Pediatric Urethral Injury and Symptoms

A] What Causes Pediatric Urethral Injury?

Pediatric urethral injury can occur due to various factors. Although rare, it can lead to major urethral damage in children. This condition calls for an immediate diagnosis and management. Trauma to the anterior urethra can happen due to straddle injuries—coming down hard on something between your legs, or pelvic fractures.  For example, a bicycle seat or crossbar, playground equipment like a horizontal bar, gymnastics beam, fence rail, horse saddle horn, seesaw, balance beam or edge of a swimming pool, or even a climbing frame. Additionally, instances of sexual assault or injury from foreign objects can also result in urethral damage. In short, any direct trauma to the genital area can cause potential trauma. Therefore, it’s essential to look out for any urethral injury signs in a child, to prevent and address this condition promptly.

B] Recognizing Symptoms of Urethral Injury in Children

Here are some key childhood urethral trauma symptoms to watch out for:

• Difficulty or Pain During Urination

Children with urethral injuries may experience pain or discomfort while urinating.

• Blood in the Urine (Hematuria)

The presence of blood in the urine is a common sign of urethral injury. It may appear as pink, red, or cola-coloured urine.

• Genital Swelling or Inflammation

Swelling or inflammation in the genital area, including the penis or vulva, can indicate trauma to the urethra. This may be accompanied by tenderness or bruising.

• Abdominal Pain

Some children with urethral injuries may experience abdominal pain, particularly if there is urinary retention or other complications.

• Urinary Retention

In severe cases, urethral injury can lead to urinary retention, where the child is unable to pass urine normally. This can cause discomfort and may require immediate medical attention.

• Changes in Urinary Habits

Parents should be alert about any shifts in their child’s urinary habits. For example, increased frequency or urgency could indicate underlying issues.

• Behavioural Changes

Children may exhibit behavioural changes in response to urethral injury, such as avoiding the bathroom or expressing fear or discomfort during urination.

• Genital Bruising or Pain

Visible bruising or pain in the genital area, especially following trauma to the pelvic region, should raise suspicion for urethral injury. Besides being aware of these symptoms of urethral injury, it’s important to also differentiate between common urinary disorders, like urinary tract infections (UTIs), and traumatic injuries to the urethra. Even if some symptoms overlap, the underlying causes and treatment approaches can differ highly.

C] Diagnostic Procedures for Pediatric Urethral Injury

Hare the main diagnostic tools used in cases of urethral trauma in children:

Urinalysis

It is a basic yet essential diagnostic test. It provides valuable information about blood in the urine (hematuria) and signs of urinary tract infection (UTI), which may accompany urethral injury.

Imaging Studies

Various imaging techniques are used to visualise the urinary tract and assess for any structural abnormalities or injuries. These include:

• Ultrasonography

Ultrasonography can be used to assess the kidneys, bladder, and urethra for any signs of trauma or obstruction. It is a non-invasive and readily available imaging modality.

• Voiding Cystourethrogram (VCUG) 

VCUG is a fluoroscopic procedure that involves injecting contrast dye into the bladder through a catheter and then observing the flow of contrast through the urethra during urination. It can help identify urethral strictures, fistulas, or other abnormalities.

• Cystoscopy

Cystoscopy includes inserting a thin, flexible tube with a camera into the bladder and urethra to directly visualise the interior structures. It allows for direct inspection of the urethra and assessment of any injuries or obstructions.

• Urethrography 

Urethrography is a radiographic imaging technique specifically focused on the urethra. It can provide detailed images of the urethral anatomy and any abnormalities, such as strictures or disruptions.

• Computed Tomography (CT) Scan

CT scans may be used in cases where there is suspected severe or complex urethral trauma, particularly in the setting of pelvic fractures. CT scans can provide detailed cross-sectional images of the pelvic region and urinary tract.

• Magnetic Resonance Imaging (MRI) 

MRI may be utilised in select cases to further evaluate urethral injuries, particularly when assessing soft tissue structures or identifying associated complications.

D] Treatment Options for Pediatric Urethral Injury

Here are some of the options available to treat pediatric urological conditions:

Suprapubic Catheterization

This involves inserting a catheter directly into the bladder through the abdomen. It allows for urine drainage while bypassing the injured urethra. It promotes healing and preventing complications.

Urethral Dilatation

Urethral dilatation involves gradually stretching the narrowed or scarred portion of the urethra using specialised instruments. It aims to improve urethral patency and urinary flow.

Endoscopic Procedures

Endoscopic techniques are one of the most widely accepted urologic disorders treatment strategies. For example, cystoscopy and ureteroscopy. It is used to directly visualise the urethra and perform interventions such as urethral dilation, stent placement, or internal urethrotomy.

• Direct Vision Internal Urethrotomy (DVIU)

DVIU is a minimally invasive procedure. It is done under direct visualisation using a cystoscope. It involves making incisions in the scar tissue or strictures. It wides the urethral lumen and improves urine flow.

• Balloon Dilation

This is a less invasive alternative to surgical procedures. The balloon is inflated within the narrowed urethral segment to widen and relieve obstruction.

Open Surgical Repair

Open surgical repair becomes necessary in terms of severe or complex urethral injuries. This involves directly accessing the injured urethra through a surgical incision and performing reconstructive procedures such as primary anastomosis or urethroplasty.

• Primary Anastomosis

Primary anastomosis involves surgically reconnecting the ends of the severed urethra. It helps to restore continuity. It is typically performed in cases of complete urethral disruption.

• Urethroplasty

Urethroplasty is a reconstructive surgery. It repairs or replaces damaged segments of the urethra using tissue grafts or flaps. It may be indicated for complex urethral strictures or defects.

• ASTRA (Anterior Sagittal Trans Anorectal Approach)

ASTRA is a surgical technique used to repair posterior urethral injuries. It provides excellent exposure of the posterior urethra and allows for precise repair under direct vision.

Stent Placement

Stents may be placed temporarily. It helps to maintain urethral patency and prevent re-structuring after surgical repair or dilation procedures.

Fistula Repair

Fistula formation complicates urethral injury. Surgical repair may be necessary to close the abnormal connections between the urethra and adjacent structures.

Follow-up Care

Long-term follow-up with a pediatric urologist is essential to monitor for recurrence of symptoms, assess urethra pain treatment outcomes, and address any potential complications.