|Year : 2021 | Volume
| Issue : 1 | Page : 55-59
Management of severe iatrogenic perineal injury: A case series
Nnamdi Jude Nwashilli, Alexander Ilo Arekhandia
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Submission||27-May-2020|
|Date of Decision||01-Aug-2020|
|Date of Acceptance||02-Sep-2020|
|Date of Web Publication||31-Mar-2021|
Dr. Nnamdi Jude Nwashilli
Department of Surgery, University of Benin Teaching Hospital, Benin, Edo State
Perineal injuries are uncommon. More uncommon are severe perineal injuries. This is attributed to the relative protection of the perineum by the bony pelvis. Common causes of perineal injury include injuries from motor vehicular accidents, fall from height, foreign body insertion into the perineum, injuries from rape, and penetrating external trauma. The management of severe perineal injury entails addressing any life-threatening condition in the patient first and, subsequently, the perineal injury. The perineal injury can be repaired primarily with or without colostomy or colostomy carried out alone without primary repair. We present four cases of severe perineal injury managed by colostomy alone without primary repair of perineal soft tissue or anal sphincters. The anal sphincters and perineal soft tissues healed secondarily and sealed without any need for repair with good outcome.
Keywords: Colostomy, good outcome, severe perineal injury
|How to cite this article:|
Nwashilli NJ, Arekhandia AI. Management of severe iatrogenic perineal injury: A case series. Sahel Med J 2021;24:55-9
| Introduction|| |
The perineum consists of that part of the trunk of the body caudal to the pelvic diaphragm (levator ani and coccygeus). A line joining the anterior parts of the ischial tuberosities divides this diamond-shaped area into a larger posterior anal region and a smaller anterior urogenital region. The anal region contains the anal canal and the ischioanal fossae, whereas the urogenital region contains the external genitalia.
Perineal injuries may be from minor perineal tear/laceration to major/severe perineal injuries that involve the anal sphincters, the anal mucosa, or the urogenital system. A severe perineal injury is a third- or fourth-degree perineal tear. A third-degree perineal injury involves the anal sphincters, whereas a fourth degree involves the anal sphincters, the anal mucosa, and the urogenital system.
Blunt and penetrating injuries to the perineum are uncommon. Particularly, uncommon is blunt injury due to the relative protection by the bony pelvis. The overall incidence of perineal injury is unknown but small. Ricciardi et al. reported an incidence of 1.1% in 16,814 patients following blunt trauma. The mechanisms of injury include iatrogenic instrumentation, foreign body insertion, rape, and blunt and penetrating external trauma.
The management of perineal injury depends on whether the injury is intraperitoneal, extraperitoneal, or both. Injuries above the peritoneal reflection are readily accessible and amenable to treatment as colon injury. Extraperitoneal injuries are difficult to access, and direct repair may not be possible; hence, the mainstay of treatment in most instances remains fecal/urinary diversion.
We present four cases of severe perineal injuries that were managed by colostomy alone without primary repair of perineal soft tissue or anal sphincters. The anal sphincter was involved in the injury in case 3, whereas the other three cases, the sphincters, were intact. The anal sphincters and perineal soft tissues healed secondarily and sealed without any need for repair with good outcome.
| Case Reports|| |
A 30-year old male, a restrained driver of a Jeep car that lost control while on high speed on express highway. He veered off the road and crashed into a side culvert. The airbag of the car deployed on the passenger's side but not on the driver's side. He sustained a deep laceration in the anorectal region with multiple facial and limb bruises. He presented a week after the injury, having being in another hospital with infected wound and features of sepsis. There was no history of fecal incontinence.
On admission, he was conscious with Glasgow Coma Score of 15. His airway was patent as he was vocalizing; respiratory rate was 28 cycles/min (normal = 12–20), pulse rate – 76 beats/min (normal = 60–100), blood pressure – 120/80 mmHg, and temperature – 37.8°C (normal = 36.1–37.2). General examination showed a young man, calm, pale, febrile, anicteric, acyanosed, and dehydrated. A deep dirty laceration was noted in the anal region involving the perineum. The right ankle was swollen and tender.
The hematocrit was 23% (normal = 40–52); he had two units of whole blood, and posttransfusion hematocrit was 27.9%. The total white blood cell count was 13.3 × 1000/mm3 (normal = 4000–11,000) and platelet was 285 × 1000/mm3 (normal = 150–400,000). Plain radiograph of the right leg showed undisplaced right fibula fracture which was managed by application of plaster of Paris cast. Random blood sugar, electrolytes, urea and creatinine, abdominal ultrasound, and trauma series of X-rays (chest X-ray anteroposterior [AP] view, neck X-ray AP and lateral views, and pelvic X-ray AP) were normal.
