Classification in the diagnosis and treatment of organ damage caused by urogenital trauma in children

The urogenital system constitutes 3-10% of all child injuries. 90% of these cases are seen after blunt trauma. Penetrating injuries are more common in older children and constitute the other 10%. In a very small part, iatrogenic injuries occur. When evaluating genitourinary traumas, other life-threatening cerebral, thoracic, abdominal and skeletal injuries should be considered [2-4]. The most common causes of blunt trauma of urogenital injuries are fall, rape, motor vehicle accidents, and sports injuries. Factors causing penetrating injuries are gunshot injuries and sharp object injuries [5].


Introduction
The frequency of genitourinary traumas occurring parallel to the technological developments in the world is increasing rapidly in children. The mortality rate of genitourinary trauma is very low; however, when long-term sequelae are taken into consideration, the importance of correct diagnosis and treatment can not be underestimated [1].
The urogenital system constitutes 3-10% of all child injuries. 90% of these cases are seen after blunt trauma.
Penetrating injuries are more common in older children and constitute the other 10%. In a very small part, iatrogenic injuries occur. When evaluating genitourinary traumas, other life-threatening cerebral, thoracic, abdominal and skeletal injuries should be considered [2][3][4].
The most common causes of blunt trauma of urogenital injuries are fall, rape, motor vehicle accidents, and sports injuries. Factors causing penetrating injuries are gunshot injuries and sharp object injuries [5].
Minor genital traumas that do not require surgical treatment constitute most of childhood genital trauma [6]. In female children, genital organ injury can easily be occurred due to tissue fragility in the prepubertal period [7]. While anterior urethra may be affected by traumas involving the penis in male children, the urethra is rarely affected by female children since it is short and mobile [8,9].
Nowadays there are many studies on child trauma but we have not been able to detect any studies in the literature related to organ injury classifi cation. Since the number of the studies emergency department admissions, the relationship between post-traumatic complications and prognosis is very small, we aimed to determine these relationships in our study.

Study design and population
This retrospective cohort study included 254 patients younger than 18years of age who were detected to have genitourinary trauma in the emergency department between January 2014 and December 2018. After the etiologic trauma factors, organ involvement and classifi cation were determined, the patients were hospitalized in the pediatric surgery clinic.
The cases excluded from the study were the causes of trauma within the fi rst 24hours, the patients that did not been taken direct radiographs required for the diagnosis, the patients who were not performed abdominal and pelvic Computed Tomography (CT) and/or Ultrasonography (US), and small household accidents and cuts. Demographic characteristics, trauma patterns, examination results, urogenital organ injuries, other organ injuries, hospitalization procedures, and results were evaluated.
Patients were classifi ed in the study. In terms of trauma, they were classifi ed into 6 groups as; falling from a height up to one meter (-1mF) 'these are usually falling from swing, bicycle, staircase and a height not more than one meter such as wall, bunk beds', falling from a height of one meter and higher (+1mF), inside of the car (ICTA) and outside of the car (OCTA) traffi c accidents, Sharp Object Injuries (SOI) and iatrogenic injuries. Kidney injury was classifi ed into 5 groups as no injuries, contusion, laceration, subcapsular and parenchymal injuries. The presence of ureteral injury was evaluated. Bladder injury was classifi ed into 4 groups as no injuries, contusion, intraperitoneal and extraperitoneal. Urethral Injury was classifi ed into 4 groups as no injuries, anterior, posterior and laceration. The American Association for the Surgery of Trauma (AAST) organ damage scale committee, which is widely used today in the classifi cation of the renal, ureteral, bladder and urethral trauma, was used [10].
Genital organs were classifi ed into two groups as male and female. The male genital organ injury was classifi ed as scrotum, testicular and penis injury. In these classifi cations, subgroups were formed according to the type of injury. Female genital organs were classifi ed into two groups as perineal and vaginal injuries.

