The Management of Perineal Trauma in Children.

Aims: This study aimed to evaluate the outcome of perineal trauma in children and to a define protocol for their management.
Methods: It is a retrospective study of children who presented with perineal injury between August 2012 and December 2020. The patients were classified into three groups: Group-1 included children with perineal and genitourinary injuries; Group-2 included patients with perineal and anorectal injuries; and Group-3 included patients with perineal, genitourinary, and anorectal injuries. All patients underwent primary repair. Those with full-thickness anorectal injury underwent an additional covering colostomy, while urethral disruption was initially managed by a diverting suprapubic cystostomy (SPC).
Results: A total of 41 patients were studied. Impalement injury (n = 11; 27%) and sexual abuse (n = 11; 27%) were the most common mechanisms of injury. Twenty (49%) patients had anorectal injuries with 10 (24%) each of partial-thickness and full-thickness injury. There were 24 (59%) genital injuries and five (12%) urethral injuries. One patient each developed anal and vaginal stenosis, both were managed with dilatation. One patient developed a rectovaginal fistula repaired surgically at a later date.
Conclusion: Perineal injuries with resultant anorectal or genital damage require a careful primary survey. Following stabilization, an examination under anesthesia as a set protocol will help determine the treatment strategy. A colostomy is essential in the acute management of severe anorectal injuries to reduce local complications and preserve continence. Urethral injuries may warrant an initial diverting SPC in selected cases. Copyright:

INTRODUCTION

Perineal injury in the pediatric age group is challenging due to its complex and uncommon nature.[1] A clinical examination is insufficient many times to assess the extent and severity of the injury.[2] The approach and the management of perineal trauma in children are widely variable due to the broad spectrum of injuries and presentation.[1] Hence, a study was conducted to evaluate the outcome of perineal trauma in children and establish an institutional protocol for their management.

METHODS

A retrospective study was conducted in the Department of Pediatric surgery which included children (<18 years), treated for perineal trauma, from August 2012 to December 2020. The children who died due to concomitant injuries were excluded from the study. A child with perineal injury presenting to the emergency room underwent hemodynamic stabilization followed by the primary examination of the wound. Immediate measures were taken to treat life-threatening conditions. The perineal wound was meticulously cleaned and dressed. Associated injuries were treated accordingly.

Broad-spectrum antibiotics (cefotaxime and metronidazole) were started at admission. Every patient underwent a complete hemogram, urine examination, X-ray, and ultrasonography of the abdomen and pelvis. All stable patients underwent a contrast-enhanced computed tomography of the abdomen and pelvis. Once the child was stabilized and evaluated noninvasively, a secondary examination of the wound was carried out. This was usually done in the form of examination under anesthesia for proper evaluation of the anus, rectum, vagina, and urethra. The children were managed according to the extent and organs of injury [Figure 1].

Figure 1

Institute protocol for managing perineal trauma

The patients were divided into three groups: Group-1 included children with perineal and genitourinary injuries; Group-2 included patients with perineal and anorectal injuries; and Group-3 included patients with perineal, genitourinary, and anorectal injuries [Figure 2]. In those children with anorectal injuries, the injury was subclassified as full thickness or partial thickness. All patients who required suturing (except urethral injury) underwent primary repair [Figure 3]. Those with full-thickness anorectal injury had an additional covering colostomy [Figure 1]. Anorectal injuries were repaired in a single layer by full-thickness interrupted sutures using polyglactin sutures (4/0 or 3/0 depending on age). Deeper layers of genital and perineal injuries were repaired with polyglactin sutures (4/0 or 3/0 depending on age) and skin was repaired with poliglecaprone (5/0 or 4/0) sutures. Urethral injuries were also classified as complete transection or partial. Those with disruption were managed with immediate suprapubic cystostomy (SPC) and delayed repair after 6 weeks [Figure 2] when end-to-end reconstruction was done with polydioxanone (6/0 or 5/0) sutures via an anterior sagittal approach. Partial urethral injuries were managed with catheterization for 1 week. A single attempt at catheterization during the initial survey determined the need for SPC.

Figure 2

STROBE flow diagram

Figure 3

A 5-year-old female presented with a history of sexual assault. Examination under anesthesia revealed a laceration of the posterior fourchette (a) with extension along the posterior wall of the vagina (b). She underwent primary repair. The wound healed well (c) without any complication

At follow–up, the anorectal injury patients were calibrated with appropriate size Hegar dilator/per rectal examination to assess the repair. The colostomy was closed 3 months following the primary repair. Those with genital (vaginal) injuries were only followed up by observing the external appearance of the introitus. The SPC in urethral injuries was clamped and removed after evaluating the repair objectively by a micturating cystourethrogram via the SPC 2 weeks after the repair.

Statistical analysis

The continuous variable, age, was expressed in mean ± standard deviation. The categorical variables such as mechanisms of injury, type of injury, and complications were expressed in number with percentages.

