KH, et al Radiologic evaluation of pediatric. .. et al Lower genitourinary injury and pelvic fractures in pediatric patients Urology 2002;59:123–126 Tasian GE, Bagga HS, Fisher PB, et al Pediatric genitourinary injuries in the United States from... Sedberry-Ross S, Pickard R, et al Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center J Urol 2006;178:246–250 Ko SF, Ng SH, Wan YL, et al Testicular dislocation: