Summary of emergency treatment experience of acute urethral trauma in girls

doi:10.21203/rs.3.rs-4663246/v1

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Summary of emergency treatment experience of acute urethral trauma in girls

https://doi.org/10.21203/rs.3.rs-4663246/v1

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Purpose

To summarize our treatment experience of acute urethral trauma in girls.

Methods

We retrospectively analyzed six girls with acute urethral trauma who were admitted to our hospital from April 2003 to April 2023 and followed up.

Results

All six patients had pelvic fractures and vaginal injuries, and one had a rectal injury. Five showed a large amount of fresh blood flowing from the perineum and an inability to urinate. However, the remaining patient had a more insidious onset, causing the emergency doctors to miss the diagnosis. Four had severe perineal tearing and had lost their normal urethral and vaginal openings, making urinary catheter insertion impossible. The diagnosis was very clear. The other two were diagnosed with urethrovaginal injury during cystourethroscopy. Five underwent urethral and vaginal repair surgery within 7 days after the injury, and two of them developed complications requiring endoscopy or reoperation. Postoperative questionnaire scoring showed that four patients had normal urinary function and two had mild dysfunction.

Conclusion

The diagnosis of acute urethral trauma in girls requires vigilance. If the patient’s vital signs are stable, emergency urethrovaginal repair surgery can be performed. Although this is difficult and requires experienced pediatric urologists, it facilitates discovery of concurrent injuries.

girls

emergency

urethral trauma

treatment

Urethral trauma in female patients is rare and only sporadically reported in the literature. Most of these patients have blunt injuries [1], the most common cause of which is external trauma resulting in pelvic fractures. An estimated 4.6–6.0% of pelvic fractures in female patients are associated with urethral injury [2, 3]. Children’s bones are not yet fully developed; they are characterized by a high cartilage ratio and higher elasticity than adults’ bones, allowing them to absorb more energy in the event of injury [4]. Pelvic fractures with pelvic ring rupture, especially Malgaigne fractures and straddle fractures, are associated with a particularly high incidence of urethral injury [5]. These unstable fractures are more common in children than in adults. Therefore, the incidence rate of pelvic fracture and urethral injury is also higher in children than in adults [6].

Urethral trauma is associated with more complex symptoms in female than male patients. In addition to urethral damage that affects urination, reports in the literature indicate that 75–87% of cases are complicated by vaginal tears [7] and that 33% of cases are complicated by rectal injuries [8]. Therefore, urethral injuries in female patients exhibit different clinical characteristics due to their combination with other types of injuries. Because of the low incidence rate and complex clinical manifestations of these injuries, the diagnosis can be easily missed if clinicians are not adequately experienced and alert. The diagnostic error rate in the emergency department is reportedly 40% in these patients [9]; therefore, further clinical experience is needed to strengthen our understanding of such injuries and improve the diagnostic rate.

The European Association of Urology recommends early repair (within 7 days) of urethral injuries in female patients rather than delayed repair or urethral realignment [10]. Although the treatment of urethral injuries in girls utilizes some of the same treatment strategies as in adults with successful outcomes described in numerous reports [11–13], there is currently no consensus on the optimal treatment method for urethral injuries in girls. Controversy regarding the optimal timing and method of surgical management has been ongoing for decades. Some doctors advocate for immediate repair of pelvic fractures causing urethral and vaginal injuries because the natural evolution of these injuries often leads to complete urethral occlusion, high-level urethral vaginal fistula, and varying degrees of vaginal stenosis. Some doctors suggest that the end of the urethra be treated with urethral realignment to avoid tissue dissection or suturing in the area of trauma [14]. In addition, some urologists suggest that early bladder fistula drainage and delayed urethral repair may be the best treatment options because they can facilitate hematoma absorption and reduce tissue inflammation [15].

