Keywords
perineal injury - perineal trauma - sexual assault - perineal reconstruction - posterior
sagittal anorectoplasty
New Insights and the Importance for the Pediatric Surgeon
Perineal trauma due to sexual assault in children may cause anorectal involvement
and severe perineal body injuries. At presentation, examination under anesthesia,
wound irrigation, and local debridement should be performed in all children. Due to
the intrinsic contamination of the wound and the likelihood of delayed presentation,
a diverting stoma with postponed perineal repair should be the procedure of choice.
This new surgical technique for perineal reconstruction leads to successful outcome
in terms of bowel control and good cosmetic results.
Introduction
The severity of perineal injuries in children can range from minor skin tears to severe
lacerations involving the anal sphincter, urogenital tract, and can even involve intraperitoneal
extension.[1] They can be due to blunt trauma, impalement injuries, obstetric injuries, or sexual
abuse. The latter always needs to be suspected and, unfortunately, is a common cause
of perineal injury in our setting.[2]
There are controversies regarding the best way to assess and manage pediatric patients
with perineal trauma with the vast majority of work focused on the acute management.
For severe injuries, most authors recommend fashioning a colostomy with delayed perineal
reconstruction. However, to our knowledge, no specific technique for perineal reconstruction
has been described.
The aim of our study is to present three children with fourth-degree perineal injuries
due to sexual assault and to describe a surgical technique derived from the posterior
sagittal anorectoplasty (PSARP) approach, used for repairing congenital anorectal
malformations to reconstruct the perineal body and sphincter complex with the goal
of creating a good cosmetic result and to allow the patient to regain faecal continence.
After obtaining ethics-committee approval (M190292), the medical records of three
patients who presented with perineal injuries secondary to sexual assault were retrospectively
reviewed. Information regarding time of presentation, type of medical and surgical
management, development of complications, and outcome in terms of bowel control was
recorded.
An extensive literature review was conducted focusing on case reports, case series,
and original articles involving the acute management of perineal injuries and perineal
reconstruction in the pediatric population with special emphasis on articles focusing
on perianal injuries due to sexual assault.
Case Reports
Case 1
A 2-month old girl with vaginal bleeding after sexual assault was brought to our Institution.
She was immediately taken to the operating room for an examination under anesthesia
(EUA). A tear of her vagina into her rectum, with partial involvement of her urethra,
was observed ([Fig. 1A]). The wound was severely contaminated and was thus debrided and booked for a relook
after 72 hours. At relook, a Hartmann's colostomy was fashioned. The perineal body
was repaired 24 days postinjury, using a new surgical technique derived from the principles
of the PSARP. Two months after the perineal reconstruction, an EUA and muscle sphincter
stimulation revealed good anal tone with no evidence of a rectovaginal fistula, and
her stoma was closed. She had an unremarkable postoperative recovery. At 2 years of
age, she underwent another EUA that confirmed the correct location of the anus with
an adequate perineal body, good sphincter contraction, a patent introitus, and the
absence of a rectovaginal fistula ([Fig. 2A]). The patient is too young to be fully potty-trained, but she feels the urge to
defecate and communicates it.
Fig. 1 The three perineal injuries at examination under anesthesia (EUA) before the perineal
repair was performed. (A) Case 1; (B) case 2; (C) case 3.
Fig. 2 The three perineal injuries at EUA after the perineal repair was performed. (A) Case 1; (B) case 2; (C) case 3. EUA, examination under anesthesia.
Case 2
A 9-year old girl was brought to our institution after being found unconscious and
naked in a field. Blood was noted around her genitalia and the decision was made to
take her to the operating room for an EUA. A torn hymen, as well as a full thickness
tear of the vagina, and disruption of the anal sphincter were identified. The surgeon
on call attempted to approximate the perineal body without opening a stoma. An EUA
performed 5 days later which revealed no signs of infection and good healing of the
perineal body. After receiving all sexually transmitted disease (STD) and HIV prophylaxis,
the child was discharged home to follow-up at the colorectal clinic. After being lost
to follow-up, she presented 3 months postrepair with faecal soiling. It was determined
that she had a total disruption of the perineal body and anterior sphincter complex
([Fig. 1B]). A repair of the perineal body using the new technique and a covering Hartmann's
sigmoid stoma was performed. The stoma was reversed 45 days after the perineal reconstruction.
Five months after the stoma closure, she was fully continent of stools ([Fig. 2B]).