He underwent emergency examination under general anesthesia (EUA). The findings were deep extensive perineal injury, loss of part of scrotal skin with anorectal laceration (Grade IV rectal injury) with wound filled with necrotic tissue, and purulent discharge [Figure 1]a. The anal sphincters were intact on digital rectal examination. A wound swab grew Klebsiella oxytoca sensitive to ciprofloxacin, and he was commenced on it. The wound was debrided, copiously irrigated with normal saline, and dressed daily with honey. Analgesics, tetanus toxoid, and human tetanus immunoglobulin were administered. Hartmann's colostomy was performed to protect the wound from fecal soilage. Postoperatively, he was continued on daily wound dressing with honey, antibiotics, and analgesics. The wound granulated and sealed without any need for secondary repair [Figure 1]b. The colostomy was closed after 12 weeks. There was no fecal incontinence afterward.
|Figure 1: (a) Deep extensive perineal injury with devitalized tissue and purulent discharge, loss of part of scrotal skin, and deep anorectal laceration (Grade IV rectal injury) at presentation. (b) The same wound in Figure 1a, now clean with healthy granulation tissue after 8 weeks of dressing with honey|
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A 23-year-old male, a passenger in a bus traveling at a high speed, had a burst tyre. The vehicle rolled over and crashed into a tree by the roadside. He sustained a deep perineal wound and laceration in the anorectal region with anal bleeding (Grade IV rectal injury). There was no history of fecal incontinence. He had abrasions on the face, back, and lower limbs.
He was conscious on admission and his airway was patent; respiratory rate was 22 cycles/min (normal = 12–20), pulse rate – 80 beats/min (normal = 60–100), blood pressure – 120/80 mmHg, and temperature – 36.5°C (normal = 36.1–37.2). General examination showed a young man in pain distress, pale, dehydrated, afebrile, and anicteric. A deep laceration in the anorectal region and perineum was noted on examination under anesthesia [Figure 2]. The anal sphincters were intact on digital rectal examination. Examination of other systems was normal. Full blood count showed a hematocrit of 30%. Other laboratory investigations were normal.
|Figure 2: Deep laceration in the anorectal region and scrotum after 4 weeks of honey dressing|
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A Hartmann's colostomy was performed to control the contamination of the wound and facilitate secondary healing. He had antibiotics (cefuroxime and metronidazole), analgesics, and daily dressing of the wound with honey. The wound gradually healed and sealed. Colostomy was closed at 12 weeks. The patient achieved good fecal continence afterward.
An 8-year-old girl, a pedestrian, was knocked off the road by a fast-moving car, and she landed with her buttocks on a sharp object. She sustained deep laceration in the anal and perineal regions. She bled from the anus and the perineal wound with complaint of severe anal pain. There was no history of fecal or urinary incontinence. She had multiple abrasions on her back, face, and lower limbs. There were no other associated injuries.
On admission, she was conscious with Glasgow Coma Score of 15. Her airway was patent as she was vocalizing, her respiratory rate was 32 cycles/min (normal = 18–30), pulse rate – 120 beats/min (normal = 70–110), blood pressure – 130/80 mmHg, and temperature – 36.2°C (normal = 36.5–37.5). General examination revealed a child in pain distress, restless, pale, dehydrated, afebrile, and anicteric. Chest, abdominal, and musculoskeletal examinations were normal.
Her hematocrit/hemoglobin was 22.9% (normal = 36–45) (7.8 g/dl) (normal = 11–15). She had two units of whole blood transfused. Posttransfusion hematocrit was 30.7% (hemoglobin = 10.6 g/dl). Her total white blood cell count was 8600/μL (normal = 4500–14,500) and platelet was 187,000/μL. Random blood sugar, electrolytes, urea and creatinine, and urinalysis were normal. Parenteral antibiotics (ceftriaxone and metronidazole), analgesic (tramadol), tetanus toxoid, and human tetanus immunoglobulin were administered.
She underwent emergency EUA. The findings were extensive laceration just beneath the posterior vaginal wall involving the anal canal, perineal body, ischiorectal fossa, and left buttocks. The anal sphincters were noted to be lax. The wound was swabbed and the culture yielded growth of Escherichia More Details coli sensitive to imipenem, and it was administered to her. The wound was debrided, copiously irrigated with normal saline, and dressed daily with honey. Hartmann's colostomy was performed to protect the wound from fecal soilage. The wound granulated, healed, and sealed. Colostomy was closed after 10 weeks. The patient is presently able to achieve fecal continence.
A 6-year-old boy fell from a fence and landed with his buttocks on a sharp hoe while running away from a barking dog. He sustained an impalement injury in the anorectal region and bled from the anus. He was taken to a nearby hospital where the wound was sutured with nonabsorbable stitch due to the bleeding before he was referred to our facility after few days. There was no history of fecal or urinary incontinence.