The literature in China and abroad contains only sporadic reports on the emergency management of urethral injuries in girls, and large-scale studies of emergency diagnosis and initial treatment in such patients are lacking. Long-term urinary dysfunction in these patients has not been evaluated using standardized questionnaires. In the present study, we retrospectively analyzed female patients with urethral injury admitted during the past 20 years with a focus on their clinical and follow-up characteristics in an effort to summarize the principles of emergency management for such patients.

Clinical data

The clinical data of six girls with acute urethral trauma admitted to our hospital from April 2003 to April 2023 were retrospectively analyzed.

Preoperative preparation

All patients underwent routine clinical trauma evaluations, including a medical history, physical examination, routine blood examination, blood biochemistry (including liver and kidney function), chest X-ray or chest computed tomography, and abdominal ultrasound or computed tomography.

Urethral injuries in girls are often caused by blunt trauma and accompanied by pelvic fractures and injuries to other organs, and the mortality rate of pelvic fractures is reportedly as high as 21.6% [16]. Therefore, emergency rescue and resuscitation are very important for all patients. In the present study, we prioritized correction of hemorrhagic shock and stabilization of the patient’s vital signs as necessary.

Diagnostic catheterization was attempted in the emergency department. If catheterization was impossible or difficult, urethral injury was considered. According to the patient’s overall injury situation, specialists from relevant disciplines were consulted for evaluation, and a suitable treatment plan was selected as soon as possible after this consultation.

Surgical treatment

The following three urologic surgeries commonly used in the emergency setting were performed in this study as necessary.

Cystoscopic examination

The patient underwent general anesthesia and was placed in the lithotomy position. After routine disinfection and draping, the cystoscope was advanced into the urethra or vagina through their external openings to examine their condition. If the patient had already undergone a cystostomy, the conditions of the bladder and urethra were endoscopically examined through the ostomy port.

Suprapubic cystostomy

The patient underwent general anesthesia and was placed in the supine position. After routine disinfection and draping, a 1.5- to 2.0-cm horizontal incision was made above the pubic symphysis. The skin and subcutaneous tissues were incised, and the linea alba was vertically cut. The rectus abdominis muscle was retracted to both sides and bluntly separated until the extraperitoneal space could be accessed. The anterior wall of the bladder was exposed and incised, and urine was aspirated and removed from the anterior wall of the bladder as necessary. A double layer of purse-string sutures was placed on the anterior wall of the bladder, with an inner diameter of approximately 1 cm. After suturing, the anterior wall of the bladder was opened, a balloon catheter was inserted, water was injected into the balloon, and the purse-string sutures were tightened. Hemostasis was ensured, and the wound was closed with interrupted sutures in layers.

Urethral anastomosis and vaginal repair with a combined transabdominal and perineal approach

Approximately 75–87% of urethral injuries in female patients are reportedly complicated by vaginal tears [7]. All patients in the present study had vaginal injuries. Therefore, simultaneous surgical repair of the urethra and vagina was required.

The patient underwent general anesthesia and was placed in the supine position. After routine disinfection and draping, a 1-cm horizontal incision was made above the pubic symphysis, and the skin and subcutaneous tissue were incised. The linea alba was vertically cut, and the rectus abdominis muscle was retracted to both sides so that the anterior wall of the bladder could be lifted out and opened.

If the site of urethral rupture was located at the distal end of the urethra, the urethral and vaginal openings were often retracted to the pelvic cavity after injury. The doctors could use their fingers to push the bladder neck and urethral opening out toward the perineum. At this time, the urethral and/or vaginal ends could be seen in the perineum. The urethra could be pulled to the vicinity of the original urethral opening below the clitoris and sutured in an interrupted pattern to form a new urethral opening. If a tear was present in the anterior and posterior walls of the vagina, an attempt was made to suture and repair it. At the same time, the anterior and posterior walls of the vagina were pulled out and fixed with the surrounding skin near the original vagina to form a new vaginal opening.

If the urethral rupture was located at the proximal end of the urethra, the bladder neck, proximal urethra, and distal urethra were freed, and the distal and proximal ends of the ruptured urethra were anastomosed.

