Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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MD, DM (Clinical Pharmacology)
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Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : PC11 - PC15 Full Version

Clinico-epidemiological and Outcome Analysis of Anogenital Injuries in Children: Retrospective Study from a Tertiary Care Centre, Central India


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/47257.15306
Umesh Bahadur Singh, Dileep Garg, Manoj Kumar Joshi, Vinay Mathur, Jitendra Grover

1. Assistant Professor, Department of Paediatric Surgery, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India. 2. Associate Professor, Department of Paediatric Surgery, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India. 3. Professor and Head, Department of Paediatric Surgery, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India. 4. Associate Professor, Department of Paediatric Surgery, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India. 5. Assistant Professor, Department of Paediatric Surgery, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India.

Correspondence Address :
Umesh Bahadur Singh,
Flat No. 01, Block E4, Windsor Hills, Gwalior, Madhya Pradesh, India.
E-mail: singhub.2008@gmail.com

Abstract

Introduction: Paediatric perineal trauma or Anogenital Injury (AGI) in the paediatric age group remains lesser reported in under-developed areas or rural areas of India. Most of these injuries remain under reported to tertiary care centres because of a social stigma or poor access to a health facility.

Aim: To present the clinico-epidemiological parameters of AGI in children and to assess the outcome of staged and definitive management in these children, comparing the results with other similar studies.

Materials and Methods: This was a retrospective study on data of 11 cases (age range 1-14 years, seven cases were boys and 4 cases were girls) of paediatric anogenital injuries, admitted at the tertiary care centre from 1st July 2018 to 30th June 2020 were analysed. Data of all the patients, demographic details, relevant clinical history such as time of presentation, mode of injury and type of management, outcomes and complications was collected and studied. All the collected data was analysed by calculating mean±SD, frequency (n) and percentages (%).

Results: Road traffic accident was the most common cause of AGI (n=5, 45.5%), followed by sexual assault (n=3, 27.3%). Wound infection in late presenters (n=5, 45.5%) was the most common complication affecting the outcome. Children with a primary diversion of the faecal stream or diversion colostomy (n=5, 45.5%) as an associated procedure had a better outcome. Primary repair without diversion (n=3, 27.3%) was noticed to have a high incidence of wound infection and anovaginal scaring.

Conclusion: A high incidence of poor wound healing related to late presentation and malnutrition noted among these AGI cases belonging to rural or semi-urban settings. Management of these injuries, therefore, needs to be individualised on case-to-case basis. The diversion stoma formation seems to be considered in all high grade anogenital injuries and selected lower grade injuries with evidence of secondary infection or poor healing of the primary repair.

Keywords

Colostomy, Faecal diversion, Malnutrition, Perineal injury

The AGI in children is a rare condition and often under-reported. Many children with anogenital injuries do not report to tertiary care centers, and hence the exact prevalence of these injuries is not known in India. However, worldwide reported incidence is 6-8% (1),(2). Globally, apart from accidents, a significant number of children sustain injuries by abuse or battering (2). Paediatric genital injuries represented 0.6% of all paediatric injuries in the United States (3).

In the Indian scenario, especially in semi-urban or rural areas, due to attached stigma and fear of medico-legal issues, a history of abuse is often concealed. So, pinpointing the exact cause of injury by gross examination is often a challenge to treating surgeons. The disease burden due to trauma is exponentially rising globally. As predicted by World Health Organisation (WHO), it may become the third leading cause of global disease burden by end of 2020 (4). The incidence of accidents or assaults in children involving the anogenital area with complex injuries is also increasing (5). Increasing numbers of perineal trauma cases are also contributed by unsafe transport practices causing road traffic accidents (6).

Anogenital injuries present with a spectrum depending upon the severity of the injury and long term morbidity. It may be a simple abrasion or contusion or small laceration affecting soft tissue superficially at the one end to extensive tears of the vulvo-vaginal and anorectal region at the other (7). Management depends on the severity and needs to be individualised depending on the degree and precise anatomic details of the injury, time of presentation, and available expertise (8),(9). The primary repair of the sphincter and perineum can be considered if there is the absence of shock, no associated grievous injuries, or no faecal contamination of the wound (9). The decision of colostomy is the most important step in the presence of rectal injury with gross soiling (8).

