Magnitude and outcomes of complex perineal injury – A retrospective analysis of five years’ data from a Level 1 trauma centre

Abstract

Complex perineal injuries pose a major diagnostic and therapeutic challenge to trauma surgeons. A retrospective review of the hospital records of 29 patients with complex perineal injury following blunt trauma was done. Demographic profile, management and outcomes were collected. Quality of life analysis was conducted for patients with complex perineal injuries who were discharged. The most predominant mode of injury was a road crash: being a pedestrian run over by a heavy motor vehicle. Pelvic fracture was seen in 20, anorectal involvement in 22 and urogenital injuries in 14. Urgent surgical debridement was done in all patients, faecal diversion in 27 and urinary diversion in 14. There were nine deaths, three from haemorrhage, and the remainder from sepsis and multi-organ dysfunction. Complex perineal injury remains a major cause of morbidity and mortality in trauma patients. There is a need to ensure adequate rehabilitation services for such patients.

Keywords

Trauma perineal injury soft tissue injury quality of life

Introduction

The management of complex perineal injuries (CPIs) continues to pose a major challenge to trauma surgeons. Although such injury is not common, CPIs present with extensive soft tissue injury, visceral and skeletal involvement which demand complex diagnostic and therapeutic work-up. There is no clear-cut guideline or consensus for the management of such patients since such injuries are limited in number.^1–4 Their morbidity and mortality remain high. Associated pelvic fractures can bleed torrentially; extensive soft tissue damage, compromised vascularity, faecal and urinary contamination predispose these patients to sepsis.

Being complex, these injuries require repeated surgery, prolonged nursing care and hospital stay. Those who survive are frequently not without sequelae. Long-term morbidity involves sphincter incontinence, gait disorders and sexual dysfunction. We reviewed five-year data to study epidemiology, patterns of injuries, management and outcomes of these injuries at our Level 1 trauma centre.

Materials and methods

We performed a retrospective analysis of patients admitted between January 2014 and December 2018 at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi with CPIs. We recorded demographic data: age, gender and mechanism of injury; clinical presentation on arrival: primary survey, type of pelvic and associated injuries, injury severity score (ISS); details of management: operative intervention for primary and associated injury, and rehabilitation; and outcome: intensive care unit (ICU) stay, hospital stay, quality of life (QoL) score, death or discharge.

Data were obtained retrospectively from the prospectively maintained registry at our institute. Study approval was granted by our institutional review board (IEC-499/05-06-2020). Statistical analysis was performed using the latest SPSS software. Patients were identified by searching the hospital registry for terms ‘Perineal injury’, ‘CPI’, ‘Anorectal injury’ and ‘Complex pelvic fractures’. Patients with extensive soft tissue injury in the perineum with associated pelvic injuries were included in the study. Descriptive parameters are reported as mean +/− standard deviation or as median (inter-quartile range) where standard deviation was very high. QoL was assessed by a telephonic interview by a psychologist using the WHOQOL-BREF questionnaire.⁵ QoL analysis was done after a minimum duration of six months after discharge, though the time interval could not be entirely uniform.

Results

Our 29 patients (18 male) had a mean age of 25.6 years (range 3–49 years). The majority of their injuries were due to road traffic injuries (27/29), a significant number being pedestrians run over by truck (10/27), or motorcyclist hit by a truck (11/27). The mean ISS was 16.8 (range 8–34). The mean time for presentation to the hospital was 16 h (range 2–72) (Table 1). All patients were initially managed in our Emergency Department according to the standard Advanced Trauma Life Support (ATLS) protocol.

Table 1.

Descriptive parameters of patients.