During surgery, the posterior wall of the vagina and rectum were closely examined. If the anterior wall of the rectum was damaged, it was repair together with a general surgeon, and a colostomy was performed if necessary.

Postoperative treatment

After surgery, the patient’s vital signs were monitored, and antibiotics were used to prevent infection as necessary. Patients who had undergone simple cystostomy underwent wound dressing changes on postoperative days 3 and 7. The bladder fistula tube was left in place until the urethral repair surgery was completed.

Other patients had rubber pads placed under the pubic symphysis for drainage for 3 days. Oil gauze was used to control vaginal bleeding and was removed within 3 to 5 days. Balloon catheters were left in the urethra for 3 weeks, with an additional indwelling balloon catheter placed above the pubic symphysis as a bladder fistula. Generally, after the urethral catheter was removed, urinary bladder urethrography was performed to confirm urinary tract patency, followed by removal of the cystostomy tube.

A pressure bandage was applied to the perineal wound to stop bleeding and could be removed after 3 to 5 days. The wound area was disinfected with iodine to prevent infection, and infrared or semiconductor laser irradiation was used to promote healing. Urethral and vaginal repairs were performed with absorbable suture, eliminating the need for suture removal.

Regular follow-up included urological ultrasound examinations to check for hydronephrosis, ureteral dilation, pelvic or adnexal masses, and residual urine volume in the bladder. If necessary, further evaluations were performed with vaginal ultrasound, urinary bladder urethrography, and urine flow rate examination.

Follow-up

Medical records

Follow-up information collected from the medical records included preoperative and postoperative clinical manifestations and imaging examination reports. All postoperative surgical complications were recorded, including hematoma formation, postoperative infection, delayed wound healing, difficulty urinating, urinary incontinence, vaginal fluid accumulation, whether repeat surgery or multiple surgeries were performed, and the specific surgical approach used. If the chief complaint was difficulty urinating and the maximum urine flow rate was < 10 mL/s, the patient was considered to have difficulty urinating. Daily use of more than one urine pad indicated urinary incontinence, and daily use of one or no pads indicated good urinary control.

Telephone or mail

Follow-up of patient-reported outcomes was conducted by contacting the patients by telephone or mailing them a survey questionnaire, including the Urogenital Distress Inventory short form (UDI-6) and the Incontinence Impact Questionnaire-7 (IIQ-7). According to the scores of these scales, urinary dysfunction was classified as normal (0–3), mild (4–7), moderate (8–11), and severe (≥ 12). Each patient’s menstrual condition was also monitored during follow-up.

General information

This study involved six patients with complete medical records who were successfully followed up by telephone or letter. Their mean age was 5.18 ± 3.13 years (range, 1.8–9.8 years), their mean follow-up time was 96.83 ± 61.32 months (range, 101–239 months), the mean surgical duration was 2.10 ± 1.08 hours (range, 0.5–3.5 hours), the mean blood loss was 38.67 ± 28.75 mL (range, 2–80 mL), the mean hospital stay was 38.17 ± 32.05 days (range, 3–95 days), and the mean surgical time after injury was 5.71 ± 5.15 days (range, 5–14 days).

Clinical manifestations

One patient was injured by a heavy object, and the other five were injured in car accidents. One patient showed perineal bleeding and urinary incontinence after injury, and the other five patients showed perineal bleeding and inability to urinate.

Treatment at other hospitals after injury

Because our hospital is a tertiary medical center, all six patients were transferred from other hospitals. When the patients arrived at the emergency department of our hospital, they had all undergone simple treatments before transfer: one patient had undergone external genital tear repair and suprapubic cystostomy, one had received a blood transfusion to correct shock followed by bladder fistula repair and external fixation of a pelvic fracture, one had received a blood transfusion for stabilization of the hemoglobin concentration, one had been treated with wound debridement and bandaging and underwent pelvic X-ray examination to confirm a pelvic fracture, one had undergone cystostomy during which a urethral vaginal fistula was discovered, and one had undergone indwelling catheterization for management of perineal bleeding and urinary incontinence after injury.