The epidemiological data on paediatric anogenital injuries in Indian rural population is still missing in available literature. To the best of our knowledge, no paediatric surgical centre from central India has reported the data on paediatric anogenital trauma cases till date. This study evaluated the patients with anogenital injuries on various clinico-epidemiological parameters and assessed their outcome.

Material and Methods

This was a retrospective study conducted on data of patients who were diagnosed of perineal trauma and admitted to the Paediatric Surgery Department at Gajra Raja Medical College, Gwalior, India, from 1st July 2018 to 30st June 2020. Out of 50 cases of paediatric trauma, 11 children were admitted for the management of anogenital trauma.

Inclusion criteria: Data of the paediatric trauma patients aged 1 to 14 years, with perineal injury with or without polytrauma who were admitted to the Paediatric Surgery Department of the study centre during the study time period. Onen’s classification was used to categorise the perineal injuries (Table/Fig 1) (7).

Exclusion criteria: Pediatric perineal injury patients with blunt trauma chest, blunt trauma abdomen and head injury were excluded from record.

Study Procedure

In all these patients, data were collected for demographic initial parameters, time of presentation, mechanism of injury, degree of injury, associated injuries, treatment received, and complications, haemodynamic stabilisation and optimal treatment of associated injuries, if any was given. Local wound care, saline wound irrigation, intravenous antibiotic, and analgesics were given along with physiological resuscitation. Careful in-dwelling urinary catheterisation was attempted in each patient. Primary repair or delayed repair with or without foecal diversion was performed depending upon the degree of injury and local wound condition.

Statistical Analysis

Results of all parameters were analysed using percentages and descriptive details.

Results

This study included a total of 11 cases, summarised in (Table/Fig 2), (Table/Fig 3). Seven cases were male, and four cases were females. The age ranged from 1 year to 14 years, mean age of presentation was 6.18 years (Table/Fig 2). The mean time lapse between injury and reporting to the hospital was 27.27 hours (ranging from 12 hours to 48 hours). Out of 11 cases, the major number of children (9) weighted below the 5th percentile of weight for age. The majority belonged to lower (class V, Score <5) socioeconomic status according to the Modified Kuppuswamy scale (Table/Fig 2) (10).

The clinical history of all subjects with differential mode of injuries and their severity grades are provided in (Table/Fig 3). All patients presented with pain as a primary symptom. Two cases had haematuria, and five cases had bleeding from the perineal wound. The majority of cases (six out of 11) patients had a loss of stool control and lower abdominal pain. Out of 11 cases, about half of the cases (45.5%) were road traffic accident victims, while three cases sustained a perineal injury by sexual assault.

The anal area was involved in a maximum number of cases (72.8%), while the rectum and perineal body were involved in 45.5% of cases. Out of 11 cases, 36.4% (n=4, females) had injuries involving the vestibule, hymen, and vaginal region. Out of 11 cases, 18.2% (n=2, male) had an injury in the scrotal region, and one male had an injury in the urethra (Table/Fig 3).

Out of 11 patients, seven cases underwent examination under anaesthesia. Two cases were managed expectantly. Faecal diversion by colostomy was done along with repair of the perineal wound in 4 cases (36.4%). In 3 (27.3%) cases, the primary repair was done without colostomy, and in one case, colostomy and delayed repair was done (Table/Fig 3).

In 4 cases (40%), there was no complication after repair. Faecal incontinence, urinary incontinence, and anal stenosis developed as a complication one case each. Vaginal stenosis occurred in two as complications after repair. Secondary wound infection developed in 5 (45.5%), and there was one mortality (Table/Fig 3). The mean follow-up time was 6.09 months (Table/Fig 2).

Discussion

Perineal injuries can exhibit as a spectrum, from superficial abrasion or lacerations of the labia or peno-scrotal skin to critical injuries that disrupt the anal sphincter and genitourinary system (11). Management of AGI in children needs to individualise. In the present retrospective study, two cases of anal assault sustained only minor anogenital abrasion, and one case of scroto-perineal laceration caused by a road traffic accident had grade I GIS. Another case of a dog bite injury with major scrotal laceration sustained grade II GIS. All other patients of the case series were of complex and higher grade anogenital trauma.

Sometimes perineal traumas are accompanied by injury to other organ structures like fracture pelvis and visceral organs. In such situations, prompt intervention for those life threatening injuries is prioritised over primary perineal wound repair (12). Also, in this series, single mortality was caused by massive blood loss due to the associated pelvic fracture and head injury, along with perineal injury.

