Combined penetrating rectal and genitourinary injuries: a challenge in management

The standard management of penetrating rectal trauma consists of perioperative antibiotics, a diverting colostomy, and presacral drainage. While providing optimal results in isolated rectal trauma, this management scheme is inadequate in combined penetrating rectal and genitourinary (GU) tract injuries. A review of more than 200 cases of penetrating rectal trauma from our institution over a 13-year period identified 17 concomitant GU tract injuries (13 bladder, three urethral, and one ureteral injury). Complications consisted of pelvic, suprapubic, or subphrenic abscesses in 3 of 17 cases (18%), rectovesical or rectourethral fistulae in 24%, chronic urinary tract infections in 18%, bladder stones in 12%, and the development of urethral strictures in 12% of patients. Factors implicated in their pathogenesis included failure to perform presacral drainage, distal rectal washout, and rectal wound repair; prolonged suprapubic drainage; and failure to separate the rectal and GU tract wounds. Careful debridement of all necrotic tissue, urinary and fecal diversion, tension-free wound closure with well-vascularized tissue, and adequate drainage and separation of the injured sites with well-vascularized tissue such as omentum should reduce the high incidence of rectourethral and rectovesical fistulae from combined rectal-GU tract trauma. Therapeutic recommendations for individualized treatment are presented.