Statistical analysis
The data obtained from this study were analyzed using SPSS 20 package program. In the evaluation of the data, crosstables of the data are arranged by specifying the arithmetic mean, ± standard deviation, number, and percentage of individuals.
To determine the relationship between trauma types and urogenital injuries, Spearman's Rho coeffi cient was calculated and the error level was calculated as 0.05.

Result
This retrospective cohort study included 254 patients younger than 18years of age who were admitted to the emergency department due to urogenital region trauma between January 2014 and December 2018. Of these, 195(76.78%) were detected to be male and 59(23.22%) were female and the mean age was 8 years (range, 1-15years). The sex distribution of the patients was given in Figure 1 and the distribution of the trauma by gender and age was given in Table 1. When we look at the distribution of trauma types according to age, it was seen that -1mF was higher in all types of trauma ( Figure 1).
The most commonly seen type of trauma was -1mF. It was found that there was the least injury among all traumas in this type of fall. The OCTA was in second place and it was followed by +1mF. The most frequent injury was seen after the OCTA, followed by after +1mF injuries. Groups with the least injury were the iatrogenic and SOI groups.
Kidneys and ureters did not show any injury in -1mF, SOI and iatrogenic traumas. Most of the injuries were in the OCTA, followed by +1mF. The most frequent injuries were Type 1 with  8(3.6%) cases, followed by Type 2 and Type 3 with 6(2.4%) cases. Type 4 kidney injury was detected in two cases. Renal injuries were most commonly associated with the ureteral injury. The ureteral trauma was most frequently seen with OCTA and SOI. Two of 8(3.6%) patients with ureteral injury had Type 4. Hematuria was present in 29(78.4%) of the patients with renal or ureteral injury (Table 2).
Contusion was seen to be the most frequent injury in the bladder and urethra. The most common cause of bladder contusion was found to be OCTA and +1mF. Type 2 damage was detected in 7 patients and Type 4 in 4 patients with bladder injury. In the urethra, there were Type 1 injuries in 4 cases, Type 2 in 9 cases, Type 3 in 6 cases and Type 5 in 1 case. Hematuria was detected in all bladder and urethral injuries ( Table 3).

