Summary
Introduction
Pediatric female genital trauma (PFGT) comprises injuries to the female external and
internal genitalia. Examination under general anesthesia (GA) in the operating room
(OR) is traditionally recommended, however repair at the bedside under conscious sedation
(CS) in the emergency department (ED) may be a safe alternative. The Genitourinary
Injury Score (GIS) objectively classifies PFGT severity, but designates all vaginal
and urethral injuries as Grade III.
Objective
To compare outcomes and cost of patients with PFGT managed under CS in the ED vs GA
in the OR.
Study design
All patients treated by a pediatric urologist from May 2009 to September 2019 with
associated ICD codes for PFGT were included. Exclusion criteria included PFGT from
sexual abuse or obstetric related complications. Clinical and demographic data was
extracted from the EMR. A cost analysis comparing ED vs OR management was performed.
Results
33 patients were identified with a median age of 6.8 years. The primary etiology was
straddle trauma. Injuries were predominately GIS I-III (30, 91%) with possible urethral
involvement in 6 patients. Sedation and repair in the ED was performed for 12 (36%)
patients vs 21 (64%) taken to the OR. For the OR cohort, 15 (71%) were taken to the
OR immediately and 6 (29%) initially underwent CS but this was aborted due to injury
complexity. Aborting CS and proceeding to the OR did not result in compromised outcome
or prolonged hospitalization.
No patients in the ED cohort required post-procedural admission whereas all patients
taken to the OR were admitted postoperatively. Cost of care for ED repair was less
than two-thirds (60%) that of surgical repair in the OR. Using Onen GIS III or less
without deep vaginal and/or urethral involvement as a cutoff for attempted bedside
repair vs proceeding directly to the OR could have spared 7 (47%) patients GA and
subsequent admission. A female-specific modification to the Onen GIS III criteria
is proposed in light of these findings.
Discussion
The present study suggests CS and bedside repair of low-grade PFGTs is safe with a
cost benefit. This is reflected by a proposed modification to the Onen GIS III criteria.
These findings should be interpreted with caution given the retrospective nature of
this single institution, small cohort study.
Conclusion
Graphical AbstractProposed GIS scale (a) and management pathway (b).
Keywords
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Article info
Publication history
Published online: December 11, 2020
Accepted:
November 30,
2020
Received in revised form:
October 31,
2020
Received:
June 3,
2020
Identification
Copyright
© 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
