Summary of emergency treatment experience of acute urethral trauma in girls

Summary of emergency treatment experience of acute urethral trauma in girls | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Summary of emergency treatment experience of acute urethral trauma in girls Guannan Wang, Ning Sun, Weiping Zhang, Jun Tian, Minglei Li, Hongcheng Song, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4663246/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Mar, 2025 Read the published version in BMC Urology → Version 1 posted 10 You are reading this latest preprint version Abstract 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 Figures Figure 1 Introduction 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. Methods 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. Results 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 Discussion 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. Study limitations 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. Conclusion 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. Declarations 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. References 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. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Mar, 2025 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 19 Dec, 2024 Reviews received at journal 29 Nov, 2024 Reviews received at journal 21 Nov, 2024 Reviewers agreed at journal 20 Nov, 2024 Reviewers agreed at journal 20 Nov, 2024 Reviewers invited by journal 18 Nov, 2024 Editor invited by journal 05 Jul, 2024 Editor assigned by journal 05 Jul, 2024 Submission checks completed at journal 05 Jul, 2024 First submitted to journal 30 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4663246","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":332480041,"identity":"70a0ec69-dfb3-46eb-8641-a13de5c25010","order_by":0,"name":"Guannan Wang","email":"","orcid":"","institution":"Beijing Children's Hospital, Capital Medical University, National Center for Children's Health","correspondingAuthor":false,"prefix":"","firstName":"Guannan","middleName":"","lastName":"Wang","suffix":""},{"id":332480042,"identity":"06aeb615-9c52-4fa2-ba57-2f769601ba28","order_by":1,"name":"Ning Sun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYLCCBAYGOQMGHhK1GJOoBQgSNxCtRX5G7rEHD3fUpm9nP3uA4UfFNgb+2Q34tRjcyEs3SDxzPHdnT14CY8+Z2wwSdw4Q0CKRYyaR2HYsd8MNHgNmxrbbQJEEQg6DaEk3IFoLww2wlpoE4rUYnHkD0nLAcGdPjsFBoF94JG4Qclh7jpnkz7Y6eXP2M4YPflTcluOfQchhEHAYTB4AYqIjtI5YhaNgFIyCUTASAQDMoUGv2oidDAAAAABJRU5ErkJggg==","orcid":"","institution":"Beijing Children's Hospital, Capital Medical University, National Center for Children's Health","correspondingAuthor":true,"prefix":"","firstName":"Ning","middleName":"","lastName":"Sun","suffix":""},{"id":332480043,"identity":"689bbcf2-ea46-423e-9688-007a1e4ce94a","order_by":2,"name":"Weiping Zhang","email":"","orcid":"","institution":"Beijing Children's Hospital, Capital Medical University, National Center for Children's Health","correspondingAuthor":false,"prefix":"","firstName":"Weiping","middleName":"","lastName":"Zhang","suffix":""},{"id":332480044,"identity":"641cf1ca-4136-49aa-80e3-bdef9b9e4ed0","order_by":3,"name":"Jun Tian","email":"","orcid":"","institution":"Beijing Children's Hospital, Capital Medical University, National Center for Children's Health","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Tian","suffix":""},{"id":332480045,"identity":"b2bab4a3-bb20-40d1-80b2-5abab7a395e4","order_by":4,"name":"Minglei Li","email":"","orcid":"","institution":"Beijing Children's Hospital, Capital Medical University, National Center for Children's Health","correspondingAuthor":false,"prefix":"","firstName":"Minglei","middleName":"","lastName":"Li","suffix":""},{"id":332480046,"identity":"195438f9-0bc6-4433-9862-70dfd5893380","order_by":5,"name":"Hongcheng Song","email":"","orcid":"","institution":"Beijing Children's Hospital, Capital Medical University, National Center for Children's Health","correspondingAuthor":false,"prefix":"","firstName":"Hongcheng","middleName":"","lastName":"Song","suffix":""},{"id":332480047,"identity":"58fe98d2-2257-4fd4-bdfc-663a16499fe9","order_by":6,"name":"Defu Lin","email":"","orcid":"","institution":"Beijing Children's Hospital, Capital Medical University, National Center for Children's Health","correspondingAuthor":false,"prefix":"","firstName":"Defu","middleName":"","lastName":"Lin","suffix":""},{"id":332480048,"identity":"b2d4b487-0740-4032-8060-6a4477894c24","order_by":7,"name":"Meng He","email":"","orcid":"","institution":"Beijing Children's Hospital, Capital Medical University, National Center for Children's Health","correspondingAuthor":false,"prefix":"","firstName":"Meng","middleName":"","lastName":"He","suffix":""}],"badges":[],"createdAt":"2024-06-30 14:53:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4663246/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4663246/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-025-01737-3","type":"published","date":"2025-03-14T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62135135,"identity":"a9a272b8-646c-4fb8-9210-bd6957d02b13","added_by":"auto","created_at":"2024-08-09 16:15:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2890378,"visible":true,"origin":"","legend":"\u003cp\u003eDiagnosis process and treatment for acute urethral trauma in girls\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4663246/v1/d6ff343545e8e803609b2171.png"},{"id":78689028,"identity":"0ed5b17c-4f49-4774-bc79-b75e820b88ce","added_by":"auto","created_at":"2025-03-17 16:10:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4508667,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4663246/v1/b67eca50-c52b-49bc-83c4-94daf8f08b63.