Case 3
A 2-year old girl presented to another institution with a vaginal injury involving
the perineal body and rectum, and an acute abdomen after a sexual assault. She underwent
an emergency exploratory laparotomy, an intraperitoneal vaginal laceration was identified
and repaired, and a colostomy formed. Following this, she was referred to our center.
She was taken to the operating room 45 days after the assault for an EUA ([Fig. 1C]). The rectum and vagina were contiguous, no perineal body was identified, the anal
sphincter was completely absent anteriorly, and the dentate line was well preserved.
A repair of the perineal body according to the new technique was performed. One month
later, an EUA revealed an anus completely surrounded by sphincters, a patent introitus,
and no rectovaginal fistula. The colostomy was closed 45 days after the reconstruction;
6 months later she was fully continent of stools ([Fig. 2C]).
Medical Management
On arrival at the center, all the three children received all the protocolled STD
prophylaxis, including HIV. At follow-up, they were tested for STD and HIV and referred
to a psychiatrist for psychological support.
Surgical Technique
The surgical technique that was used followed principles of the PSARP technique to
repair anorectal malformations (ARM). [Figs. 3]–[5] illustrate the key steps of the approach.
A urinary catheter is placed and the patient is positioned prone with the hips elevated.
Stay sutures are positioned on the common wall between the rectum and the vagina ([Fig. 3A]). Using a needle-tip diathermy, an incision is made just below the stay sutures
and the dissection begins to separate the anterior rectal wall from the posterior
vagina ([Fig. 3B]). A self-retaining retractor or a lone-star retractor can be used to provide exposure.
An additional line of stay sutures is then positioned on the vaginal wall ([Fig. 4A]). Exerting a countertraction on the two suture lines, the dissection is continued
to separate the two walls. The separation is only complete when the typical fibroareolar
plane has been reached that exists between two structures ([Fig. 4B]). At this stage, the position of the sphincter complex is assessed with the muscle
stimulator. The perineal body is then reconstructed with interrupted absorbable sutures
and the sphincter complex is reapproximated ([Fig. 5A]). The key step involves bringing back together, anterior to the anus, the sphincter
that was torn during the injury. If redundancy of the anal or vaginal mucosa is encountered,
trimming may be appropriate. Reconstruction is completed with an anoplasty of the
anterior rectal wall which is sutured to the now reconstructed perineal body. The
skin is then closed with interrupted absorbable sutures ([Fig. 5B]).
Fig. 3 With the patient prone, a lone star retractor is positioned to facilitate exposure.
The perineal reconstruction is then performed. (A) Stay sutures are positioned on the common wall between the rectum and the vagina.
(B) Using a needle tip diathermy, an incision is made just below the stay sutures and
the dissection begins to separate the anterior rectal wall from the posterior vagina.
Fig. 4 (A) An additional line of stay sutures is then positioned on the vaginal mucosa. Exerting
a countertraction on the two suture lines the dissection is continued to separate
the rectum from the vagina. (B) The separation is only complete when an areolar plane has been reached between two
structures.
Fig. 5 (A) The perineal body is then reconstructed with interrupted absorbable sutures and
the sphincter complex is reapproximated. (B) Reconstruction is completed with an anoplasty of the anterior rectal wall which
is sutured to the reconstructed perineal body. The skin is then closed with interrupted
absorbable sutures.
Postoperatively antibiotics are given for 48 to 72 hours, the urinary catheter is
kept in place for 24 hours and the patient can be discharged home after 48 hours if
a covering colostomy is present. The stoma can be reversed once the perineal wound
is healed and an EUA shows a patent anus completely surrounded by sphincter muscles.
Discussion
Perineal trauma is uncommon in the pediatric population with a prevalence varying
from 0.2 to 8% of all pediatric trauma.[3]
[4] According to the mechanism, injuries can be classified as blunt (77%) or penetrating
(23%).[1] Falling from a height is the leading cause of perineal trauma (67% of cases), followed
by motor vehicle collision (28%).[5] Obstetric injuries are also a possible cause of perineal trauma in the pediatric
population but they are usually classified as a different entity and addressed separately
in all the reports that we encountered.[6]
[7] It is estimated that 5 to 21% of pediatric perineal trauma is secondary to sexual
abuse.[1]
[5] However, the true incidence and prevalence is not known and is likely underestimated,
since most cases of sexual assault are under-reported by the victims because of the
associated stigma.[2]
Perineal injuries can be classified according to the genital injury score (GIS) or
according to the Sultan's classification ([Fig. 6]).[1]
[8] The former is in an anatomical classification that can be used for children of both
genders, and it groups perineal injuries into five different types according to the
extent of the injury.[1] It does not take into consideration that the mechanism of the perineal injury, however,
most of the injuries from sexual assault belong to 3rd and 4th degree.[1] The latter is specific for sexual assault injuries which is based on the adult classification
of birth-related perineal tears in women and only applies to female patients.[8]
Fig. 6 The two classifications used for perineal trauma.[1]
[8] GIS, genital injury score.
