Pediatric emergency medicine trisk 3334 3334
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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.