Comorbidities

All patients had concurrent pelvic fractures. All patients also had concurrent vaginal injuries (anterior and posterior vaginal wall tears in four patients and anterior-only vaginal wall tears in two patients). Only one patient with concurrent rectal injury was found to have a rectovaginal fistula during surgery, which was repaired at the same time. Two patients’ injuries were complicated by closed abdominal injury, multiple fractures, extensive skin avulsion injury, and hemorrhagic shock, resulting in longer hospital stays of 48 days and 95 days, respectively.

Postoperative complications

No patients developed serious complications such as hematoma, severe infection, or pulmonary embolism.

Early postoperative complications (within 3 weeks after surgery)

One patient developed bleeding from the wound, which improved after application of pressure bandaging. One patient developed a wound infection, which improved after dressing changes, topical medication, and local physical therapy.

Late postoperative complications (more than 3 weeks after surgery)

Four patients achieved good postoperative urinary control and no symptoms of urinary incontinence. From 3 to 6 months after urethral and vaginal repair surgery, urinary bladder urethrography showed an unobstructed urinary tract and no urethral vaginal fistula. Urinary tract ultrasound indicated normal upper urinary tract function. The maximum average urine flow rate was > 10 mL/s. All patients’ menstrual condition was normal; two of them already had children.

One patient developed postoperative urinary incontinence. She underwent emergency urethral anastomosis and vaginal repair, and cystoscopy was performed 1 year postoperatively because of urinary incontinence and dribbling. During the procedure, a 13F cystoscope could be inserted from the urethral opening. The bladder mucosa was smooth, the bladder neck could be contracted and closed, and the urethra was approximately 3 cm long. No urethral–vaginal fistula was found, and no fistula was observed during vaginal examination. After 3 years, because of continued urinary incontinence, a second cystoscopy was performed followed by bilateral ureteral reimplantation and bladder neck tightening surgery. The patient recovered well. At the time of this writing, the patient was 13.8 years old with smooth urination and no urinary incontinence. She had experienced menarche and had regular menstruation. Her scores were 3 points on the UDI-6 Short Form and 1 point on the IIQ-7 Short Form.

One patient experienced difficulty urinating 2 months after emergency urethral anastomosis and vaginal repair. Urinary cystourethrography revealed bladder obstruction and proximal urethral stricture. Cystoscopy and urethral dilation were then performed. During the operation, a cystoscope was inserted into the vagina and a stenosis was found; however, it was not treated because of the patient’s young age. More than 4 years later, the patient underwent vaginal dilation twice in another hospital because of poor drainage during menarche. At the time of this writing, the patient was 19.7 years of age and had normal urination, no urinary incontinence, and smooth menstruation. Her scores were 3 points on the UDI-6 Short Form and 2 points on the IIQ-7 Short Form (see Table 1).

UDI-6 and IIQ-7 Short Form scores

The six patient’s UDI-6 and IIQ-7 scores are shown in Table 1. According to these scores, the urinary dysfunction was classified as normal (0–3), mild (4–7), moderate (8–11), and severe (≥ 12)(see Table 1).

Table 1

Patients’ clinical characteristics and UDI-6 and IIQ-7 Short Form scores
CASE No.	Age of injury	Current age	Emergency surgical methods	Early postoperative complications	Surgery for complications	UDI-6 score	IIQ-7score
1	1.8	13.8	urethral anastomosis, vagina and rectal repair	urinary incontinence	Cystoscopy, bilateral ureteral reimplantation and bladder neck tightening surgery	3	1
2	7.7	19.7	urethral anastomosis and vaginal repair	Difficulty in urination	cystoscopy and urethral dilation	3	2
3	5.2	14.2	urethral anastomosis and vaginal repair			7	6
4	2.1	14.1	Suppubic cystostomy			5	3
5	9.8	39.1	Cystoscopy, urethral anastomosis and vaginal repair	wound infection		2	1
6	4.5	35	Cystoscopy, urethral anastomosis and vaginal repair	bleeding		3	2