Parameter	Numbers
Age	25.6 years
Mechanism of injury:
Road traffic injury	27
Railway track injury	1
Fall of a heavy object	1
Male:female	18:11
Mean injury severity score (ISS)	16.8
Meantime for the presentation from time of injury	16 h
Haemorrhagic shock at presentation	8 (5 – Responders, 3 – Non-responders)
Septic shock at presentation	1

Most of our patients had significant visceral and skeletal injuries along with extensive soft-tissue defects. Anorectal involvement was seen in 22 (76%), while the urogenital system was involved in 14 (48%). Associated injuries are listed (Table 2). Pelvic fractures were associated in 20 (69%), anteroposterior compression fracture predominating.

Table 2.

Associated injuries with CPI.

Pelvic fracture	20
Antero-posterior compression (APC)	11
Lateral compression (LC)	4
Vertical shear (VS)	2
Mixed	3 (APC + VS in 2, LC + APC in 1)
Genitourinary injuries	14
Bladder injury	2
Urethral injury	7
Bladder + urethral injury	2
Testicular injury	3
Anorectal injury	22
Deep venous thrombosis	1

All patients were taken for early surgical debridement and wound lavage, the need for diversion colostomy being assessed as positive in all but two. Nine underwent suprapubic cystostomy for urinary drainage, the remainder being managed with free urethral catheter drainage. Most required repeated wound debridement and dressings. Thirteen underwent lower limb amputations amongst whom five required hip disarticulations because of extensive soft tissue and bony injury (Table 3).

Table 3.

Surgical procedures in the patients.

Surgical procedure	Number of patients
Acute procedures
Diversion stoma	27
Suprapubic cystostomy	9
External fixation	7
Lower limb amputations	13
NPWT	15
Average number of debridement	3 per patient
Reconstructive procedures
STSG	18
Flap	2 (Rotation flap and Tensor Fascia Lata flap)

NPWT: negative pressure wound therapy; STSG: split thickness skin grafting.

The mean ICU stay was five days and the mean hospital stay was 33 days. Nine patients died, three from haemorrhagic shock and six from sepsis and multi-organ dysfunction. Of the 20 survivors, 12 responded to QoL analysis by telephonic interview (Table 4); their mean score was 68.5, environmental support having the highest mean score (22.1) with social relationships the poorest (7.4).

Table 4.

Outcome measures.

Outcome parameter
Mean ICU stay	5 days
Mean hospital stay	33 days
Death	9
Discharge	20
WHO Quality of life Score	18.6
Domain 1 (Physical Health)	17.1
Domain 2 (Psychological Health)	7.4
Domain 3 (social relationships)	22.1
Domain 4 (environmental support) Total	68.5

Discussion

CPIs, without a doubt, are associated with high morbidity and mortality. Even after much experience and advances in management, the mortality rate remains high (Table 5). However, the individual surgical experience remains low as the numbers of victims with such injuries remain low. Furthermore, this injury represents a major resource burden, requiring much in the way of equipment and medications, a prolonged hospital stay (often in ICU), surgical expenses, and management of long-term associated multi-factorial morbidity.

Table 5.

Mortality rates of CPIs in various studies.

Study	Year	Pelvic haemorrhage	Pelvic sepsis	Others	Total mortality
Maull et al.³	1977	4	3	1	8 (67%)
Kusminsky et al.¹	1982	3	3	0	6/14 (43%)
Naam et al.⁴	1983	3	4	0	7/19 (37%)
Kudsk et al.²⁹	1990	7 (Acute-6, chronic-1)	1	0	8/18 (44%)
Birolini et al.³⁰	1990	5	6	1	12/38 32%)
Kudsk et al.²	2003	6	0	2	8/32 (25%)
Petrone et al.²⁴	2009	6	1	0	7/68 (13%)
Mossadegh et al.³¹	2012	NA	NA	NA	57/118 (47%)
Present study	2019	3	6	0	9/29 (31%)

NA: not available.

Very few classification systems exist for grading CPI. A classification system for perineal soft tissue injuries was proposed, dividing the perineum into an anal and a perineal zone,⁶ and associated genitourinary or gastrointestinal injury. This was utilised on only eleven patients and further validation of this classification is required. It does not incorporate associated pelvic fractures and the haemodynamic status of the patient on arrival, which both have a huge impact on outcomes.

