Pediatric emergency medicine trisk 3327 3327
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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
