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Renal AAST classification from 1999 + 2011, from Campbell's

Indications for renal imaging, from Campbell's

Indications for intervention for Grade 4-5 injuries, from Campbell's

Renal injuries

Pediatric population concerns

• More susceptible to injury - less perirenal fat, less abdominal muscles, less rib protection
• Hydronephrosis and UPJO are 3-5x more common in pediatric than adult trauma
• Hypotension occurs at a much later stage (better BP reserve)
• Absence of hematuria does not rule out renal injury
• FAST exam: low sensitivity (22-96%) for renal injuries, CTU recommended

General management

• Imaging indications: any abdominal/flank penetrating trauma, or blunt trauma with -> gross hematuria, microscopic hematuria (> 50 RBC) + hypotension, rapid deceleration injury, or direct flank injury
• Deceleration injury specific to children: UPJ avulsion (more mobile spine), intimal tear of renal artery (less perirenal fat, more mobile renal pedicle)
• Confirm hemodynamically stable and grade renal injury
• Grade 1-3: usually conservative management, especially if blunt injury
• Grade 4-5: can attempt conservative management vs endoscopic/surgical intervention
• Surgical indications: hemodynamic instability with renal hemorrhage, expanding pulsatile retroperitoneal hematoma (found during laparotomy), post-embolization bleeding
• Conservative management: bed rest, serial Hgb, serial exams - continue bed rest until hematuria resolved and Hgb stable
• Consider repeat renal US in 48-72hrs for Grade 4-5 (not required), only repeat CT if needing more info
• 25% angioembolization and 15% urinoma risk for hemodynamically stable Grade 3-5
• On-table IVP: 2mL/kg contrast bolus, KUB 10-15 minutes later, confirms presence/absence contralateral kidney
• Obtain follow up renal scan if concern for loss of function or hypertension
• Use flank protection for contact sports if solitary kidney after trauma

Specific management:

• Urinoma: 85% resolve spontaneously, persistent urinoma presents with flank pain + ileus + low grade fever, recommend stent (4-6 weeks) + foley to maximize drainage (90% resolution), require percutaneous drain for persistent leaks, nephrostomy tube rarely required
• Delayed bleed: appear 1-4 weeks after injury, consider 2-3U RBCs prior to embolization if stable, otherwise up-front embolization, 80% success
• Postembolization syndrome: flank pain, fever, ileus, occurs in < 10% patients, if fever persists consider reimaging for abscess
• Operative indications: persistent hemodynamic instability or inability to control with embolization
• Renal artery occlusion: can consider nephrectomy vs angioplasty/stent
• UPJ disruption or rupture: can immediately repair vs stent if stable
• Nephrectomy required ~5% all injuries, usually if renal artery injured

Ureteral AAST classification, from Campbell's

Ureteral injuries

Presentation

• 10% mortality rate due to severity of associated abdominal injuries
• Iatrogenic ureteral injuries ~1% for GI/GYN
• Delayed phase CT required to assess for extravasation or obstruction

Management

• Stent and drain placement if concern for ureteral injury after penetrating injury
• General concept: no intervention (Grade 1), endoscopic +/- open (Grade 2-3), open (Grade 4-5)
• If unstable, can perform diversion with delayed repair - cutaneous ureterostomy with stent, ligation with nephrostomy tube, or drain placement
• If delayed diagnosis, divert urine and repair 6-12 weeks later, can attempt stent placement for partial injuries
• If no formal repair, remove stent and obtain US in 4-6 weeks, then annual US for 2-3 years

Bladder AAST classification, from Campbell's

Urethral AAST classification, from Campbell's

Bladder + Urethral injuries

Bladder injuries

• Blunt trauma underlying cause for 80%
• 50% bladder injuries also have pelvic injury
• Obtain cystogram (XR/CT) if pelvic fracture + hematuria, concerning mechanism + hematuria, or pelvic fracture + concern for bladder rupture
• Repair indications: intraperitoneal injury, exposed bone, rectal/vaginal injury, bladder neck injury, need for internal fixation or abdominal surgery
• Keep catheter for 1-2 weeks, then obtain cystogram prior to removal

Urethral injuries

• Perform urethrography if concerning mechanism, urinary retention, or hematuria
• Place suprapubic tube if unable to obtain urethral drainage
• Immediate open repair not recommended due to high complication/failure rate
• Follow up after formal repair for 1 year to assess for recurrent strictures
• Complications: stricture recurrence (10%), incontinence (20%), erectile dysfunction