Discussion
Human life begins with labor that is a trauma and trauma is encountered until the child completes his/her development, from the fi rst breath [11,12]. Today, trauma is a leading cause of child mortality [13]. Permanent disabilities occurring more frequently than trauma-related deaths and decreased quality of life are also an important health problem [14]. Perirenal adipose tissue is not well developed in the kidneys, so it can not absorb the direct force applied to the abdomen and protect the organ. The fi brous capsule tries to prevent the fragmentation of the kidney tissue due to its being elastic [15]. However, vascular structures and ureters restrict the movement of the kidney [16]. The most frequently injured organ due to trauma in the urogenital system is the kidney.
There are renal injuries in 8-10% of cases with abdominal trauma [17]. The most common causes of renal injury are blunt trauma caused by falling from a height and traffi c or game accidents. Sharp object injuries are extremely rare compared to adults [2,3].
Our cases of renal and ureteral injury in our study were blunt traumas that frequently occurred as a result of +1mF and traffi c accidents. There was no sharp object injury case or no injury cases due to -1mF and iatrogenic causes. Falling from a height and OCTA comprised 27 (96.4%) of all renal injuries.
Karakoc [18] and Soto [19] et al., state that stage 1 renal trauma is the most common observed injury via computerized tomographic examination technique, with a prevalence of 85%. Streaking in the perirenal adipose tissue, a hyperdense subcapsular hematoma can be observed. Large size subcapsular hematoma may cause pressure in the parenchyma. In contrasted abdomen tomography, the contusion areas are as irregularly bordered, oval or round shaped hypodense areas.
In our study, the most common observed injury is stage 1 minor contusion. Of these, 7(25%) were +1mF and 4(14.3%) were blunt trauma due to OCTA. These cases were followedup by bed rest. No complications were observed. In our cases, 4 (14.3%) of the lacerations in stage 2 were smaller than one cm, and 5(17.8%) were larger than one cm. The patients who were followed up with bed rest and urinalysis were discharged without any problems. There were 5(17.8%) cases with subcapsular hematoma. Hemodynamic follow-up and absolute bed rest for two weeks were applied to these patients and no In the analysis of trauma types for male and female genital organ injury; the most common injuries were observed to occur as a result of -1mF. These were scrotal skin, testicular and penile lacerations. Scrotal rupture, testicular rupture, and penile fracture were detected in 3, 2 and 1 cases, respectively.
Perineal skin laceration was most frequent in women, perineum rupture was detected in 9 cases, a vaginal tear in 5 patients, and hymenal tear associated with the vaginal tear in 2 patients (Table 4).
According to the results obtained in Spearman's Rho test, correlation coeffi cients were associated between trauma types and kidney, ureteral, bladder and urethra injuries. These statistically signifi cant coeffi cients were found to be signifi cant only as relation criteria (Table 5).  complication was observed. One of the 2(2.1%) patients with Type 4 injury was followed-up nonoperatively. In the other case, laceration repair was performed surgically. Nephrectomy was not needed in any case with renal trauma.
Traumatic ureteral injuries are rarely seen due to their good protection by the structures around the ureter and small size. It constitutes 1% of all genitourinary injuries. Ureters are usually the result of iatrogenic and penetrating injuries [20]. It is more common in children than in adults. The most common injured surface is the ureteropelvic junction and 4 cm portion of the proximal ureter. There is no hematuria in 1/3 of the cases. Injury can easily be overlooked [18,19,21,22].
In our study, the ureteral injury was observed in 8(3.6%) cases among all trauma cases. Two of the cases had Type 4. The other six cases were associated with renal injury and were seen in the ureteropelvic junction. In patients with complete rupture, a double J catheter was inserted surgically and an end-to-end primary anastomosis was performed. The other six patients underwent cystoscopy and a double J catheter was inserted and followed-up with bed rest. Blunt, penetrating or iatrogenic injuries of the bladder can be encountered. Bladder rupture is a common type of injury.
It occurs in multiorgan injuries in full bladder, penetrating trauma in the tracheal bladder or pelvic bone fractures. Bladder trauma is seen in 5-10% of pelvic fractures. Pelvic fracture is present in almost all cases with bladder injury [2,7,23]. In minor injuries, spontaneous recovery may occur in 1-2weeks.
In our study, there were 24(9.4%) cases with bladder injury. One of these cases was iatrogenic as a result of bladder catheterization, two cases were sharp object injury due to falling on a tree, and all other cases developed as a result of blunt trauma. All blunt traumatic bladder injuries were detected to be accompanied by pelvic fracture. In 13 of these 24 cases, Type 1 was present and catheter drainage and bed rest were applied until hematuria disappeared. 7(2.8%) cases with Type 2 bladder injury were detected. These patients were applied for primary surgical repair and drainage. To uncomplicated Type  [25]. Except for the iatrogenic injuries of the urethra, almost all are accompanied by pelvic fractures [2,26].
In our study, we detected urethral injury in 20(7.9%) child cases with urogenital trauma. Three of these cases were iatrogenic, three were due to SOI, while in all other cases there was blunt trauma such as falling and traffi c accident.   Pelvic fracture and hematuria were present in cases except for iatrogenic and SOI. Six cases with Type 3 urethral rupture were inserted foley catheter under scopy, and followed-up.
