Z. Glaser1, N. Singh2, C. Koch2, P. Dangle1 1University Of Alabama at Birmingham,Urology,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA
Introduction:
Pediatric female genital trauma(PFGT) is rare but potentially devastating and requires intervention to avoid long-term sequelae. Traditionally, evaluation and treatment under general anesthesia(GA) in the operating room(OR) is recommended. Alternatively, examination and repair under sedation in the emergency department(ED) may yield equivocal outcomes. Onen’s genitourinary injury score(GIS) objectively describes PFGT severity but may not correlate with the level of care warranted. The purpose of this study was to evaluate outcomes of PFGTs managed in the ED vs. OR, propose a modified Onen’s GIS scale, and introduce a treatment algorithm.
Methods:
All patients treated at our institution from May 2009 to the present with associated ICD codes for PFGT were evaluated. Demographic, treatment and follow-up information was extracted from the electronic record. A cost analysis was performed.
Results:
A total of 37 patients was identified; the median age of 6.4 years, 19(51%) presented within 6 hours of injury, and straddle injury(27,72%) was the most common mechanism. Injuries were predominately Onen’s GIS I-III(33,89%) with possible urethral involvement in 6(16%) patients. Sedation and repair in the ED were performed for 13(35%) patients vs. 24(65%) in the OR. The two cohorts did not significantly differ in Onen GIS severity (p>0.05), and no major complications were observed. The majority of the OR cohort 18(75%) did not initially undergo sedation and attempted repair in the ED. Concern for vaginal mucosa or urethral involvement was the most common reason to forgo sedation, but ultimately none of these patients were found to have a urethral injury, and 11(61%) could have been safely managed in ED under sedation using Onen GIS = Grade 3 without urethral involvement as a cutoff. A female-specific modification to Onen’s GIS Grade III to differentiate isolated distal vaginal mucosa(III-a) and deep vaginal mucosa and/or urethral involvement(III-b) is proposed, and a treatment algorithm was generated. The cost of services increased more than five-fold when taken to the OR. Repair in the OR was also associated with a greater than 35% increase in the cost of supplies and ancillary services. These differences did not account for the additional costs of anesthesiology and postoperative hospitalization.
Conclusion:
Detailed evaluation and potential surgical repair under sedation in the ED as an initial step for all patients may conserve resources without compromising outcomes. Low-to-moderate severity PFGTs may be safely managed without GA in the OR with a significant cost-benefit.