Low incidence rate of urethral trauma in girls

As the largest tertiary medical center for children in North China, our hospital has treated only 6 female patients with acute urethral injuries during the past 20 years, compared with 29 male patients during the same period, highlighting a significant difference in incidence rates between the two sexes. This lower incidence rate in girls aligns with other reports in the literature [17]. Since 2014, our hospital has not treated any new cases of this type, suggesting that increased awareness of traffic safety and enhanced child safety measures may be reducing the number of such injuries. In addition, most patients involved in vehicle accidents are pedestrians hit by motor vehicles rather than passengers. With the development of the social economy and urbanization, more children are traveling inside cars rather than outside, which may also contribute to the decreased incidence of these injuries.

Causes of injury

The injuries in five (83%) of the six patients were caused by car accidents, and all patients had both pelvic fractures and vaginal injuries. One patient also had a rectal injury. These ratios are close to those reported in the literature [7, 8].

A atypical clinical manifestations and risk of misdiagnosis

Five of the six patients presented with a large amount of fresh blood flowing from the perineum and the inability to urinate, which is consistent with common clinical symptoms after acute urethral injury. Notably, however, some patients who present with such injuries may have a more subtle onset of symptoms, and emergency doctors may miss the diagnosis.

In a special case of our study, the patient developed perineal bleeding and urinary incontinence after injury. The patient was successfully treated by indwelling catheterization at an external hospital, resulting in clear urine. After transfer to our hospital, due to the unobstructed drainage from the indwelling catheter and clear urine, the emergency doctor focused on managing the vital signs and pelvic fractures, neglecting a thorough examination of the urethra and vagina. Two weeks after admission, the patient still experienced urinary incontinence after the catheter was removed. Following a consultation with a urologist, urethral and vaginal injuries were suspected. Cystoscopy revealed a urethral–vaginal fistula, and a suprapubic cystostomy was performed. One year later, the patient returned to the hospital for a second-stage repair surgery.

According to literature reports, traumatic pelvic fractures in female patients may lead to simple urethral contusions as well as partial or complete transverse or longitudinal urethral injuries. Because of the extremely rare occurrence of urethral injuries in girls with traumatic pelvic fractures, which are often accompanied by other visceral injuries, doctors may not be sufficiently vigilant or may be preoccupied with managing other injuries. This type of injury, especially longitudinal urethral injuries, can easily be overlooked initially [18].

Most patients with urethral injuries have tears, where either the normal urethral opening is not visible at the perineum or a catheter cannot be inserted into the bladder through the urethra. This is one of the indicators used by emergency doctors to confirm urethral injuries. Longitudinal urethral tears may be less severe injuries [18] because patients can often urinate on their own and the catheter can pass smoothly through the urethra into the bladder, making these injuries easy to overlook. This case reminds us that any young female patient with combinations of vaginal bleeding, pelvic fractures, or sacral spinal injuries should carefully evaluated for urethral or vaginal injuries. Even if the catheter can be smoothly inserted into the bladder through the urethra, vigilance cannot be relaxed.

Diagnosis without urination or cystourethrography: Use of cystoscopy (although not suitable for all patients)

Urinary bladder urethrography is an essential examination for the diagnosis of urethral trauma in male patients. However, the diagnostic reliability of imaging for urethral injuries in female patients has always been controversial. According to literature reports, only half of such cases are correctly diagnosed through cystography [19]. Most urethral injuries in female patients are diagnosed through cystoscopy under anesthesia [20].

In the present study, none of the patients underwent urinary bladder urethrography examination. Four patients had severe perineal tears with no visibility of the normal urethral and vaginal openings, making it impossible to insert a urinary catheter. The diagnosis of urethral and vaginal injury was very clear. The urological ultrasound of all six patients showed no bladder rupture and no obvious abnormalities in the upper urinary tract. Additionally, the patient had pelvic fractures and frequent movement was not advisable, so further imaging was not performed. Two other patients were diagnosed with urethrovaginal injury during cystoscopy under general anesthesia. Therefore, we believe that if physical examination and catheterization can confirm the presence of urethral injury in girls, the diagnosis can be made without relying on urinary bladder urethrography and cystoscopy. For patients suspected to have urethral injury during physical examination, urethral endoscopy under general anesthesia can be performed to confirm the diagnosis.

