AT THE NASPAG ANNUAL MEETING
ORLANDO (FRONTLINE MEDICAL NEWS) – Most cases of accidental genital trauma in girls are caused by straddle injury and are isolated to the labia, and most can be managed expectantly or treated in the emergency department, according to findings from a retrospective cohort study.
Penetrating injuries, however, should be considered an indication for management in the operating room, Dr. Tazim Dowlut-McElroy reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
A review of 359 cases showed that the vast majority – 82% – were minor and managed expectantly.
“Only 18% required surgical management. Of those, 37% required general anesthesia in the OR, but 63% were adequately evaluated and treated in the ED,”said Dr. Dowlut-McElroy of Children’s Mercy Hospitals and Clinics, Kansas City.
About 2/3 (64%) of the patients presented during the day, and 36% presented at night. The most common presenting complaint was bleeding and pain (89% of cases), followed by voiding issues in 8% of cases. No presenting complaint was recorded in the remaining patient charts.
The most common mechanism of injury was straddle injury (73% of cases), followed by non-straddle blunt trauma in 15% of cases, and penetrating injury in the remaining cases, Dr. Dowlut-McElroy said.
Injuries included lacerations in 86% of cases, abrasions or contusions in 7%, and hematomas in 3%.
Factors associated with a need for treatment in the OR included greater mean age (mean age was 8 vs. 6 years for OR vs. ED cases), transfer from another institution (77% of OR cases vs. 31% of ED cases), penetrating injury (54% of OR cases vs. 8% of ED cases), injury to the urethra or anus (46% of OR cases vs. 7% of ED cases) and lesion size greater than 3 cm (63% of OR cases vs. 7% of ED cases), she noted.
Logistic regression analysis showed that factors significantly associated with treatment in the OR under general anesthesia were lesion size greater than 3 cm (odds ratio 5.5), and transfer from another hospital (odds ratio 4.1). Presentation at night approached significance (odds ratio 3.2).
Pediatric genital injuries comprise 0.2% to 8% of reported childhood trauma, and despite public health efforts to reduce injuries, the number of such pediatric injuries continues to rise, Dr. Dowlut-McElroy said.
As was the case in the current study, straddle injuries are the most common cause of accidental genital trauma (AGT), and most injuries are external and isolated to the labia.
However, genital bleeding, which is the most common presenting symptom after blunt genital trauma, usually requires a thorough evaluation of the location and severity of injury and may require surgical repair, she said.
Injuries may not consistently result in external bleeding, and without careful examination, injuries to the urogenital tract can be missed and result in delays in repair that can lead to urethral and vaginal stenosis and chronic fissures and fistulas, she said.
“Therefore, a key question is whether all patients should undergo examination under anesthesia in the operating room rather than undergoing evaluation and treatment in the emergency department,” she said, citing reports of discordant examination for the severity and extent of injury after AGT between an initial assessment in the ED and treatment in the OR, which have led some authors to recommend that all patients with AGT be evaluated under general anesthesia.
In one retrospective review of 22 patients with AGT, the most common mechanism of injury was straddle injury, and every patient was initially evaluated in the ED by an emergency physician and then by a pediatric surgeon. All were taken to the OR, and the findings on examination under anesthesia in the OR demonstrated significant disagreement with the findings in the ED, Dr. Dowlut-McElroy said.
In fact, 76% of patients had more significant injury than determined by the ED evaluation; 27% had complete disruption of the perianal sphincter, and 95% required surgical repair (Ped. Emerg. Care. 1995; 11:372-5).
In contrast to those findings, a 2008 review showed that only 19% of 105 cases – also due mainly to straddle injury – required examination under anesthesia in the OR, while 7% underwent conscious sedation in the ED. Only 21% of subjects required surgical repair ( Ped. Emerg. Care 2008;24:831-5 ).
Conflicting reports such as these have results in considerable variation in recommendations for managing AGT, Dr. Dowlut-McElroy said.
“We sought to determine the characteristics of those managed in ED vs. those requiring treatment in the OR,” she added.
Patients included in the current review were identified by a medical database query from January 2000 to July 2014. They were aged 0-18 years and had been treated in the ED for genital trauma; those with obstetrical injuries were excluded.
Though limited by the retrospective and single center design, as well as by errors associated with misclassification of variables and missing data, the finding suggest that with adequate sedation, most girls with AGT, with the exception of those who experience penetrating injury, can undergo a thorough examination and repair in the ED, she concluded.
Dr. Dowlut-McElroy reported having no disclosures. One of her co-authors, Dr. Julie Strickland, is a Nexplanon trainer for Merck.
