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"The bruises and the battles."

Updated: Mar 23

From falls to tackles, how we mend the war wounds of youthful explorers.


Renal and Ureteral Injuries


In the sphere of paediatric urology, renal and ureteral injuries are a significant concern that demands meticulous attention due to their potential to result in severe complications if not addressed promptly. These injuries are often a result of blunt or penetrating trauma, and while they are less common in children than in adults, their management is critical in preventing future renal impairment.


Renal injuries are classified based on their severity, ranging from minor contusions to severe lacerations that may necessitate nephrectomy. Minor injuries, such as contusions or small lacerations, often heal spontaneously with conservative management including bed rest, pain control, and close observation. Serial imaging may be required to monitor the resolution of the injury and to ensure no complications arise, such as urinoma or abscess formation.

In contrast, severe renal injuries, such as shattered kidney or renal pedicle injury, may necessitate immediate surgical intervention. The surgical management of these injuries can be challenging and may involve renal reconstruction or, in the most severe cases, nephrectomy. The aim is always to preserve as much renal function as possible, as the loss of a kidney can have significant long-term implications for a child's health.


Ureteral injuries are less common than renal injuries but can be just as serious. They most often occur as a result of iatrogenic injury during abdominal surgery. Ureteral injuries can be difficult to diagnose immediately, as the symptoms may not present until several days post-injury. Symptoms may include flank pain, haematuria, and signs of urinary tract infection. If a ureteral injury is suspected, imaging such as a computed tomography (CT) scan or intravenous urogram can help confirm the diagnosis.

Management of ureteral injuries depends on the severity of the injury. Minor injuries may be managed conservatively with a ureteral stent to facilitate healing. However, more severe injuries, such as complete transection of the ureter, require surgical repair. This may involve ureteroureterostomy, in which the injured section of the ureter is removed and the two healthy ends are reconnected,


Ureteroureterostomy
Ureteroneocystostomy








or ureteroneocystostomy, where the ureter is reimplanted into the bladder.


In all cases of renal and ureteral injuries, the primary goal is to restore urinary tract function and preserve as much kidney function as possible. This is especially important in children, who have a long life ahead of them and therefore a greater potential for long-term complications from renal impairment.


Furthermore, the psychological impact of these injuries and their management should not be underestimated. Children and their families may require support and counselling to help them cope with the injury and its implications.


In conclusion, renal and ureteral injuries, while relatively uncommon in paediatric patients, require prompt recognition and appropriate management to prevent long-term complications. With careful management, most children with these injuries can expect to lead healthy, normal lives.


Bladder and Urethral Injuries


Bladder and urethral injuries are relatively uncommon, yet they can pose significant challenges in diagnosis and management. These injuries often occur as a result of blunt or penetrating trauma, and may be associated with other injuries, making a comprehensive evaluation essential.



The bladder, being a hollow organ, is susceptible to rupture. When the bladder is full, it becomes more vulnerable to injury. This can occur through blunt trauma, such as a fall or a blow to the lower abdomen, or through penetrating trauma, for instance, in the case of a gunshot wound. The severity of bladder injuries can range from contusions to complete rupture. Bladder ruptures are classified as either extraperitoneal, intraperitoneal, or both, depending on whether the rupture extends to the peritoneal cavity.


The black area shows the area where urine extravasates

In the case of extraperitoneal bladder injuries, they typically result from a direct blow to a filled bladder, causing it to rupture against the pelvic brim. These injuries are often associated with pelvic fractures. The child may present with lower abdominal pain, difficulty or inability to void, and signs of peritonitis if the injury is severe. Diagnosis is usually confirmed by a cystogram, which can identify the site and extent of the rupture.


Intraperitoneal bladder injuries, on the other hand, are less common but more severe. They typically result from a forceful blow to the lower abdomen when the bladder is distended, causing it to rupture at the dome. The urine then leaks into the peritoneal cavity, leading to chemical peritonitis. The child may present with signs of acute abdomen, and diagnosis is confirmed by a cystogram showing extravasation of contrast into the peritoneal cavity.


Urethral injuries in children are rarer than bladder injuries and are usually associated with pelvic fractures or straddle injuries. The male urethra, because of its length and location, is more prone to injury than the female urethra. Urethral injuries can be partial or complete and can occur at any part of the urethra. The child may present with blood at the urethral meatus, inability to void, a palpable bladder, or a high-riding prostate on rectal examination.



Diagnosis of urethral injuries is typically confirmed by a retrograde urethrogram, which can show the site and extent of the injury. An antegrade cystourethrogram (adjacent figure) can also be done if there is a suspicion of a bladder injury. The management of urethral injuries depends on the severity and location of the injury, but often involves suprapubic catheterization for urinary diversion and delayed urethral reconstruction.


In summary, bladder and urethral injuries in children, although uncommon, can be severe and necessitate prompt diagnosis and appropriate management. A high index of suspicion is required, especially in children presenting with lower abdominal pain, inability to void, and signs of peritonitis or acute abdomen after a trauma. Early diagnosis and appropriate management can minimize complications and improve outcomes.

 

Genital Injuries


One of the areas that can often cause significant distress to both the child and the parents is genital injuries. These injuries can occur due to various reasons, such as accidents, falls, sports-related injuries, and even abuse. It is crucial to understand the types of injuries, their management, and the potential complications that could arise.


The most common type of genital injury in boys is trauma to the testicles. This can result from a direct blow to the scrotum, leading to excruciating pain and swelling. Although most testicular injuries are minor and resolve with basic measures such as rest, ice, compression, and elevation (RICE), some may lead to serious complications like testicular rupture or torsion. These conditions require immediate surgical intervention to prevent testicular loss.





Another common injury is zipper injury to the prepuce in uncircumcised boys. A rather distressing condition, which if managed promptly can save a lot of morbidity and pain. Sometimes it might need circumcision.




Adapted from Netter's Atlas of anatomy

In girls, the most common genital injury is labial trauma, often caused by straddle injuries, where the child falls with one leg on each side of an object, causing direct trauma to the genitals. These injuries usually cause minor lacerations or bruising but can occasionally lead to more significant injuries like urethral or vaginal tears. The management of these injuries depends on their severity and may range from conservative treatment to surgical repair.


Another type of genital injury that can occur in both boys and girls is burns. These can occur due to hot liquids, open flames, or chemical exposure. Genital burns are particularly concerning due to the risk of scarring and subsequent impact on sexual function and fertility.


The initial management of genital burns involves cooling the area with cold water, removing any clothing or jewellery, and covering the burn with a clean, non-adhesive dressing. Severe burns require immediate medical attention and possibly surgical intervention.


A unique aspect of paediatric urology is the management of genital injuries resulting from child abuse.

These injuries can be challenging to identify and manage due to the sensitive nature of the subject. It is crucial to maintain a high index of suspicion in children presenting with unusual or unexplained genital injuries, recurrent urinary tract infections, or behavioural changes. The management of these cases involves not only medical treatment but also reporting to child protective services and providing psychological support to the child.


Managing genital injuries in children also involves addressing the psychological impact of these injuries. Children may experience fear, embarrassment, or anxiety following a genital injury. It is essential to provide reassurance, explain the treatments in child-friendly language, and involve a child psychologist or counsellor if needed.


In conclusion, genital injuries in paediatric urology present unique challenges in terms of diagnosis, management, and follow-up. The key to successful management is a thorough understanding of the types of injuries, prompt and appropriate treatment, and a multidisciplinary approach involving surgeons, paediatricians, and psychologists. It is also crucial to educate parents and children about the prevention of genital injuries, particularly in relation to sports and play activities.



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