All three cases have had with grade-4 injuries according to the GIS classification
and with fourth-degree injuries according to Sultan's classification.
Most of the articles found on the topic focus on the acute medical and surgical management
of patients with perineal injuries, with only rare case reports describing the specific
technique used for the perineal reconstruction.[5]
[9]
[10]
The pediatric patient who has experienced a sexual assault, the need for adequate
resuscitation, collection of appropriate forensic evidence, investigation, treatment,
and follow-up for STD and HIV is well documented.[11]
General agreement exists to perform a physical examination under general anesthesia
in all patients, at the time of presentation. Debridement of devitalized tissue and
wound irrigation with saline and antiseptic solutions are considered the cornerstones
of therapy.[9] The subsequent management depends on the extent of the injury and the degree of
contamination.[1]
[5]
[9] While most authors agree that isolated genital injuries can be repaired primarily,
controversy arises regarding the management of injuries with combined genital and
anorectal involvement.[4]
[9] It has been demonstrated that the risk of postoperative complications due to primary
perineal repair is higher in patients without a diverting colostomy, with more severe
contamination, with prolonged delay before EUA, and with more severe genitoperineal
injuries.[1] Therefore the safest approach consists of an initial wound disinfection and debridement,
as well as a diverting colostomy, postponing the perineal repair to a later stage.[1]
[5] However, the role of routine faecal diversion has recently been questioned with
more authors having attempted primary repair in patients with perineal trauma, especially
if the injury is limited to the anus, without involving the rectum.[1]
[4]
[9]
In our series, the only patient who underwent primary perineal repair without a covering
stoma subsequently developed a wound dehiscence, with disruption of the anterior anal
sphincter and soiling. Based on our experience, we believe that perineal injuries
due to sexual assault are intrinsically associated with severe perineal contamination,
because of the mechanism of trauma and the likelihood of delayed presentation, and
should, therefore, all be treated with a diverting stoma and delayed perineal repair.[9] We believe that the repair can be safely performed 6 weeks after the injury, once
the perineal wounds have healed, and the patients has completed treatments for STD
and HIV.
Reconstructive surgery using muscle flaps and skin grafts has been described in patients
with perineal trauma.[1] A Swenson's type endorectal pull-through has been performed in a child with pelvic
disruption due to a gunshot wound and a posterior sagittal incision has been used
to repair a rectovaginal fistula secondary to sexual assault.[4]
[10] Our technique is based on the principles learned from the PSARP. However, only the
posterior vaginal wall and the anterior rectal wall are mobilized. The posterior aspect
of the rectum is left completely untouched thus preserving nerves, sphincter muscles,
and the anoderm. This approach allows excellent exposure without sacrificing nerves
and muscles. Moreover, reaching the fibroareolar plane allows a complete separation
between rectum and vagina and minimizes the risk of postoperative rectovaginal fistulae.
The prone position is ideal as it provides the best visualization. We believe that
this technique could also be used potentially for any acquired rectovaginal fistulae;
HIV associated or trauma related.[12] In this case, the risk of recurrent fistulae can be minimized by the use of a fat
pad to interpose between rectum and vagina.[13]
The long-term results achieved both from cosmetic and functional points of view in
our presented approach are very promising, with no surgically related complications
observed so far. We are aware that the series in which we have used this new technique
is too small to draw any significant conclusion; however, the outcomes are good in
terms of bowel control and cosmesis.
Conclusion
In our setting, perineal trauma due to sexual assault in children is unfortunately
not a rare event. Patients may have genital injuries with anorectal involvement. At
presentation, examination under anesthesia, wound irrigation, and local debridement
should be performed in all children. Due to the intrinsic contamination of the wound
and the likelihood of delayed presentation, a diverting stoma with postponed perineal
repair should be the procedure of choice. We propose, this new surgical technique
leads to successful outcome in terms of bowel control and good cosmetic results. The
prone position and good repair of the perineal body, provided by separating fully
the posterior vaginal wall from the anterior rectal wall, are the key elements.