Haemodynamic instability is the priority, dealt with by pelvic binding, wound or pre-peritoneal pelvic packing, external fixator application,⁷ and/or vessel ligation. A massive transfusion protocol may need to be activated, tranexamic acid infusion started, and rapid attention to haemostasis. Angio-embolisation of bilateral internal iliac arteries or balloon aortic occlusion^8,9 are measures for patients in extremis. Survival in such cases depends very much on the efficiency and readiness of rescue services.

Haemodynamically stable patients are further evaluated in search of associated injuries. ATLS protocols are followed, but certain features must be emphasised: a digital rectal and perineal examination are mandatory: blood on the examining finger, anal sphincter tone, perineal bruising or laceration, vaginal injury, and blood at the urethral meatus are noted.

The reported sensitivity of proctosigmoidoscopy is 88% for the diagnosis of extraperitoneal rectal injury in penetrating injuries,¹⁰ and increases to 95% when supplemented by rectal and perineal examination.¹¹ A urethral injury may be suspected by the presence of blood at the meatus, perineal hematoma, and inability to pass urine despite full bladder, while bladder injury is suspected when haematuria is present.^12,13 In the case of suspected urethral injury, a retrograde urethrogram is advised. Where available, a CT scan of the pelvis including a cystogram in suspected bladder injury and rectal contrast in suspected anorectal injury^14,15 is extremely helpful. Major vascular injury can also be well demonstrated with CT angiography.

After identification of injuries, further management involves prioritising these. Perineal wounds (Figure 1) are most commonly caused by blunt injury, which frequently affect the microvasculature. They may be heavily contaminated,^16,17 but may appear to be associated with closed fractures but hide a Morel-Lavallée (internal degloving) lesion beneath. Thorough lavage and debridement are key in preventing sepsis and may be required repeatedly. Broad-spectrum antibiotics should be instituted as soon as possible, and awareness of the development of fungal infection, suggested by leukopenia and non-responsiveness to antibiotic therapy, kept in mind.

Figure 1.

Complex perineal injuries. (a): Extensive degloving injury involving groin and perineum. (b): CPI with the exposed rectum. (c): Frictional injury with underlying soft tissue injury. (d). Extensive contamination can be noted.

Negative pressure wound therapy is ideal in managing these patients, as it helps to prevent large wounds from being soaked. It also helps in making nursing easier and enhances neovascularisation,^18,19 as does the use of hyperbaric oxygen therapy,²⁰ but it must be stressed that there is no substitute for surgical debridement of dead and necrotic tissues. Perineal wounds near the anal sphincter are prone to faecal contamination. Early faecal diversion is recommended to prevent perineal sepsis.²¹ Placing the stoma high up in the left hypochondrium serves two purposes: (i) it does not disturb a pelvic external fixator and thus pin-site infection is prevented, (ii) it does not impinge on hip disarticulation. Distal rectal wash and presacral drainage are now obsolete being of no definite advantage.^22,23

Likewise, bladder sphincter or urethral injury requires urinary diversion in the form of suprapubic cystostomy. Some, as in our present study, later needed percutaneous nephrostomy due to a high output vesico-cutaneous and vesico-rectal fistula respectively. Reconstruction of soft tissue wound defects may involve flaps, the Gracilis flap being particularly useful, and skin grafting. Extensive wound area leads to nutritional and fluid loss and hence early wound coverage is recommended. The reported incidence of anorectal injury in CPIs ranges from 25–40%.^2,24 Anal sphincter reconstruction may be done on a delayed basis by placing an artificial sphincter, sacral nerve stimulation, or gracilioplasty.²⁵

Urethral injuries have a reported incidence of 60–80%.^1,2,24 The management of such urethral injuries is complicated by the associated pelvic fractures and urethral distraction. Normally again delayed urethroplasty is advised. Extraperitoneal bladder injuries can normally be managed conservatively by free urethral catheter drainage, but operative intervention is recommended when exploration is required for associated rectal or vaginal injuries, bony fragments impinging on the bladder, bladder neck injury, or associated intraperitoneal bladder injuries.

