To our knowledge this is the first comprehensive analysis of GU injuries in children presenting to US hospital EDs. Each year approximately 28,000 children present to the ED with GU injuries. This rate is similar to the yearly incidence of pediatric injuries associated with in-line skates and with baby walkers before 1992. Injuries associated with these products decreased significantly after the American Academy of Pediatrics issued recommendations to wear protective gear during in-line skating and the Consumer Product Safety Commission strengthened safety standards for baby walkers, respectively.13,14
We observed that the yearly incidence of GU injuries was similar throughout the 9-year study period. This stability suggests that preventive measures to decrease the risk of GU injury have not been identified or have not yet impacted the number of GU injuries sustained each year.
We identified epidemiological characteristics associated with pediatric GU injuries. Children were more likely to sustain injuries during the summer than in the winter. Girls sustained more overall injuries than did boys. However, boys consistently sustained proportionally more injuries than girls after age 7 years. We hypothesize this shift may be due to older boys engaging in greater risk taking behavior. We observed, as have others, that GU injuries are usually treated in the ED and seldom require admission or transfer to another, presumably specialty care, hospital.15
Compared to the overall sample, patients who were admitted or transferred to another hospital were older and approximately 25% had kidney injuries. Children who sustained renal trauma were more likely to require hospitalization than those with other GU injuries.
In our study we observed a lower incidence of major renal injury than have others.16–19
This finding is likely due to differences in the sample population studied and possibly the exclusion of patients with injuries due to automobiles and motorcycles. These prior studies were derived from trauma center databases, which receive more severely injured patients than general hospitals and often exclude those patients not admitted to the hospital. Conversely NEISS is a nationally representative sample of emergency visits for almost all types of injuries. Therefore, it is likely that genital contusions are more likely to occur than major renal injury.
We observed that GU injuries are commonly associated with certain consumer products. Each year approximately 1,100 boys catch the penis or scrotum in a zipper. Zipper injuries to the male external genitalia accounted for 4 times the number of all injuries caused by backpacks, which have been identified as an item worthy of injury prevention initiatives.20
Zipper injuries most often occurred in prepubescent boys, which is consistent with previous single institution series.21,22
The number of these injuries could be greatly reduced if boys at greatest risk for zipper related scrotal or penile injuries wore jeans with snaps or buttons. A similar number of injuries occurred due to the toilet seat falling on the penis. Toilet seats that slowly lower to a horizontal position or have a larger gap between the overlying seat and toilet rim may prevent these injuries.
Bicycles were the product most often associated with pediatric GU injuries. Most bicycle injuries were due to a straddle mechanism. Although most children who sustain these injuries are discharged from the ED, we believe that such bicycle associated GU injuries should be a focus of injury prevention. However, we recognize there are limited resources for injury prevention programs and there are many other injuries, such as concussion, that pose a public health hazard.23
Therefore, we do not advocate that new bicycle injury prevention programs be developed. Rather, we believe that our observations can be used to strengthen and expand existing bicycle injury prevention efforts, such as the American Academy of Pediatrics bicycle safety program. Prior studies have shown that of patients who sustained traumatic injuries from bicycles none was wearing protective gear.24
Simple preventive measures such as ensuring a proper fit for the bicycle and using protective gear (eg soft pads for the top tube of a bike) when riding may decrease the incidence and severity of GU injuries.
The approach of strengthening current injury prevention efforts to emphasize GU safety is also applicable for other sports injuries. Our observations support advocating for using appropriate protective gear and reinforcing extant recommendations such as limiting body checking during hockey.25
We hope that increased compliance with these recommendations may further decrease unintentional sports related GU injury. However, we acknowledge that nearly all protective gear worn in sports and recreation has no testing or evaluation standards.26
Shoulder pads and so-called hip and kidney pads are not regulated and may in some cases give a false sense of protection. Additionally, although we believe that many GU injuries are preventable, we acknowledge that some GU injuries cannot be realistically reduced through the implementation of preventive measures. The significant number of injuries associated with pieces of furniture are likely due to “kids being kids” and climbing on or jumping over the piece of furniture.
This is the first known study to investigate the epidemiology of GU injuries sustained by children who present to hospital EDs representative of the wide variety of hospitals that comprise the delivery of emergency health care in the US. Its strengths include using a large, nationally representative sample and a time frame that spans nearly a decade to estimate the prevalence of pediatric GU injuries. Nevertheless, limitations to the study exist. Most significantly, insight into the details of the injury, such as specific product (eg brand), circumstances surrounding the injury (eg whether the injury occurred associated with product malfunction or through normal use) and specifics regarding the injury (eg method of treatment), is limited by the information included in the NEISS data set. Further investigation into the circumstances and products identified as having a high association with GU injuries at a local level may help provide greater clarity into how these injuries occur and facilitate development of specific risk reduction strategies. Secondly, children who sustain GU injuries due to automobiles or motorcycles and those who present to their primary pediatrician or an urgent care center with an injury are not captured by NEISS. Therefore, it is likely that this study underestimates the true incidence of pediatric GU injuries and may underestimate minor and some major injuries.
Finally, this study does not provide an estimate of the cost associated with these injuries. Determining the direct and indirect costs of disease and injury will become increasingly important to develop cost-effective models for injury treatment and prevention. Further investigation into how to best implement prevention measures will assist in the development of educational programs and policies aimed at preventing GU injuries in children.