Combined penetrating injury of the perineum and abdominal viscera

Abstract

This is a rare presentation. A farmer aged 52 years old was brought to the emergency service of Government District (Doon) Hospital in the late evening having significant bleeding per rectum. He had injured his perineum on a sharp wooden stick during a fall near a tube well. The wooden stick had been extracted by his relatives, which had resulted in profuse bleeding. The patient was managed with intravenous crystalloids and rushed to the operating theatre for examination under analgesia. Blood transfusion was arranged and the wound explored under general anaesthesia. The patient had unusual associated visceral injuries as well as sphincter, rectum, urinary bladder, ileal loop and mesentery injuries. The injured bowel, mesentery, urinary bladder and rectum were repaired with diversion of the upper pelvic colon. In addition, debridement of the perineal wound with rectal sphincter repair was performed and the presacral space drained. The colostomy was closed after 3 months, and the patient survived and is continent.

Background

Combined penetrating rectal and visceral injuries preset a challenge to the surgeon. Most of the injuries are sustained in accidents. The mortality in such cases is due to exsanguinations from pelvic or visceral injuries. Whereas the standard treatment for penetrating rectal trauma (intraperitoneal) consists of perioperative antibiotics, a diverting colostomy and presacral drainage, in addition distal rectal washouts have been advocated for extraperitoneal rectal injury. This management scheme is inadequate for penetrating rectal trauma combined with urinary tract and other visceral injury. It is suggested that in every case of penetrating perineal injury, a combined rectal and urinary tract injury should be ruled out accordingly to avoid any mortality.

Case presentation

A stout 52-year-old local man, a farmer, was brought in to the emergency service of the district hospital as a case of traumatic perineal injury. The patient had experienced a fall from some height near a tube well in the fields that had resulted in a sharp wooden stick getting driven through his perineum. The wooden stick was extracted by some locals using moderate force. The patient bled profusely and was brought to the hospital. On examination he was found to be in a state of shock. He was bleeding from the rectum and perirectal area. He reported severe hypogastric pain, in addition rigidity was present in the lower abdomen. Shock was managed with rapid blood transfusions and intravenous fluids and the patient was moved to the operating theatre.

The patient was examined under general anaesthesia. He had a perineal wound in the post anal area near the midline with the rectum; the direction of injury tract was anterior–superior as well as cranial (fig 1). Laparotomy through a long incision revealed laceration in the anterior rectal wall, base and superior surface of the urinary bladder in addition to lacerations of ileal loops and mesentery.

Figure 1.

Direction of sharp object.

Outcome and follow-up

There were no significant postoperative complications and the patient fared well (table 1).

Table 1.

Treatments performed

Injured structure	Operative procedure
Ileal loops, mesentery	Repair of ileal lacerations, excision of ragged tissue and closure of mesenteric rents
Urinary bladder	Tear was extended to fundal area to repair posterior bladder wall from inside followed by fundal repair and indwelling malecot catheter left in bladder
Rectum	Rectosigmoid mobilised, peritoneum reflected and rectum pulled up to repair anterior wall and omental patch interposed between repaired bladder wall and rectum. Pelvic colostomy (proximal to repair) followed by peritoneal lavage and laparotomy closure with pelvic drain.
Perineal wound	Limited debridement, sphincter repair and presacral drain inserted; posterior rectal wall repaired through anus
Supportive treatment	Heavy antibiotics plus blood transfusion and intravenous supplementation
Late management	Malecot removal after 2 weeks, colostomy closure after 3 months

There has been no evidence of rectal stricture to date.

Discussion

Rectal or visceral injuries may be sustained due to falls onto blunt edges or spiked objects. In addition, multiple visceral injuries can occur that sometimes present as acute abdominal issues with or without shock; some cases can present only with rectal bleeding. There have been case reports/series/meta analysis published on rectal trauma.^1–14 However, there have been limited case reports on combined urinary and rectal trauma. Franko et al¹⁵, in a review of 200 cases of penetrating rectal trauma (17 cases had in addition genitourinary injuries), concluded that the standard treatment of penetrating rectal trauma consists of perioperative antibiotics, a diverting colostomy and presacral drainage. They have added that this management scheme is inadequate in combined penetrating rectal and genitourinary tract injuries. They have advised careful debridement of all necrotic tissue, urinary and faecal diversion, tension free wound closure with well vascularised tissue and adequate drainage, in addition they advise separation of injured sites with omentum to reduce high incidence of rectourethral and rectovesical fistula in cases of combined rectal and genitourinary tract trauma. David et al¹⁶ have also reported perineal injuries in complicated pelvic trauma. The management of complex perineal injuries has been discussed by Kudsk et al.¹⁷ They have recommended debridement, faecal diversion and rectal washouts as the primary therapy for the complex perineal lacerations. Biriukov et al¹⁸ presented results of treatment of extraperitoneal rectal and perineal injuries for 153 patients. Wide opening and drainage of the wound was carried out in all cases. They have advocated this method for extraperitoneal, rectal and perineal injuries; the method also allows colostomy. Ganzalez et al¹⁹, in a review, concluded that non-destructive rectal injuries can be successfully managed by faecal diversion. Crispen et al²⁰ suggested omental flap interposition between the rectum and bladder to decrease incidence of fistula and urinoma formation. Rectal impalement associated with intraperitoneal and extraperitoneal bladder rupture was reported in a 9-year-old boy by Kim et al.²¹ The high mortality in combined penetrating trauma to rectum and urinary system has been highlighted by Steiner et al.²² After a retrospective analysis of similar cases, Liu et al²³ have concluded that in penetrating anorectal wounds, early recognition of concomitant injuries, selection of appropriate surgical interventions and strengthening of perioperative care are the key to improve the curative effects.

Learning points

• In all cases of perineal injury due to sharp objects that involve the rectum and urinary tract, visceral injury should be suspected and treated.

• Exploratory laparotomy to control the visceral damage coupled with diversion of pelvic colon should be performed. In addition, debridement of the perineal wound and presacral drainage are to be instituted.

• If such a protocol is followed then the high mortality in cases of pelvic injuries may be reduced significantly.