Our experience in emergency surgical management

The management of urethral injuries in girls is relatively complex, and there is currently no clear guideline. Whether to immediately repair the urethra or delay its repair until after life-threatening trauma has been treated and vital signs have been stabilized has long been controversial. Five of the six patients in our study underwent urethral and vaginal repair surgery within 7 days after injury, and one patient also underwent rectal repair surgery.

Our experience highlights the following three points. First, if the patient’s condition permits, emergency urethral and vaginal repair surgery can be safely performed. If the patient’s hemodynamics are stable, emergency urethral and vaginal repair surgery can be considered. If necessary, reduction and fixation of pelvic fractures should be completed in advance. This can restore partially twisted anatomical structures, making urethral surgery easier and helping to prevent serious sequelae in the lower urinary and reproductive tracts [21]. If the patient’s vital signs are unstable and the fracture is accompanied by severe clinical symptoms or related injuries, immediate suture repair is extremely difficult. Therefore, performing a pubic cystostomy and secondary urethral reconstruction is ideal in such cases(Fig. 1).

Second, emergency urethrovaginal repair surgery is associated with certain difficulties and requires experienced pediatric urologists. In our study, five patients underwent emergency repair surgeries for the urethra and vagina performed by surgeons who had worked in pediatric urology for more than 15 years. They had treated multiple cases of old urethral trauma in girls and urethral trauma in boys. They were very familiar with the pelvic anatomy and surgical approach and had rich experience in urethral anastomosis.

Third, emergency repair surgery is beneficial for detecting concurrent injuries. In the present study, one patient was found to have a tear in the anterior wall of the rectum during surgery, and rectal repair was performed simultaneously.

Postoperative complications

Early postoperative complications after repair of acute urethral injury are not common or severe. In the present study, two patients developed postoperative wound bleeding and infection, which improved quickly after symptomatic treatment. Among the five patients who underwent emergency repair surgery, two developed Clavien–Dindo grade IIIb complications after surgery, necessitating endoscopic or surgical treatment under general anesthesia. The success rate was 60%, which is lower than that reported in the literature. We considered two reasons for this lower success rate. First, the success rate reported in the literature primarily pertains to adult female patients, who differ from pediatric patients. Second, because of the rarity of acute urethral injuries, our management experience was limited.

UDI-6 and IIQ-7 scoring

The current gold standard for diagnosing urinary incontinence is urodynamic examination, which is an invasive examination that is difficult for pediatric patients to tolerate and challenging for parents to accept. Patient-reported outcome scales mainly evaluate patients’ subjective feelings, conscious symptoms, and satisfaction with treatment, providing an effective supplement to clinical objective examinations. In the present study, we selected the two most commonly used questionnaires for patient follow-up: the IIQ-7 and the UDI-6. The IIQ-7 has good structural validity, contains fewer questions, and is convenient for patients to answer. It is currently one of the most widely used urinary incontinence quality-of-life scales in international research on pelvic floor dysfunction. The UDI-6 is used to evaluate the degree of distress caused by lower urinary tract dysfunction and genital prolapse symptoms in female patients. Higher scores are associated with more obvious urinary incontinence symptoms. The UDI-6 is currently the most widely used questionnaire to evaluate the degree of distress caused by urinary incontinence symptoms. Using this scale, urinary dysfunction is classified as normal (0–3), mild (4–7), moderate (8–11), and severe (≥ 12).

In the present study, the six patients were 13.8, 19.7, 14.2, 14.1, 39.1, and 35.0 years old, and all were able to complete the scoring on their own. The results showed that four patients had normal urinary function and that two had mild urinary dysfunction.

