Patterns of accidental genital trauma in young girls and indications for operative management

doi:10.1016/j.jpedsurg.2010.02.024

Journal of Pediatric Surgery

Volume 45, Issue 5, May 2010, Pages 930-933

https://doi.org/10.1016/j.jpedsurg.2010.02.024 Get rights and content

Abstract

Background/purpose

The aim of this study was to define the injury patterns of accidental genital trauma (AGT) in female patients and examine the indications and outcomes of operative intervention.

Methods

Review of patients younger than 16 years with AGT from 1980 to 2007 excluding sexual- and obstetric-related injuries.

Results

One hundred sixty-seven patients met the criteria. Mean (±SEM) age was 6.9 (0.2) years. There were 70.5% straddle injuries, followed by nonstraddle blunt injuries (23.5%) and penetrating injuries (6.0%). Injuries to the labia were most frequent (64.0%). Injuries to the posterior fourchette (7.8%) and hymenal disruption (8.4%) were less frequent. There was 87.9% of AGT that was managed expectantly without further sequelae. Twenty patients (12.1%) were managed operatively. Penetrating injuries were more likely to require operative management (P ≤ .03). The operative group was also more likely to have multiple genital injuries (60% versus 25%, P < .01). Proctoscopy, vaginoscopy, and/or cystoscopy were performed in 55% of patients in the operative group.

Conclusions

Accidental genital trauma is most commonly caused by straddle-type injuries and is usually amenable to nonoperative management. Hymenal disruption and injuries to the posterior fourchette are uncommon with these types of injuries.

Section snippets

Methods

With institutional review board approval, we queried the Mayo Clinic Rochester surgical and medical databases from 1980 through 2007 and identified all female patients 16 years or younger treated for genital trauma defined as injuries to the labia, vulva, urethra, vagina, hymen, perineum, or rectum. Each medical record was then reviewed to obtain patient demographics, the reported mechanism of injury, presentation, physical findings, management, and outcomes. Patients with sexually related

Results

We identified 167 young girls who met the criteria for AGT. The mean age was 6.9 years (range, 1-16 years). Straddle injuries were the most frequently encountered mechanism of injury accounting for 70.5% of all injuries, followed by nonstraddle blunt injuries (23.5%) and penetrating injuries (6.0%). The labia was the most frequent site of injury (64.0%) followed by the perineum (21.5%), the vulva (8.9%), the posterior fourchette (7.8%), the vagina (5.9%), and then the rectum (2.9%; Table 1).

Discussion

Most data regarding genital trauma in young girls have focused on nonaccidental trauma-related etiologies. As a result, the literature lacks a clear description of the injury patterns seen in AGT. Nonsexual, nonobstetric gynecologic injuries in young girls can broadly be categorized into 3 types based on the mechanism of injury: (1) straddle (the most frequent mechanism), (2) nonstraddle blunt injuries, and (3) penetrating trauma.

Most AGT is isolated to the labia and can be managed expectantly.

References (6)

PokornyS.F. et al.
Acute genital injury in the pre-pubertal girl
Am J Obstet Gynecol
(1992)
HegerA. et al.
Appearance of the genitalia in girls selected for non-abuse review of hymenal morphology and non-specific findings
J Pediatr Adolesc Gynecol
(2002)
BondG.R. et al.
Unintentional perineal injury in prepubescent girls: a multicenter, prospective report of 56 girls
Pediatrics
(1995)

There are more references available in the full text version of this article.

Cited by (36)

