From the Guidelines
The best next step for a 7-year-old girl with genital trauma and mild bleeding after a bicycle straddle injury is prompt medical evaluation by a healthcare provider, preferably in an emergency department. The child should be kept comfortable with clean, loose clothing and gentle cleansing of the external area with warm water if needed. Parents should apply gentle pressure with a clean cloth if active bleeding continues, but should avoid aggressive cleaning or probing of the area. At the medical facility, healthcare providers will perform a careful examination to determine the extent of injury, which typically involves superficial lacerations to the labia or perineum in straddle injuries. Most cases can be managed conservatively with cleaning and observation, though more significant lacerations may require suturing under sedation. Pain management with acetaminophen or ibuprofen at age-appropriate doses is usually sufficient. This prompt evaluation is essential to rule out more serious injuries to the urethra, vagina, or rectum, and to document the injury pattern, which is typically consistent with the accident history in legitimate straddle injuries. According to the American Academy of Pediatrics 1, any signs of trauma, including laceration, should be noted, and the presence of any blood coming from the vagina should be evaluated. Additionally, the American Urological Association guideline 1 recommends performing retrograde urethrography in patients with blood at the urethral meatus after pelvic trauma, which may be relevant in this case if there is concern for urethral injury.
Key Considerations
- The patient's age and mechanism of injury suggest a high likelihood of superficial lacerations to the labia or perineum
- Prompt medical evaluation is necessary to rule out more serious injuries to the urethra, vagina, or rectum
- Conservative management with cleaning and observation is usually sufficient, but more significant lacerations may require suturing under sedation
- Pain management with acetaminophen or ibuprofen at age-appropriate doses is usually sufficient
- Documentation of the injury pattern is important to confirm consistency with the accident history
Potential Complications
- Urethral injury, which may require retrograde urethrography for diagnosis 1
- Vaginal or rectal injury, which may require further evaluation and treatment
- Infection, which may require antibiotic treatment
- Long-term sequelae, such as urinary incontinence or vaginal stenosis, which may require ongoing medical evaluation and treatment.
From the Research
Assessment and Management of Genital Trauma
The patient, a 7-year-old girl, presents with genital trauma and mild bleeding after a straddle injury from a bicycle accident. The best next step in care involves a thorough assessment and management of the injury.
- Initial Assessment: The patient's presentation of groin pain, mild bruising, and edema of the labia majora, along with a small amount of blood in her underwear, indicates the need for a careful examination to determine the extent of the injury 2.
- Physical Examination: A physical examination is crucial in assessing the severity of the injury. However, evidence suggests that clinical examination may not always reliably detect significant injuries, especially in cases of pelvic trauma 3.
- Urinalysis: Considering the mechanism of injury and the potential for urologic injury, a urinalysis may be useful. Studies have shown that microscopic hematuria can be an indicator of urologic injury in children, although its predictive power is moderate 4.
- Imaging Studies: The decision to perform imaging studies such as a computed tomography (CT) scan of the abdomen and pelvis should be based on the patient's clinical presentation and stability. In asymptomatic pediatric blunt abdominal trauma patients with pelvic free fluid on focused assessment with sonography in trauma (FAST) examinations, clinical examination and hemodynamic stability should guide the decision to order a CT scan 5.
- Pelvic Examination: The utility of a pelvic exam in the emergency department has been questioned, with some studies suggesting that it may not always add useful information to the management plan 6. However, in cases of genital trauma, a careful and gentle examination is necessary to assess the extent of the injury.
Considerations for Care
Given the patient's age and the nature of the injury, it is essential to approach the examination and management with sensitivity and care. The goal is to provide a thorough assessment while minimizing discomfort and trauma to the patient.
- Multidisciplinary Approach: Involving pediatricians, emergency medicine specialists, and possibly gynecologists or urologists in the care team can ensure a comprehensive approach to managing the patient's injuries.
- Patient and Family Support: Providing emotional support and clear communication to the patient and her family is crucial throughout the assessment and management process.