This study involved only six patients, which was too few to conduct an effective statistical analysis. Further research with a larger sample size is needed. The lack of urodynamic indicators is due to the fact that some of these patients are now adults who are unable to return to the children’s hospital for urodynamic examination. Additionally, some patients currently have normal urination and menstruation, and they do not have the motivation to undergo urodynamic tests. The most ideal research method for this purpose would be prospective studies. However, urethral injury in girls is relatively rare, making such ideal research is difficult to achieve.

The diagnosis of acute urethral trauma in girls requires vigilance. Girls who present with vaginal bleeding, pelvic fractures, or sacral spinal injuries in combination should carefully evaluated for the presence of urethral or vaginal injuries. Even if a catheter can be smoothly inserted into the bladder through the urethra, vigilance cannot be relaxed. If the presence of urethral injury can be determined through physical examination and catheterization tests, diagnosis can be made without relying on urinary cystourethrography and cystourethroscopy. For patients suspected to have urethral injury during physical examination, cystourethral endoscopy under general anesthesia can be performed to confirm the diagnosis.

If the patient’s vital signs are stable, emergency urethral and vaginal repair surgery can be performed. This procedure is difficult and requires experienced pediatric urologists. However, the success rate of a single surgery is relatively high and helps in detecting composite injuries.

Ethics approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Beijing Children's Hospital( No.[2024]-E-100-R ). We obtained informed consent from the legal guardians of participants or the patients themselves who are over sixteen years old.

Consent to publish

Legal guardians or the patients themselves who are over sixteen years old signed informed consent regarding publishing their data.

Availability of data and materials

All data that support the findings of this study are included in this manuscript.

Competing interests

The authors have no financial or proprietary interests in any material discussed in this article.

Funding

No funding was received for conducting this study.