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Summary of emergency treatment experience of acute urethral trauma in girls","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrethral trauma in female patients is rare and only sporadically reported in the literature. Most of these patients have blunt injuries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], the most common cause of which is external trauma resulting in pelvic fractures. An estimated 4.6\u0026ndash;6.0% of pelvic fractures in female patients are associated with urethral injury [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Children\u0026rsquo;s bones are not yet fully developed; they are characterized by a high cartilage ratio and higher elasticity than adults\u0026rsquo; bones, allowing them to absorb more energy in the event of injury [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Pelvic fractures with pelvic ring rupture, especially Malgaigne fractures and straddle fractures, are associated with a particularly high incidence of urethral injury [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUrethral 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\u0026ndash;87% of cases are complicated by vaginal tears [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and that 33% of cases are complicated by rectal injuries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; therefore, further clinical experience is needed to strengthen our understanding of such injuries and improve the diagnostic rate.\u003c/p\u003e \u003cp\u003eThe European Association of Urology recommends early repair (within 7 days) of urethral injuries in female patients rather than delayed repair or urethral realignment [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. 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 [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], 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 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe 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.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eClinical data\u003c/h2\u003e \u003cp\u003eThe clinical data of six girls with acute urethral trauma admitted to our hospital from April 2003 to April 2023 were retrospectively analyzed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative preparation\u003c/h2\u003e \u003cp\u003eAll 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.\u003c/p\u003e \u003cp\u003eUrethral 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% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. 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\u0026rsquo;s vital signs as necessary.\u003c/p\u003e \u003cp\u003eDiagnostic catheterization was attempted in the emergency department. If catheterization was impossible or difficult, urethral injury was considered. According to the patient\u0026rsquo;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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical treatment\u003c/h2\u003e \u003cp\u003eThe following three urologic surgeries commonly used in the emergency setting were performed in this study as necessary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eCystoscopic examination\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSuprapubic cystostomy\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eUrethral anastomosis and vaginal repair with a combined transabdominal and perineal approach\u003c/h2\u003e \u003cp\u003eApproximately 75\u0026ndash;87% of urethral injuries in female patients are reportedly complicated by vaginal tears [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. All patients in the present study had vaginal injuries. Therefore, simultaneous surgical repair of the urethra and vagina was required.\u003c/p\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003cp\u003eIf 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.\u003c/p\u003e \u003cp\u003eIf 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.\u003c/p\u003e \u003cp\u003eDuring 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative treatment\u003c/h2\u003e \u003cp\u003eAfter surgery, the patient\u0026rsquo;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.\u003c/p\u003e \u003cp\u003eOther 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.\u003c/p\u003e \u003cp\u003eA 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.\u003c/p\u003e \u003cp\u003eRegular 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eMedical records\u003c/h2\u003e \u003cp\u003eFollow-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 \u0026lt;\u0026thinsp;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.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTelephone or mail\u003c/h2\u003e \u003cp\u003eFollow-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\u0026ndash;3), mild (4\u0026ndash;7), moderate (8\u0026ndash;11), and severe (\u0026ge;\u0026thinsp;12). Each patient\u0026rsquo;s menstrual condition was also monitored during follow-up.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eGeneral information\u003c/h2\u003e \u003cp\u003eThis study involved six patients with complete medical records who were successfully followed up by telephone or letter. Their mean age was 5.18\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13 years (range, 1.8\u0026ndash;9.8 years), their mean follow-up time was 96.83\u0026thinsp;\u0026plusmn;\u0026thinsp;61.32 months (range, 101\u0026ndash;239 months), the mean surgical duration was 2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08 hours (range, 0.5\u0026ndash;3.5 hours), the mean blood loss was 38.67\u0026thinsp;\u0026plusmn;\u0026thinsp;28.75 mL (range, 2\u0026ndash;80 mL), the mean hospital stay was 38.17\u0026thinsp;\u0026plusmn;\u0026thinsp;32.05 days (range, 3\u0026ndash;95 days), and the mean surgical time after injury was 5.71\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15 days (range, 5\u0026ndash;14 days).