RESULTS

A total of 43 children presented with perineal trauma to our institution during the study period. Two patients were excluded as they expired due to concomitant head injury. Hence, 41 patients were included in the study with 22 girls and 19 boys. The mean age of the study group was 6.8 ± 3.2 years. The etiology of injury was impalement by objects (n = 11; 27%), sexual abuse (n = 11; 27%), road traffic accidents (RTA, n = 8; 20%), dog bite (n = 4; 9%), and straddle injury due to fall [n = 7; 17%; Table 1 and Figure 1].

Table 1

Etiology of perineal injury

Etiology	n (%)	Type of injury
Impalement injury	11 (27)	Partial-thickness anorectal injury (n=2)
		Full-thickness anorectal injury (n=4)
		Genital injury (n=6)
Sexual abuse	11 (27)	Partial-thickness anorectal injury (n=3)
		Full-thickness anorectal injury (n=2)
		Genital injury (n=10)
RTA	8 (19)	Partial-thickness anorectal injury (n=5)
		Full-thickness anorectal injury (n=3)
		Genital injury (n=1)
Dog bite	4 (10)	Urethral injury (n=1)
		Genital injury (n=4)
Straddle injury	7 (17)	Urethral injury (n=4)
		Genital injury (n=6)
		Full-thickness anorectal injury (n=1)

RTA: Road traffic accidents

All children presented within 24 h of injury. Twenty-one (51%) children belonged to Group 1 (perineal and urogenital), 14 (34%) children belonged to Group 2 (perineal and anorectal), and the rest six (15%) belonged to Group 3 (perineal with both urogenital and anorectal injuries) [Figure 2]. Four (10%) children also had polytrauma, two with a femur fracture, one with a fracture of the pelvis and ribs, and the other with facial abrasions and ear laceration, all were managed accordingly. When counted as involved systems, there were 20 (49%) anorectal injuries (10 partial-thickness and 10 full-thickness injuries), 27 (66%) genital injuries, and five (12%) urethral injuries (of which two were complete disruption of urethra requiring SPC initially). To subclassify, all were anterior urethral injuries. The penile urethra was involved in three children and bulbar urethral involvement was seen in two children [Figure 2].

One patient who had a combined partial-thickness anorectal injury and vaginal injury developed a rectovaginal fistula following the repair, which was repaired after 3 months, under colostomy cover. A patient with isolated vaginal injury developed vaginal stenosis following primary repair and was managed by vaginal dilatation. A urethrocutaneous (coronal) fistula was seen in a child 3 months post repair of an isolated full-thickness anorectal injury for RTA which was repaired surgically. One patient with full-thickness injury developed anal stenosis after the repair, which was managed by anal dilatation [Table 2 and Figure 2]. We had no surgical site infection. There was no fecal or urinary incontinence.

Table 2

Management of individual injuries

Organ injured	Type of injury	n (%)	Management
Genital injury	Vaginal laceration	12 (29)	Primary repair
	Labial injury	2 (5)	Primary repair
	Clitoral injury	3 (7)	Primary repair
	Scrotal laceration	5 (12)	Primary repair
	Penile laceration	3 (7)	Primary repair
	Introitus hematoma	2 (5)	Conservative
Urethral injury	Partial injury	3 (7)	Primary repair
	Complete disruption	2 (5)	SPC followed by urethroplasty 6 weeks later
Anorectal injury	Partial-thickness anorectal injury	10 (24)	Primary repair
	Full-thickness anorectal injury	10 (24)	Primary repair + colostomy

SPC: Suprapubic cystostomy

DISCUSSION

Although uncommon in children, perineal injury carries high morbidity. The age, site, complex nature of injury involving adjacent anorectal and urogenital organs, and absence of standard protocol of management make pediatric perineal trauma a challenging condition to the treating doctor.

The mechanisms of perineal injury vary. Broadly, mechanics of injury may be grouped as straddle injury, blunt injury, and penetrating injury. Straddle injury or falling astride leads to tissues being compressed between the bony pelvis and an external surface (using the analogy of a compactor) or overstretching of skin and underlying tissues. Straddle injury may result in either hematomas, tissue loss secondary to pressure necrosis, or infrequently, even lacerations. Blunt injuries often cause bruising or hematomas. Penetrating injuries are due to objects that pierce through skin or mucosa, also termed impalement, and result in lacerations.

Sexual assault is a trauma entity where any of the above modes may come into effect. RTA and falls may involve any or all of the above modes of injury too.

The etiology of perineal injuries varies widely. Hashish and Oztürk et al. found RTA as the most common cause, while Leaphart et al. quoted sexual abuse and firearm injuries as the most common.[134] Fall from height was the most common injury in studies by Bakal et al., Samuk et al., and Sogut et al.[256] We found impalement injuries and sexual abuse as the most common mechanisms of perineal injury in our study similar to Vincent et al. and Black et al.[78]

Impalement as a mode of injury was not with sharp objects piercing but with any object that could penetrate, secondary to a forceful impact of the perineum on the object. Moreover, falling from height or RTA also resulted in impalement injury. Moreover, the injury was not laceration alone but crush injury of surrounding tissues.