To one case with Type 5 urethral rupture, the urethral repair was performed on foley catheters surgically. The case was followed-up with suprapubic drainage. After the foley catheter was inserted, the patients were checked with urethrogram for leakage and no leakage was observed. Of the nine patients with anterior urethral injury, four had catheter insertion and fi ve patients were only followed-up. No patient needed urethroplasty.
0.4% to 8% of childhood traumas include genital traumas [23]. Most of these traumas do not require surgical treatment [6]. Falling from a height in a horse riding manner, traffi c accidents, cycling, and playing equipment, sports trauma are the most common causes of genital organ injuries in this age group [24,25]. In female children, genital organ injury can easily be occurred due to tissue fragility in the prepubertal period [25]. While anterior urethra may be affected in traumas involving the penis in male children, the urethra is rarely affected by female children since it is short and immobile [8,9].
In our study, few minor traumas require surgery in parallel with the literature. In males, scrotal were seen as the most common, while perineum skin lesions were seen in females.
Male genital injuries are mostly seen as a result of blunt traumas and they are the injuries that the scrotum and testicles are more affected. Testicular rupture can be diffi cult to understand since even mild traumas may cause edema and ecchymosis in the scrotum. Besides, it is possible to encounter situations where the scrotum is opened, the testicles are out of the scrotum and the testicles are completely separated. Scrotum skin lacerations are seen as the most common in genital area injuries. Also, the accompanying penile skin lesions are not few. In these cases, the ruptures of the penis corpus cavernosum should be considered. Penetration or blunt penile injuries are usually accompanied by urethral injuries [1].
In our study, there were 69(27.2%) cases with male genital organ injury. In three of these cases, the scrotal rupture was observed. Primary surgical repair was performed. All other cases required minor surgery and short-term follow-up. Bilateral total testicle and scrotal rupture were found in 2 of 24 cases (9.4%) with a testicular injury. The severe pelvic fracture was also present in these cases occurred as a result of a traffi c accident. By plastic surgery and pediatric surgery, primary surgical repair and reimplantation were performed in these two cases. After treatment, almost complete recovery was seen in one testicle of both cases, while atrophy was developed in the other two testicles. 19(7.5%) cases with penile trauma were detected. The penile fracture was seen in one of these trauma cases and penile rupture in another. In the penile fracture, the hematoma was emptied, bed rest and elevation were applied. Surgical debridement and grafting were performed in penile rupture. Skin integrity was achieved. Bed rest was applied.
Genital injuries in girls are generally falling to a hard place where their legs were open, traffi c accidents, sexual assaults and penetrating injuries [27]. In our study, no cases were requiring serious intervention in girls. In two of the total of 42cases (16.5%) vaginal tear accompanied by hymenal tear was detected. Primary repair was performed. The minor repair was performed in other cases. No complication was observed in any of the cases.
As a result, urogenital system injuries can be seen in patients admitted to the emergency department due to trauma.
Since these traumas may accompany multiorgan injuries, accurate evaluation can reduce potential complications.
Hematuria is a valuable fi nding in the trauma of the urogenital system, however, its absence does not exclude the possibility of urological injury. Patients whose injuries are limited with renal parenchyma and having unimpaired hemodynamics can be followed-up with nonoperative treatment. Double J catheter is suffi cient in the treatment for the partial ureteral injury, while the surgical repair is required for complete injuries.
Catheter drainage is suffi cient for extraperitoneal bladder injuries and minor intraperitoneal bladder injuries, however, intraperitoneal major injuries require surgical repair. In patients with blunt trauma pelvic fractures, the possibility of bladder injury should not be forgotten.
The association between the form of trauma and the degree of organ injury is a guide in the selection of diagnostic methods. The classifi cation of urogenital damages helps to select appropriate treatment and predict outcomes. Also, standardization in diagnosis will bring standardization in treatment. A careful examination is essential not to overlook minor genital and perineal traumas, besides the major urogenital trauma.

Limitations of the study
The most important limitation of the study was that it is single centered and retrospective. For this reason, diffi culty was experienced in attaining some data. Some of these were; not coming back for control after admission to the emergency department, and the diffi culty in accessing the urography and computed tomography results were other limitations. The fact that trauma score was not performed, other multiple traumas could not be included in the study and the medication use history that could affect its prognosis could not be reached were among the most important limitations.

Conclusion
Urogenital organ injuries, which constitute a small part of childhood traumas, are specialized issues with a multitude of etiologic factors, rapid psychological impact in children and legal aspects. Protection of post-traumatic organ functions of children who will form the future increases the importance of the treatment method to minimize the possible complications and provide good rehabilitation.