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eClinical manifestations\u003c/h2\u003e \u003cp\u003eOne 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTreatment at other hospitals after injury\u003c/h2\u003e \u003cp\u003eBecause 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eComorbidities\u003c/h2\u003e \u003cp\u003eAll 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\u0026rsquo; 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative complications\u003c/h2\u003e \u003cp\u003eNo patients developed serious complications such as hematoma, severe infection, or pulmonary embolism.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEarly postoperative complications (within 3 weeks after surgery)\u003c/h2\u003e \u003cp\u003eOne 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLate postoperative complications (more than 3 weeks after surgery)\u003c/h2\u003e \u003cp\u003eFour 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 \u0026gt;\u0026thinsp;10 mL/s. All patients\u0026rsquo; menstrual condition was normal; two of them already had children.\u003c/p\u003e \u003cp\u003eOne 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\u0026ndash;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.\u003c/p\u003e \u003cp\u003eOne 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\u0026rsquo;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\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eUDI-6 and IIQ-7 Short Form scores\u003c/h2\u003e \u003cp\u003eThe six patient\u0026rsquo;s UDI-6 and IIQ-7 scores are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. According to these scores, the urinary dysfunction was classified as normal (0\u0026ndash;3), mild (4\u0026ndash;7), moderate (8\u0026ndash;11), and severe (\u0026ge;\u0026thinsp;12)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients\u0026rsquo; clinical characteristics and UDI-6 and IIQ-7 Short Form scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCASE No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge of injury\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCurrent age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEmergency surgical methods\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEarly postoperative complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurgery for complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUDI-6 score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIIQ-7score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eurethral anastomosis, vagina and rectal repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eurinary incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCystoscopy, bilateral ureteral reimplantation and bladder neck tightening surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eurethral anastomosis and vaginal repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDifficulty in urination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ecystoscopy and urethral dilation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eurethral anastomosis and vaginal repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuppubic cystostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCystoscopy, urethral anastomosis and vaginal repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ewound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCystoscopy, urethral anastomosis and vaginal repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ebleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eLow incidence rate of urethral trauma in girls\u003c/h2\u003e \u003cp\u003eAs 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 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eCauses of injury\u003c/h2\u003e \u003cp\u003eThe 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 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eA atypical clinical manifestations and risk of misdiagnosis\u003c/h2\u003e \u003cp\u003eFive 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.\u003c/p\u003e \u003cp\u003eIn 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\u0026ndash;vaginal fistula, and a suprapubic cystostomy was performed. One year later, the patient returned to the hospital for a second-stage repair surgery.\u003c/p\u003e \u003cp\u003eAccording 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 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost 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 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eDiagnosis without urination or cystourethrography: Use of cystoscopy (although not suitable for all patients)\u003c/h2\u003e \u003cp\u003eUrinary 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 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Most urethral injuries in female patients are diagnosed through cystoscopy under anesthesia [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eOur experience in emergency surgical management\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003cp\u003eOur experience highlights the following three points. First, if the patient\u0026rsquo;s condition permits, emergency urethral and vaginal repair surgery can be safely performed. If the patient\u0026rsquo;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 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. If the patient\u0026rsquo;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.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSecond, 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.\u003c/p\u003e \u003cp\u003eThird, 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.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative complications\u003c/h2\u003e \u003cp\u003eEarly 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\u0026ndash;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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eUDI-6 and IIQ-7 scoring\u003c/h2\u003e \u003cp\u003eThe 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\u0026rsquo; 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\u0026ndash;3), mild (4\u0026ndash;7), moderate (8\u0026ndash;11), and severe (\u0026ge;\u0026thinsp;12).