Girls were more in number in our study as there were many cases of trauma due to sexual abuse. Studies by Hashish AA, Leaphart et al., Samuk et al., Vincent et al., and Black et al. had a higher incidence in boys contrary to the studies by Bakal et al., Oztürk et al., and Sogut et al.[12345678] Anorectal injuries were the most common injuries following trauma to the perineal area which was consistent with Hashish, Vincent et al., and Black et al.[178] From our study, no specific reason for this predominance could be deduced. It was also observed that in all the girls with vaginal and labial injuries, the urethra was spared, but the anorectum was involved often. A probable explanation for this is that most of these injuries were the result of sexual assault and girls were very young. The trauma, therefore, caused vaginal, posterior fourchette, and anal injuries akin to third-degree perineal tear during delivery.

In our series, urethral injuries were noted only in boys. While pelvic fractures from RTA usually cause posterior urethral injuries, the incidence is low, especially compared to those in adults.[9] We found only anterior urethral injuries and with variable etiology including dog bites. A selective nonoperative approach to incomplete injuries gave satisfactory results in a series by Holland et al.[10] Since there is diversity in location and the type of injury in the male urethra, the approach to urethral trauma varies. Anterior sagittal transrectal approach to the posterior urethra or perineal approach for the bulbar urethra, end-to-end repair or use of buccal mucosal grafts for reconstruction, primary repair versus initial SPC, and delayed repair, the surgeon usually has to individualize the approach.[11]

As all cases were anterior urethral injuries, we had no complications at follow-up. Stricture, incontinence, and impotence are long-term sequelae of posterior urethral disruptions.[10]

Although unrelated to primary injury, as mentioned in the results, one boy had a coronal urethral fistula 3 months post repair of anorectal injury due to RTA. We could only hypothesize the reasons as being ischemia with delayed presentation as fistula or missed injury as the child was catheterized with ease and no surface injuries of penis were noted at primary or secondary survey.

We had no surgical site infection and only three complications. Two of the three complications (vaginal stenosis and anal stenosis) were managed successfully by conservative methods and only one complication (rectovaginal fistula) required surgical intervention (repair). The development of a rectovaginal fistula in a partial thickness anorectal injury with associated vaginal injury highlights the need to consider colostomy for all complex injuries in females that involve rectum and genitalia regardless of whether it is a partial or full-thickness anorectal injury. Perineal injury and combined genito-rectal injuries may result in internal ischemic damage that may not be apparent at the initial examination. This may predispose to the development of a fistula.

None of our patients developed fecal incontinence which is better than Hashish, Oztürk et al., and Black et al.[138] Early presentation in our patients could also be a contributing factor for a good outcome.

Every perineal injury should be meticulously handled. Early and apt diagnosis with adequate and timely repair of perineal injury reduces morbidity.[2] The absence of external injury does not rule out underlying anorectal, genital, or urinary injuries. Leaphart et al. had missed three rectal perforations even after per rectal examination.[4] Hence, a thorough examination and adequate investigations are necessary to reduce morbidity. An examination under anesthesia is necessary in all cases as even radiological investigations are not good enough to rule out anorectal and genital injuries.[212] It helps in minimizing the chances of missing an injury. It also helps in deciding the type and extent of surgical intervention; for example, the partial-thickness anorectal injury does not need a colostomy, whereas the full-thickness anorectal injury does.[8]

Delayed presentation is not uncommon. Guha et al. reported a case of rectal impalement injury presenting as a vesical calculus.[13] Castellan et al. reported a case of inflammatory pseudotumor secondary to impalement injury presenting 5 years later.[14] We had a case of coronal urethrocutaneous fistula presenting 2 months later. Blunt injuries may cause ischemic damage and it was hypothesized that this could have resulted in the fistula formation in this case.

A complete hemogram, urine analysis, X-ray, and ultrasonography of the abdomen and pelvis are must in all cases of perineal injury. Hemodynamically stable patients must undergo a contrast-enhanced computed tomography. Leaphart CL et al. recommends the use of intravenous, oral, and rectal (triple) contrast to evaluate the extent of the injury.[4]

As there are no standard protocols to evaluate and treat perineal injuries, we reviewed our cases and devised an institution protocol for managing perineal injuries. We recommend primary repair for all perineal injuries. Covering colostomy is required in patients with full-thickness anorectal injuries and complex injuries. Associated injuries should be managed accordingly.

CONCLUSION

Perineal injury in the pediatric age group carries high morbidity. Meticulous evaluation and timely intervention are a must for a good outcome. Following stabilization, an examination under anesthesia, as a preset protocol, will help determine the treatment strategy. All perineal injuries can be repaired primarily. Covering colostomy is required in full-thickness anorectal injuries and complex injuries. Anterior urethral injuries may warrant an initial diverting SPC only in selected cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.