On admission, he was conscious and his airway was patent; respiratory rate was 20 cycle/min (normal = 18–30), pulse rate – 74 beats/min (normal = 70–110), and temperature – 36.4°C (normal = 36.5–37.5). General examination revealed a young boy in pain distress, pale, afebrile, anicteric, and dehydrated. Abdominal examination revealed suprapubic fullness with tenderness, blood at the tip of the penis, and scrotal swelling. Attempt at urethral catheterization failed and suprapubic cystostomy was carried out with size 20, 3-way Foley's urethral catheter which drained blood-stained urine.
His hematocrit was 24% (normal = 36–45), and he had three units of blood. The total white blood cell count was 7.4 × 1000/μL (normal = 4500–14,500) and platelet – 150 × 1000/μL. Urine culture yielded Klebsiella Spp. sensitive to imipenem, and it was administered to him. Other blood investigations were normal.
He underwent emergency EUA. The findings were deep impalement perineal injury with involvement of the anal canal mucosa (Grade IV) and urethral injury with purulent discharge. The anal sphincters were intact. An active bleeding vessel was seen and ligated with absorbable suture. A Hartmann's colostomy was performed. Postoperatively, he was continued on the imipenem, analgesic, and daily dressing of the wound with honey. The wound healed and colostomy was subsequently closed after 10 weeks. He had no fecal incontinence. A micturating cystourethrogram carried out was suggestive of membranous urethral injury, and he was referred to the urologist for further management.
| Discussion|| |
Perineal injury occurs more commonly in boys (males) than in girls (females). This is attributable to aggressive play and more strenuous activities by the boys (males) which can lead to injury. Three out of the four reported cases were male.
EUA is recommended in perineal injury to avoid the underestimation of the severity of the injury as well as the probability of missed injuries. The absence of obvious external injury does not preclude genitourinary tract injury or rectal injury, especially in impalement mechanism. The reported cases had EUA and the findings helped to categorize the injury as a severe perineal injury with gross contamination which informed the decision to carry out colostomy alone without attempting any primary repair.
Out of the four cases reported, three occurred as a result of blunt trauma from motor vehicular accident, whereas one occurred following fall from height. This differs from the study of Demetriades and Salim that reported gunshot wound accounting for 80%–85% of anorectal injuries, stab wound 3%–5%, and blunt trauma 5%–10% of cases. Burak et al. also reported a similar trend of gunshot wound to the perineum accounting for 33.3%, stab wound 23.8%, and blunt trauma 25.4%.
All the four patients reported sustained severe perineal injuries (3rd- or 4th-degree perineal injury). These injuries were extraperitoneal with gross contamination following trauma as well as fecal contamination from the anorectum. This necessitated the decision to carry out colostomy alone without primary repair of the tissues. The wounds gradually healed secondarily and sealed. A cohort study comparing matched groups of patients with extraperitoneal injuries reported that fecal diversion without repair resulted in the fewest complications. Velmahos et al. reported that diverting colostomy without rectal repair or drainage appears to be safe for the management of most civilian retroperitoneal gunshot wounds. This was further corroborated by Navsaria et al. in their work on civilian extraperitoneal rectal gunshot wounds that fecal diversion is the most important of the interventions available.
Two out of the four cases were pediatric patients. There is no standard management for perineal trauma in children. Current management options in children are similar to that of adults and entail: primary repair of the sphincter and/or all soft-tissue injuries without colostomy in extraperitoneal partial-thickness anorectal injury, sphincter injury, and minimal contaminations; primary repair of the sphincter, vaginal, urethral, and soft-tissue injuries with colostomy in full-thickness anorectal and sphincter injury or in combined anorectal and vaginal injury; and fecal diversion, urinary diversion, and wound drainage without repair in combined anorectal, sphincter, urethral, and vaginal injuries. This agrees to what Amel reported in the management of five cases of severe perineal trauma in children out of 32 cases of perineal trauma. Two of the patients had combined anorectal and sphincter injury, another two had combined anorectal and urethral injury, whereas one patient had combined anorectal and vaginal injury. Fecal diversion (colostomy), urinary diversion, and wound drainage without repair were the management options adopted with good outcome.
Wound infection was noted in three patients, whereas one had urinary tract infection. Following trauma, organisms can be introduced from outside the body into the wound or from gross fecal contamination from anorectum. Amel also reported wound infection in a case out of five cases with severe perineal injury in addition to other complications such as wound disruption, urethral stricture, and fecal incontinence.
| Conclusion|| |
Severe perineal injury is uncommon. Colostomy alone without primary repair prevents gross fecal contamination of wound, thereby facilitating secondary healing of the wound with good outcome. Anal sphincteric repair may not be necessary in some cases after the wound has healed and sealed with good fecal continence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]