Genital injury in children: when is it urgent?

What kinds of injuries happen?

Genital injuries in children are usually accidental: a knock during sport, a straddle fall onto a bike crossbar or a fence, getting caught in a zipper. Most are minor and settle at home. But some signs can point to an injury of the urethra, the testicle or internal organs and need an urgent examination.

A blow to the scrotum

Almost all scrotal injuries are blunt blows: sport, bicycles, road accidents. Brief pain after a blow is normal.

He needs an examination the same day, without delay, if:

the pain does not settle or gets worse,
the scrotum swells, bruises or gets bigger,
there is nausea or vomiting.

In these cases the covering of the testicle can tear (testicular rupture). The doctor does a Doppler ultrasound of the testicle. But in the first hours ultrasound does not always show a tear, and examining by hand is not enough either. So if suspicion is high, the testicle is checked in an operation. Early surgery improves the chance of saving the testicle: when surgery is delayed by 3 days, the testicle is lost much more often.

A testicular torsion can also follow a blow. With sudden, severe pain, go straight to the emergency department.

The penis and zipper injuries

Zipper injuries are most common in preschool and early school-age boys: the skin of the penis gets caught while doing up or undoing trousers.

Do not pull hard or keep trying to undo the zipper at home: this causes your child a lot of pain.
If the trousers cannot be taken off, you can cut them away around the zipper.
Take your child to the emergency department. There they give pain relief first, then free the skin by cutting the zipper with a special tool.

Small scrapes and bruises usually heal well. The doctor checks that the urinary opening is not damaged.

After a blow to the penis or the area between the legs, if blood comes from the urinary opening, there is visible blood in the urine, peeing hurts or he cannot pee, the urethra may be injured. This is an emergency.

Straddle falls in girls

Girls can fall astride a bike crossbar, a fence or the edge of furniture. Before puberty the tissues in this area are delicate and have a rich blood supply. So even a small injury can look like heavy bleeding, although most injuries are minor.

Press gently with a clean cloth; you can apply a cold pack wrapped in cloth.
For a minor injury, salt water baths can ease discomfort. If peeing stings, the doctor may suggest a cream.

Go straight to the emergency department if the bleeding does not stop, you cannot see how deep the wound is or where its edges are, the swelling keeps growing, she cannot pee, or the wound was caused by something sharp or pointed. Sometimes the examination is done under anesthesia so that the wound can be seen properly.

Kidney injury

In children the kidney is injured by a blow more easily than in adults. If blood appears in the urine after a hard blow to the belly, side or lower back, a fall or an accident, seek care right away. In a serious injury there may be no blood in the urine at all, so a doctor should examine your child after any major trauma. More: blood in urine.

Why does the doctor ask so many questions?

The doctor asks how, where and when the injury happened and writes it down. This is done for every child. Genital injuries in children are accidental in most cases. But if your child says someone hurt them, or something about what happened worries you, tell the doctor openly: specialist help is available to keep children safe.

When to seek urgent care

If any of the following is present, do not wait for a routine appointment: call the doctor or go to the nearest emergency department.

Blood from the urinary opening, visible blood in the urine, or your child cannot pee
Severe pain, rapidly increasing swelling, nausea or vomiting after a blow to the scrotum
Bleeding that does not stop with pressure
A cut or puncture wound, a wound whose edges you cannot see, or swelling that keeps growing
Blood in the urine after a blow to the belly or lower back

Call your local emergency number (112 in Europe, 911 in North America)

Note for pediatricians and family doctors

Trauma is the leading cause of morbidity and mortality in children; mechanisms listed by the EAU include falls, car accidents, sports, physical assault and sexual abuse. Signs of urethral injury: blood at the meatus, visible hematuria, pain on voiding or inability to void; perineal swelling and a hematoma involving the scrotum may be present. Retrograde urethrography is strongly recommended when urethral injury is suspected; straddle (bulbar urethral) injuries often have no associated injuries. Children are more likely than adults to sustain renal injury after blunt trauma, and significant renal injury can occur with little or no hematuria. 94.5% of pediatric scrotal trauma is blunt (sport, bicycles, road traffic); color Doppler ultrasound is quick and useful but can miss testicular fracture (tunica albuginea disruption) in the acute period, and physical examination alone is unreliable. In high-risk cases early exploration gives an excellent chance of testicular salvage: a 72-hour delay was associated with a 45% orchiectomy rate versus 9% after acute exploration (Cass et al.). About half of traumatic hematoceles have a tunica albuginea injury; torsion may present after trauma. In prepubertal girls the unestrogenized genital tissues are friable and very vascular, so even minor trauma can cause bleeding that looks extensive; ongoing bleeding, wound edges not visualized, labia minora tear, inability to void or clinician concern make an injury non-minor, and examination under anesthesia should be considered; the examination should be done once, by a senior clinician. In zipper injury early analgesia is vital; if tissue is caught in the zipper head, the median bar is cut, and if it is caught between the teeth, the zipper is cut across below the entrapment; surgical referral is needed if this fails, and the meatus should be checked for damage. Urogenital trauma frequently raises the question of non-accidental injury but is uncommonly associated with it; if the history does not match the injury, this should be assessed, documented and referred appropriately.

What happens at the visit?

We ask how the injury happened and examine the child gently after pain relief.
For scrotal injuries a Doppler ultrasound of the testicle is done; if a ruptured testicle is suspected, surgery is discussed without delay.
If a urethral injury is suspected, further tests are arranged; for minor injuries, home care is explained.

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Frequently asked questions

He was hit in the testicle by a ball and the pain went away after 10 minutes. Does he need to see a doctor?

If the pain has gone completely and there is no swelling or bruising, watch him at home. If the pain comes back, the testicle swells or he starts vomiting, he needs an examination the same day. A testicular torsion can sometimes follow a blow.

My daughter fell astride her bike crossbar and is bleeding. What should I do?

Press gently with a clean cloth for a few minutes. Tissues in this area have a rich blood supply, so a little blood looks like a lot, and most of these injuries are minor. If the bleeding does not stop, you cannot see how deep the wound is, or she cannot pee, go straight to the emergency department. For a minor injury, salt water baths can ease discomfort.

The doctor asks in detail how the injury happened. Why?

This is a routine question asked about every child. Most genital injuries are accidental. But if your child says someone hurt or touched them, or something about the event worries you, tell the doctor openly: specialist help is available to keep children safe.

Genital injuries in children: scrotum, penis and straddle injuries