Author contributions

All authors contributed to the study conception and design. Data collection and analysis were performed by Guannan Wang, Defu Lin, and Meng He. The surgeries were performed by Ning Sun, Weiping Zhang, Jun Tian, Minglei Li, and Hongcheng Song. The first draft of the manuscript was written by Guannan Wang, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Eric Song, Areeb Shah, John Culhane, Sameer Siddiqui(2023)Traumatic blunt urethral injuries in females A retrospective study of the National Trauma Data Bank.Canadian Urological Association journal 17(5):E116-E120.https://doi.org/10.5489/cuaj.8137
Orkin, L. A(1991) Trauma to the bladder, ureter, and kidney. In: Gynecology and Obstetrics. Edited by J. J. Sciarra. Philadelphia: J. B. Lippincott, vol. 1, chapt. 88, pp. 1– 8.
Perry, M. O. and Husmann, D. A(1992) Urethral injuries in female subjects following pelvic fractures. J Urol 147(1):139-43. https://doi.org/10.1016/s0022-5347(17)37162-8
Carolina de la Calva, Nadia Jover et al(2023) Pediatric pelvic fractures and differences compared with the adult population. Pediatr Emerg Care 36(11):519-522. https://doi.org/10.1097/PEC.0000000000001411
Koraitim MM, Marzouk ME, Atta MA, Orabi SS(1996) Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 77: 876–80. https://doi.org/ 10.1046/j.1464-410x.1996.01119.x
Ranjan P, Ansari MS, Singh M, Chipde SS, Singh R, Kapoor R(2012) Post traumatic urethral strictures in children: what have we learned over the years? J Pediatr Urol 8: 234–239. https://doi.org/10.1016/j.jpurol.2011.06.004
Podestá ML, Jordan GH(1999) Pelvic fracture urethral injuries in girls. J Urol 2001;165:1660-5.
Venn SN, Greenwell TJ, Mundy AR. Pelvic fracture injuries of the female urethra. BJU Int 83:626-30. https://doi.org/10.1046/j.1464-410x.1999.00001.x
Peter C Black, Elizabeth A Miller et al(2006) Urethral and Bladder Neck Injury Associated With Pelvic Fracture in 25 Female Patients.The Journal of urology 175(6):2140-2144. https://doi.org/ 10.1016/S0022-5347(06)00309-0
Efraim Serafetinidis, Felix Campos-Juanatey, Peter Hallscheidt et al(2023) Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma. European urology focus S2405-4569(23)00196-7. https://doi.org/ 10.1016/j.euf.2023.08.011
Onen A, Subasi M, Arslan H, Ozen S, Basuguy E(2005) Long-term urologic, orthopedic, and psychological outcome of posterior urethral rupture in children. Urology 66: 174–9. https://doi.org/ 10.1016/j.urology.2005.01.056
Ritesh Kumar Singh, Devashish Kaushal et al(2018) Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion.Indian journal of urology 34(1):76-78.https://doi.org/10.4103/iju.IJU_118_17
Yatam Lakshmi Sreeranga,Pankaj Mangalkumar Joshi, Marco Bandini et al (2022)Comprehensive analysis of paediatric pelvic fracture urethral injury: a reconstructive centre experience.BJU international 130(1):114-125 https://doi.org/ 10.1111/bju.15686
Lalgudi N Dorairajan, Harendra Gupta, Santosh Kumar(2004) Pelvic fracture-associated urethral injuries in girls: experience with primary repair. BJU international 94(1):134-6. https://doi.org/ 10.1111/j.1464-4096.2004.04874.x
Hemal AK, Dorairajan LN, Gupta NP(2000) Post traumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management. J Urol 163(1):282–287.
Chuan Tseng, I-Jung Chen, Ying-Chao Chou, Yung-Heng Hsu, Yi-Hsun Yu(2020) Predictors of Acute Mortality After Open Pelvic Fracture: Experience From 37 Patients From A Level I Trauma Center. World journal of surgery 44(11):3737-3742.https://doi.org/10.1007/s00268-020-05675-z
Amjad Alwaal 1, Uwais B Zaid 2, Sarah D Blaschko et al(2015) The incidence, causes, mechanism, risk factors, classification, and diagnosis of pelvic fracture urethral injury.Arab journal of urology 13(1):2-6.https://doi.org/ 10.1016/j.aju.2014.08.006
Peter C Black, Elizabeth A Miller et al(2006) Urethral and Bladder Neck Injury Associated With Pelvic Fracture in 25 Female Patients.The Journal of urology 175(6):2140-2144.https://doi.org/10.1016/S0022-5347(06)00309-0
Perry, M. 0. and Husmann, D. A(1992) Urethral injuries in female subjects following pelvic fractures. The Journal of urology 147(1):139-143. https://doi.org/ 10.1016/s0022-5347(17)37162-8
Devin N. Patel , Cynthia S. Fok et al(2017) Female urethral injuries associated with pelvic fracture:a systematic review of the literature.BJU international 120(6):766-773.https://doi.org/ 10.1111/bju.13989
M L Podestá, G H Jordan(2001) Pelvic fracture urethral injuries in girls.The Journal of urology 165(5):1660-5.

No competing interests reported.

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Summary of emergency treatment experience of acute urethral trauma in girls

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusion

Figures

Introduction

Methods

Clinical data

Preoperative preparation

Surgical treatment

Cystoscopic examination

Suprapubic cystostomy

Urethral anastomosis and vaginal repair with a combined transabdominal and perineal approach

Postoperative treatment

Follow-up

Medical records

Telephone or mail

Results

General information

Clinical manifestations

Treatment at other hospitals after injury

Comorbidities

Postoperative complications

Early postoperative complications (within 3 weeks after surgery)

Late postoperative complications (more than 3 weeks after surgery)

UDI-6 and IIQ-7 Short Form scores

Discussion

Low incidence rate of urethral trauma in girls

Causes of injury

A atypical clinical manifestations and risk of misdiagnosis

Diagnosis without urination or cystourethrography: Use of cystoscopy (although not suitable for all patients)

Our experience in emergency surgical management

Postoperative complications

UDI-6 and IIQ-7 scoring

Study limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1