Radiologic Imaging Does Not Add Value for Female Pediatric Patients with Isolated Blunt Straddle Mechanisms
2022, Journal of Pediatric and Adolescent Gynecology
Citation Excerpt :
Additionally, the anatomical structures injured by straddle mechanisms are congruent with injury rates of other studies.2,4,5 Previous studies have also described “definitive care” for straddle injuries as EUA that allows for complete assessment and management of injuries sustained.6,9 With over half of this study's patients requiring EUA, over 70% of these patients recording a follow-up encounter, and no missed injuries recorded within the 35 patients who did not require EUA, the findings of this study support EUA with repair as indicated for definitive evaluation and treatment of blunt straddle injuries in young females.
The purpose of this study was to characterize the utility of radiologic imaging and examination under anesthesia in female pediatric patients with isolated blunt straddle injuries.
Retrospective review.
Single health care system with a children's hospital and level 1 pediatric trauma center.
Female patients aged 1-17 years with blunt straddle injuries from 2006 to 2018.
None.
Radiologic imaging performed, number of patients requiring exam under anesthesia (EUA), number of injuries not identified in patients who did not undergo EUA.
The study cohort included 83 patients. Of these, 11 (13%) had imaging performed. Thirty-four patients were managed as outpatients, 28 were discharged from the emergency department without need for intervention, and 49 patients were admitted. Of these, 48 (98%) went to the operating room for exam EUA. No occult injuries were identified on radiologic studies. Imaging was not associated with need for EUA. No missed injuries occurred in children who were not imaged. Two patients who were imaged returned for EUA following evolution of symptoms.
Radiologic imaging did not add diagnostic value for female pediatric patients with blunt straddle injuries. These data emphasize the importance of EUA with repair and advocates for minimization of radiologic imaging in this patient group.
Pediatric and Adolescent Gynecologic Emergencies
2022, Obstetrics and Gynecology Clinics of North America
Hymenal transections in children found by photocolposcopy in suspected sexual abuse cases is associated with a history of bleeding
2021, Journal of Forensic and Legal Medicine
To investigate the difference in selected variables between children with and without hymenal transection, which is a healed defect that extends through the entire depth of the posterior hymenal membrane to the vaginal wall.
All female children from Southern Denmark who were examined by photocolposcopy in a six-year period were included in a retrospective cohort study. Statistical analyses included a chi-square test and a logistic regression analysis.
Eighty girls under 15 years of age who were suspected to have been sexually abused were included. Sixteen of the girls had hymenal transections. There was a statistically significant correlation between the presence of hymenal transections and reported fresh bleeding after the assault.
Bleeding after an assault could indicate more severe lesions, which might explain why these patients did not heal completely.
Pediatric female genital trauma managed under conscious sedation in the emergency department versus general anesthesia in the operating room- a single center comparison of outcomes and cost
2021, Journal of Pediatric Urology
Pediatric female genital trauma (PFGT) comprises injuries to the female external and internal genitalia. Examination under general anesthesia (GA) in the operating room (OR) is traditionally recommended, however repair at the bedside under conscious sedation (CS) in the emergency department (ED) may be a safe alternative. The Genitourinary Injury Score (GIS) objectively classifies PFGT severity, but designates all vaginal and urethral injuries as Grade III.
To compare outcomes and cost of patients with PFGT managed under CS in the ED vs GA in the OR.
All patients treated by a pediatric urologist from May 2009 to September 2019 with associated ICD codes for PFGT were included. Exclusion criteria included PFGT from sexual abuse or obstetric related complications. Clinical and demographic data was extracted from the EMR. A cost analysis comparing ED vs OR management was performed.
33 patients were identified with a median age of 6.8 years. The primary etiology was straddle trauma. Injuries were predominately GIS I-III (30, 91%) with possible urethral involvement in 6 patients. Sedation and repair in the ED was performed for 12 (36%) patients vs 21 (64%) taken to the OR. For the OR cohort, 15 (71%) were taken to the OR immediately and 6 (29%) initially underwent CS but this was aborted due to injury complexity. Aborting CS and proceeding to the OR did not result in compromised outcome or prolonged hospitalization.
No patients in the ED cohort required post-procedural admission whereas all patients taken to the OR were admitted postoperatively. Cost of care for ED repair was less than two-thirds (60%) that of surgical repair in the OR. Using Onen GIS III or less without deep vaginal and/or urethral involvement as a cutoff for attempted bedside repair vs proceeding directly to the OR could have spared 7 (47%) patients GA and subsequent admission. A female-specific modification to the Onen GIS III criteria is proposed in light of these findings.
The present study suggests CS and bedside repair of low-grade PFGTs is safe with a cost benefit. This is reflected by a proposed modification to the Onen GIS III criteria. These findings should be interpreted with caution given the retrospective nature of this single institution, small cohort study.
CS and bedside repair of low-grade PFGT appears to be safe and cost effective. Delineating GIS III injuries according to urethra and/or deep vaginal involvement may improve the GIS scale's clinical utility.
Genital injuries acute evaluation and management
2018, Best Practice and Research: Clinical Obstetrics and Gynaecology
Genital trauma may result in external injuries to the labia, vulva or vagina, urethra and anus and internal injuries to the bony pelvis, bladder, bowels and reproductive organs. Worldwide, the most common cause of genital trauma in reproductive age women is injury sustained during childbirth, but in this chapter we will focus on accidental genital injuries as well as those arising from sexual violence, and female genital mutilation. While genital injuries alone rarely result in death; if not properly managed, chronic discomfort, dyspareunia, infertility, or fistula formation may result. Clinicians need to be able to recognize these injuries and provide initial management, and assure that the patient's mental, emotional and physical needs are addressed.
Patterns of Treatment of Accidental Genital Trauma in Girls
2018, Journal of Pediatric and Adolescent Gynecology
To evaluate the characteristics of girls with accidental genital trauma (AGT) who can be managed in the emergency department (ED) vs the operating suite (OS).
Retrospective cohort.
ED at a children's hospital in a metropolitan area.
Girls aged 0-18 years with AGT.
Factors associated with need for evaluation and repair of AGT in the OS.
A total of 359 girls were included in the analysis. The mean age was 6 ± 3 years. Most girls presented with pain and bleeding, 321/359 (89%). Straddle injury was the most common mechanism, 258/355 (73%). The most commonly injured site was the labia, 225/358 (63%) and the most common type of injury was laceration, 308/357 (86%). Factors significantly associated with treatment in the OS included older age, transfer from another institution, penetrating injuries, injuries involving the hymen/vagina/urethra/anus, and injuries larger than 3 cm in size. The odds of requiring general anesthesia in the OS were 5.5 times higher for injuries larger than 3 cm (95% confidence interval, 2.8-10.9; P < .0001) and 4.1 times greater if the patient was transferred from another facility (95% confidence interval, 1.3-13.3; P < .02).
Most AGT can be managed expectantly. Penetrating injuries, injuries to the hymen/vagina/urethra/anus, and injuries with a maximal size of 3 cm should be considered as indications for management in the OS. With adequate procedural sedation, most girls with minor injuries as a result of AGT can undergo a thorough examination and repair of AGT in the ED.

View all citing articles on Scopus

: Presented at the 41st Annual Meeting of the Canadian Association of Paediatric Surgeons, Halifax, Nova Scotia, Canada, October 1-3, 2009.

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CAPS PaperPatterns of accidental genital trauma in young girls and indications for operative management

Abstract

Background/purpose

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Am J Obstet Gynecol

J Pediatr Adolesc Gynecol

Unintentional perineal injury in prepubescent girls: a multicenter, prospective report of 56 girls

Pediatrics

CAPS Paper
Patterns of accidental genital trauma in young girls and indications for operative management