The incidence of pelvic fractures in CPIs ranges from 45–65%. A pelvic binder usually helps by reducing pelvic volume, prevents clot disruption, and stabilises bony fragments,²⁶ but may distract shear injuries of the pelvis further, in which case external fixation is ideal. This is also indicated in a haemodynamically unstable patient (whilst resuscitative measures are taken); reduces pain, stabilises the fracture fragments, decreases pelvic volume, and nonetheless, its drawbacks of pin-site infection, displacement, and nerve impingement, must be taken into account. Definitive pelvic fracture fixation, if still necessary, is performed once any infection is controlled and the wound is closed.

Nutritional support is crucial: a high protein and high-calorie diet should be instituted preferably enterally. This is gradually increased as tolerated;²⁷ supplementation by parenteral nutrition is rarely required.

Patients with such complex injuries are necessarily immobilised, predisposing them to pressure sores and deep venous thrombosis (DVT).²⁸ Nursing care is difficult as frequent position change with large wounds causes great discomfort and pain to the patient. Hoists, careful attention to pressure points and wounds, avoidance of fluid spillage are mandatory, along with DVT prophylaxis with anticoagulants as soon as haemostasis is achieved possible in the form of mechanical prophylaxis and/or pharmacological prophylaxis.

Quality of life has not been studied extensively in CPIs. In pelvic fractures, personal relationships and particularly, sexual activity, are affected the most. Erectile dysfunction due to injury to cavernous nerves is common, as are chronic pain and urinary dysfunction. Our experience that such patients had a good score in the 4th domain of the WHO BREF score, i.e. financial, social, and health safety, shows that, if treated well and given adequate opportunity, these patients can do well.

Our study had its limitations. Our sample size is small despite our centre having an average annual footfall of 75,000 trauma patients with an admission rate of about 5000 patients annually. Our follow-up of quality of life for our patients was limited.

Footnotes

Acknowledgements

We would like to thank Ms. Gunjan Gulia, Clinical Psychologist in the Division of Trauma Surgery and Critical Care for helping during the QoL assessment of the patients.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Harshit Agarwal https://orcid.org/0000-0002-6658-9626 Pratyusha Priyadarshini https://orcid.org/0000-0001-6436-811X Amit Gupta https://orcid.org/0000-0001-8912-0647 Sushma Sagar

References

Kusminsky

Shbeeb

Makos

, et al. Blunt pelviperineal injuries. Dis Colon Rectum 1982; 25: 787–790.

Kudsk

Hanna

. Management of complex perineal injuries. World J Surg 2003; 27: 895–900.

Maull

Sachatello

Ernst

. The deep perineal laceration-an injury frequently associated with open pelvic fractures: a need for aggressive surgical management. A report of 12 cases and review of the literature. J Trauma 1977; 17: 685–696.

Naam

Brown

Hurd

, et al. Major pelvic fractures. Arch Surg 1983; 118: 610–616.

WHOQOL Group. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med 1998; 28: 551–558.

Wang

Qin

, et al. Modified classification and repair of perineal soft tissue injuries associated with open pelvic fractures. J Reconstr Microsurg 2015; 31: 12–19.

Burlew

Moore

Stahel

, et al. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg 2017; 82: 233–233.

Tanizaki

Maeda

Matano

, et al. Time to pelvic embolization for hemodynamically unstable pelvic fractures may affect the survival for delays up to 60 min. Injury 2014; 45: 738–741.

Lendrum

Perkins

Chana

, et al. Pre-hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation 2019; 135: 6–13.

10.

Hargraves

Magnotti

Fischer

, et al. Injury location dictates utility of digital rectal examination and rigid sigmoidoscopy in the evaluation of penetrating rectal trauma. Am Surg 2009; 75: 1069–1072.

