A 5-year-old girl was climbing a fence and sustained a traumatic straddle injury. She is brought into the ER and is hemodynamically stable. After an appropriate trauma survey and administration of antibiotics, she is brought to the OR for an exam under anesthesia. She is found to have a posterior vaginal laceration extending through the perineum into the rectum. The injury involves the lower 1/3 of her vagina. The anterior sphincter complex is transected, and the anorectal injury extends 5 cm above the dentate line. What is the most appropriate management?

 

A Diverting colostomy

 

B Primary repair with diverting colostomy

 

C Primary repair alone

 

D Primary repair with perineal drains

 

E Primary repair, diverting colostomy, and presacral drains

A

B

Correct answer

B Primary repair with diverting colostomy

 

Perineal injuries are uncommon in children and mechanisms include falls, impalement, blunt trauma, and child abuse. Depending on the force and mechanism of injury, children may sustain injuries ranging from abrasions to complex lacerations (as in this case). Management begins with a complete trauma survey followed by careful inspection of the genitalia, perineum, and anus. In most cases, an exam under anesthesia is required to accurately identify the extent of the injury. EUA consists of careful inspection and visualization with vaginal and anal speculum. Digital rectal examination, and possible proctoscopy and sigmoidoscopy. Muscle stimulation is also a helpful adjunct to assess the anal sphincter complex.

 

Once all the injuries are accurately identified, then primary repair is performed. Diverting colostomy is indicated for complex injuries and/or dirty or highly contaminated fields. Use of perineal and sacral drains are controversial and may be helpful when diverting colostomy is not performed. Although limited to small case series, reports demonstrate a high rate of successful fecal continence. Those with associated nerve or crush injury are at higher risk of developing incontinence.

 

Additional work-up including CT scan of abdomen/pelvis or contrast enemas may be required to assess for additional injuries. Child abuse should always be kept in mind and appropriate services should be consulted.

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