\u003c/p\u003e \u003cp\u003eIn 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.\u003c/p\u003e \u003c/div\u003e"},{"header":"Study limitations","content":"\u003cp\u003eThis 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\u0026rsquo;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.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe 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.\u003c/p\u003e \u003cp\u003eIf the patient\u0026rsquo;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.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Beijing Children\u0026apos;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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLegal guardians or the patients themselves who are over sixteen years old signed informed consent regarding publishing their data.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data that support the findings of this study are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no financial or proprietary interests in any material discussed in this article.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 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.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEric 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\u003c/li\u003e\n\u003cli\u003eOrkin, 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\u0026ndash; 8. \u003c/li\u003e\n\u003cli\u003ePerry, 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\u003c/li\u003e\n\u003cli\u003eCarolina 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\u003c/li\u003e\n\u003cli\u003eKoraitim MM, Marzouk ME, Atta MA, Orabi SS(1996) Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 77: 876\u0026ndash;80. https://doi.org/ 10.1046/j.1464-410x.1996.01119.x\u003c/li\u003e\n\u003cli\u003eRanjan 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\u0026ndash;239. https://doi.org/10.1016/j.jpurol.2011.06.004\u003c/li\u003e\n\u003cli\u003ePodest\u0026aacute; ML, Jordan GH(1999) Pelvic fracture urethral injuries in girls. J Urol 2001;165:1660-5.\u003c/li\u003e\n\u003cli\u003eVenn 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\u003c/li\u003e\n\u003cli\u003ePeter 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\u003c/li\u003e\n\u003cli\u003eEfraim 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\u003c/li\u003e\n\u003cli\u003eOnen 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\u0026ndash;9. https://doi.org/ 10.1016/j.urology.2005.01.056\u003c/li\u003e\n\u003cli\u003eRitesh 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\u003c/li\u003e\n\u003cli\u003eYatam 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\u003c/li\u003e\n\u003cli\u003eLalgudi 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\u003c/li\u003e\n\u003cli\u003eHemal 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\u0026ndash;287.\u003c/li\u003e\n\u003cli\u003eChuan 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\u003c/li\u003e\n\u003cli\u003eAmjad 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\u003c/li\u003e\n\u003cli\u003ePeter 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\u003c/li\u003e\n\u003cli\u003ePerry, 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\u003c/li\u003e\n\u003cli\u003eDevin 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\u003c/li\u003e\n\u003cli\u003eM L Podest\u0026aacute;, G H Jordan(2001) Pelvic fracture urethral injuries in girls.The Journal of urology 165(5):1660-5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"girls, emergency, urethral trauma, treatment","lastPublishedDoi":"10.21203/rs.3.rs-4663246/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4663246/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo summarize our treatment experience of acute urethral trauma in girls.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed six girls with acute urethral trauma who were admitted to our hospital from April 2003 to April 2023 and followed up.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll 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.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe diagnosis of acute urethral trauma in girls requires vigilance. If the patient\u0026rsquo;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.\u003c/p\u003e","manuscriptTitle":"Summary of emergency treatment experience of acute urethral trauma in girls","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 16:15:23","doi":"10.21203/rs.3.rs-4663246/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-19T17:42:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-29T15:45:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-21T12:54:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158323049451408545456336466368197257950","date":"2024-11-20T16:42:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104312826074140906011122103878331179618","date":"2024-11-20T12:25:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-18T16:26:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-05T10:21:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-05T10:20:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-05T10:19:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-06-30T14:45:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea00e592-c843-41db-b6f5-d35d48098381","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T16:03:59+00:00","versionOfRecord":{"articleIdentity":"rs-4663246","link":"https://doi.org/10.1186/s12894-025-01737-3","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2025-03-14 15:58:14","publishedOnDateReadable":"March 14th, 2025"},"versionCreatedAt":"2024-08-09 16:15:23","video":"","vorDoi":"10.1186/s12894-025-01737-3","vorDoiUrl":"https://doi.org/10.1186/s12894-025-01737-3","workflowStages":[]},"version":"v1","identity":"rs-4663246","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4663246","identity":"rs-4663246","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}