[Perineal injuries in complicated pelvic trauma].

Severe comminuted pelvic ring fractures are often associated by genitourinary and rectal injuries. Because of severe retroperitoneal bleeding, shock management has to be initiated before further diagnosis of the perineal lesions. If normotonic conditions cannot be achieved by volume replacement, a pelvic clamp is indicated providing immediate reduction of the posterior pelvic ring. A subsequent emergency laparotomy has to be considered if stable circulatory conditions cannot be achieved by these emergency procedures. After the initial management of the hypovolemic shock further examination of the rectum by endoscopy and endosonography is performed. Urethral lesions have to be excluded by ultrasound of the bladder, retrograde urethrography and intravenous urography. Urethral and bladder injuries can be initially treated by suprapubic fistula, whereas rectal and pararectal wounds have to be managed by immediate debridement, jet-lavage and wound drainage. Rectal wall and sphincter lacerations are initially restored by suture because delayed reconstructions have poor results. A deviation colostomy is mandatory in cases of colonic and rectal injuries about the internal sphincter.