Penile AAST classification, from Campbell's

Scrotal AAST classification, from Campbell's

Testis AAST classification, from Campbell's

Vaginal AAST classification, from Campbell's

Vulvar AAST classification, from Campbell's

Genital injury

Penile injury

• Amputation: usually from circumcision or strangulation, can repair without microvascular reanastomosis and catheter 1-2 weeks if urethral repair
• Animal bites: debride, irrigate, can loosely close or allow to heal via secondary intent

Scrotal/Testis injury

• <5% cause for acute scrotum
• US warranted if concern for testicular rupture
• If no violation of tunica vaginalis, can irrigate and close
• If concern for tunica vaginalis injury, perform formal debridement and repair in OR with possible drain placement
• Exploration warranted if concern for rupture, debride and close tunica albuginea
• Scrotal skin loss managed with primary closure
• Follow up in 6 weeks with exam and US to confirm no missed injury

Vaginal/Vulvar injury

• 80% are straddle injuries, 5% penetrating injuries
• Hymenal injury correlated with sexual abuse
• If concern for associated injuries, EUA + cystoscopy + vaginoscopy warranted

Sexual Abuse

• Risk factors: other forms of abuse, high stress environment, poor social/familial support, increased risk during adolescence
• Exam statements: always preface with "we are going to examine [insert age-appropriate genital description], this is okay because I am a doctor and your [caregiver] is here, otherwise no one else should look at or touch your private areas"
• Speculum: usually no need unless active vaginal bleeding
• Rectal exam: DRE usually not needed, endoscopic exam only if bleeding present, otherwise just examine externally
• Majority of post-abuse exams do not have any abnormal findings
• Diagnostic findings: evidence of ejaculation or pregnancy, SUI (syphilis, gonorrhea, HIV) not acquired perinatally/IV, new genital/anal injuries in absence of adequate accidental explanation, abnormally enlarged hymenal opening for age

Hematuria in children

Evaluation

• History: duration, timing, recent illness, other GU conditions, activity, medications
• Exam: check for hypertension, rash, petechiae, pallor, abdominal masses, external genitalia
• Labs: confirm RBC on microscopy (not dipstick), assess for UTI
• Glomerulonephritis evaluation: serum creatinine, complement C3, CBC, antistreptolysin O, anti-DNase B, urinary Ca/Cr ratio, family history
• Renal biopsy indications: onset < 1yo, hematuria + HTN, systemic symptoms, low C3 > 8wks, family history renal failure, hearing loss

Specific diagnoses

• Benign familial hematuria: family history hematuria without hearing loss or renal failure
• Alport syndrome: hematuria/proteinuria, hearing loss, and ocular abnormalities, males more affected (X-linked), evaluate with nephrology and audiology evaluations
• Post-strep glomerulonephritis: develops 1-3 weeks after skin/URI, usually self-resolving, may require management of fluid retention and HTN, antibiotics will not shorten GN course
• IgA nephropathy: develops within days of URI, occasionally progresses to renal failure, managed with steroids
• Membranoproliferative glomerulonephritis: many inciting factors, usually treated with steroids, often progresses to renal failure
• Henoch Schonlein purpura: systemic vasculitis with palpable lower extremity purpura, hematuria/proteinuria, joint pain/swelling, vomiting/abdominal pain, managed with supportive therapy (steroids)
• Lupus (SLE): variety of presenting symptoms, renal biopsy findings help determine treatment options
• Microscopic polyangiitis nodosa (MPN) + granulomatosis with polyangiitis (GP): rapidly progressive small vessel vasculitis, can have sinusitis, cough, pulmonary hemorrhage, renal biopsy positive for P-ANCA (MPN) or C-ANCA (GP), may require plasmapheresis
• Hypercalciuria: thought to be caused by trauma from calcium crystals, diagnosed with urinary Ca/Cr ratio > 0.2-0.5, screen with spot test and confirm with 24hr collection (> 4mg/kg/d), check serum Ca, Phos, Vit D, and PTH, manage with salt restriction and increased fluid intakes, consider citrate supplements and thiazides
• Sickle cell: hypoxia causes decreased medullary blood flow, leading to congestion and papillary necrosis and bleeding