Pediatric emergency medicine trisk 3328 3328
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (70.76 KB, 1 trang )
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
7 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 do 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 5 to 7 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.