11.

MacFarlane

Vaizey

Benn

. Battle injuries of the rectum: options for the field surgeon. BMJ Mil Heal 2002; 148: 27–31.

12.

Battaloglu

Figuero

Moran

, et al. Urethral injury in major trauma. Injury 2019; 50: 1053–1057.

13.

Mahat

Leong

Chung

. A contemporary review of adult bladder trauma. J Inj Violence Res 2019; 11: 101–101.

14.

Kumar A, Agarwal H, Gupta A, et al. Imaging modalities in trauma and emergency — a review. Indian J Surg 2020. https://doi.org/10.1007/s12262-020-02346-0..

15.

Lee A.E., Fitzgerald K., Laufenberg L.J. Rectal Injuries. In: Docimo Jr. S., Pauli E. (Eds). Clinical Algorithms in General Surgery. Springer, Cham. 2019. pp.687–691.

16.

Polk T.M., Martin M.J., Barbosa R.R. Damage Control Surgery in the Blast-Injured Patient. In: Galante J., Martin M., Rodriguez C., Gordon W. (Eds). Managing Dismounted Complex Blast Injuries in Military & Civilian Settings. Springer, Cham. 2018, pp. 57–76.

17.

Lim R.B., Johnson E.K., Steele S.R. The Bowel: Contamination, Colostomies, and Combat Surgery. In: Martin, M., Beekley, A., Eckert M. (Eds). Front Line Surgery. Springer, Cham. 2017, pp. 111–129.

18.

Pasquier

Malgras

Mérat

. Application of negative-pressure wound therapy in improvised explosive device-related pelviperineal injuries. J Trauma Acute Care Surg 2012; 73: 1630–1630.

19.

Milcheski

Zampieri

Nakamoto

, et al. Negative pressure wound therapy in complex trauma of perineum. Rev Col Bras Cir 2013; 40: 312–317.

20.

Lam

Fontaine

Ross

, et al. Hyperbaric oxygen therapy: exploring the clinical evidence. Adv Skin Wound Care 2017; 30: 181–90.

21.

Woods

O’Keefe

Rhee

, et al. Open pelvic fracture and fecal diversion. Arch Surg 1998; 133: 281–286.

22.

Savoie

Beazley

Cleveland

, et al. The utility of presacral drainage in penetrating rectal injuries in adult and pediatric patients. J Surg Res 2017; 219: 279–278.

23.

Brown

CVR

Teixeira

Furay

, et al. Contemporary management of rectal injuries at level I trauma centers: the results of an American Association for the Surgery of Trauma multi-institutional study. J Trauma Acute Care Surg 2018; 84: 225–233.

24.

Petrone

Inaba

Wasserberg

, et al. Perineal injuries at a large urban trauma center: injury patterns and outcomes. Am Surg 2009; 75: 317–320.

25.

Singh

Kinsley

Huang

, et al. Gracilis flap reconstruction of the perineum: an outcomes analysis. J Am Coll Surg 2016; 223: 602–610.

26.

Bagaria

Banerjee

Kumar

, et al. Effective use of bed sheet as pelvic binder in resource constraint situations. Int J Sci Res 2019; 8: 44–45.

27.

McClave

Taylor

Martindale

, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). J Parenter Enter Nutr 2016; 40: 159–211.

28.

Montgomery

Geerts

Potter

, et al. Thromboembolic complications in patients with pelvic trauma. Clin Orthop Relat Res 1996; 329: 68–87.

29.

Kudsk

McQueen

Voeller

, et al. Management of complex perineal soft-tissue injuries. J Trauma 1990; 30: 1155–1159.

30.

Birolini

Steinman

Utiyama

, et al. Open pelviperineal trauma. J Trauma 1990; 30: 492–495.

31.

Mossadegh

Tai

Midwinter

, et al. Improvised explosive device related pelvi-perineal trauma: anatomic injuries and surgical management. J Trauma Acute Care Surg 2012; 73: S24–31.