What is the recommended management for perineal trauma in children?

Management of Perineal Trauma in Children

Children with perineal trauma require immediate evaluation for life-threatening injuries, mandatory fecal diversion via colostomy for anorectal involvement, and careful assessment for child abuse in all cases. 1

Initial Assessment and Stabilization

All injured children must be evaluated and stabilized by providers with basic competency in pediatric trauma care, with transfer to appropriate pediatric trauma facilities for the youngest and most severely injured. 1

Critical Initial Steps:

• Assess hemodynamic stability first - resuscitation takes priority over definitive repair 1
• Perform careful rectal examination and proctosigmoidoscopy for all perineal injuries to identify anorectal involvement 2
• Evaluate for genitourinary tract injury through physical examination and imaging as indicated 2
• Screen for child abuse in every case - perineal trauma warrants mandatory reporting of concerns to appropriate authorities 1

Distinguishing Accidental from Abusive Injury:

• Obtain detailed history from the child, supervising adults, and any child witnesses 3
• Inspect the impaling object and scene - accomplished by medical providers or police in collaboration 3
• Use multidisciplinary assessment involving child protection agencies when abuse is suspected 3
• Remember that ambulatory children can sustain accidental perineal impalement injuries, often occurring in the home (71%) and bathroom (38%) 3

Operative Management Algorithm

For Anorectal Injuries:

Mandatory colostomy is the standard of care for all anorectal perineal injuries in children. 4, 2

• Create a loop colostomy to provide total fecal diversion 2
• Evacuate and washout distal fecal content during the initial operation 2
• Provide drainage of the pararectal space when the rectum is directly involved 2
• Administer broad-spectrum antibiotics to prevent sepsis, which is the most important complication 4

Critical pitfall: Primary reconstruction without fecal diversion leads to wound infection requiring secondary colostomy 4. Three cases attempted primary repair without colostomy and all required secondary diversion due to infection 4.

Timing of Definitive Repair:

• Delay definitive perineal reconstruction for 2-7 weeks post-injury to allow tissue stabilization 5
• Perform examination under anesthesia in most cases (77% required this in accidental injuries) 3
• Surgical repair is required in 59% of perineal impalement cases 3

Surgical Technique for Perineal Body Disruption:

Use a posterior sagittal approach (modified PSARP technique) for fourth-degree perineal injuries: 5

• Position child prone in jack-knife position 5
• Place stay-sutures on the common wall between rectum and vagina 5
• Perform transverse incision with needle-tip diathermy to separate rectal and vaginal walls completely 5
• Reconstruct deep and superficial perineal body using absorbable sutures 5
• Perform anterior anoplasty and introitoplasty 5
• Close colostomy 6 weeks post-reconstruction 5

Special Considerations for Urogenital Involvement

For associated bladder or urethral injuries in children, suprapubic cystostomy is recommended after surgical repair. 1

• Obtain urinary drainage as soon as possible for traumatic urethral injury 1
• Non-operative management should be the first option in pediatric urogenital trauma when viable and safe 1
• Decisions must be based on physiology, anatomy, and associated injuries 1

Hemorrhage Management

Hemorrhage may be more severe than with closed injuries due to loss of tamponade. 2

• Consider hypogastric artery ligation at the time of exploration and colostomy if hemorrhage is significant 2
• Remember that severe internal injuries may accompany minor external findings 3
• Four cases in one series had bowel perforations despite varying external appearance 3

Psychological and Social Support

All injured children and their families must be evaluated and referred for stress reactions related to injury. 1

• Psychological needs should be addressed as part of comprehensive trauma care 1
• This is particularly critical in cases involving sexual assault 5

Expected Outcomes

With appropriate surgical technique including fecal diversion, excellent cosmetic outcomes and full fecal continence can be achieved. 5

• All three patients in one series had excellent cosmetic outcomes at 1+ year follow-up 5
• All achieved full continence for stools 5
• No complications occurred in cases where primary colostomy was performed 4