In the present study, a majority of anogenital injuries were caused by road traffic accidents, and the second most common cause was sexual assault. Based on the severity of AGI grading, most of the high-grade injuries caused by a road traffic accident. This was followed by sexual assault as the second most common cause (Table/Fig 4), (Table/Fig 5).

In this retrospective study, low socioeconomic status was observed with two major modes of anogenital trauma, the road traffic accident, and the sexual assault. The low socioeconomic status of an area or an individual appears to increase the risk of being injured in road traffic accidents (13). A research on sexual abuse victim adolescents explained that family structure was significantly associated with sexual assault (14).

The poor nutritional status or malnutrition of a trauma victim child also adds to the morbidity of anogenital trauma, as it severely affects the wound healing status of the patient (15). In the present study as well, most of the cases are affected by malnutrition as 90.9% cases weighted 5th percentile. A delay of more than 24 hours was also noticed in the presentation of these cases, resulting in infected and grossly contaminated wounds. This delay appears to be indirectly related to low socioeconomic status because of the lack of awareness of the intensity of injury and lack of early access to a health facility (16).

In this study, the parents of a sexual abuse victim female child (case number 5 in (Table/Fig 4)), tried to conceal the actual history of sexual abuse. In the first instance, parents gave the history of fall from the height. This highlights the stigma and fear of medico-legal issues associated with such types of injuries in some underdeveloped society. After examination under general anaesthesia,, the history was re-evaluated, and parents had re-interviewed to give true history. Subsequently, the actual history of sexual abuse was revealed by some relative. Detailed and correct history along with a comprehensive physical examination is a critical part of the management. The extraction of history becomes a challenging task in paediatric anogenital trauma cases and more so in cases of sexual assault when the victim is of young age or mentally traumatised. Out of three cases of sexual assault (case number 1, 2 and 5 of (Table/Fig 4)), history was given by parents, as all victims were minor. Out of these three cases, two cases gave suspicious history initially, probably out of fear or to cover the culprit who was their family members. Such social stigma appears to be more prevalent in this semi-urban or rural population.

At times, radiological modalities may be insufficient in assessing the actual extent of tissue damage in severe trauma cases. In such cases, a diagnostic endoscopic examination under anaesthesia is relevant to fully discern the anatomy of the injury (17). In the present study, examination under anaesthesia was required in the majority of cases to fully ascertain the anatomical extent of AGI before repair. Timely diagnosis and prompt surgical reconstruction of an anogenital trauma give the best outcome (17).

Accidental AGI often happens from an impact to the groin or straddles trauma. In boys, penoscrotal traumatic wounds are frequently caused by accidents, while anal injuries are prevalent in sexual abuse. In female child victims, wounds to the perineum are prevalent following accidental traumas, while hymen, posterior fourchette, or labial injuries are more prevalent following sexual assault (12). A complete knowledge of injured tissues can be helpful to aid in the differential diagnosis of the cause of anogenital injuries if history is doubtful. Determining the appropriate injury classification helps to define an appropriate treatment approach, and the Genital injury score (GIS scale) is very useful for choosing the approach for an injury (7). It is of optimum importance to select the type of management, depending on the location of the injury and involved organs or tissues. Occult injuries may not be evident during the primary clinical assessment. The endoscopic evaluation like rectoscope, cystoscopy, or vaginoscopy can be performed in cases of major perineal traumas as and when required in a female child (18). In the present study, however, the endoscopic evaluation was not required in any patient.

It is preferable to examine a child under general anaesthesia, which renders added diagnostic or therapeutic means to be employed if required during the single sitting. The “conscious” sedation can be inefficient due to the lack of an analgesic effect of various sedatives (19). All patients of this case series having grade III-V, were examined under general anaesthesia, a surgical procedure was done in the same sitting. In the case of a 3-year-old female child (case number 5 in (Table/Fig 4)), a sexual assault victim, the examination under anaesthesia revealed extended anorectovaginal tear (Table/Fig 6) with the incomplete suturing done in a peripheral hospital one day back. The wound was grossly contaminated and infected. For this case, diversion colostomy was done, and the definitive repair through anterior sagittal approach was performed after three months of diversion colostomy (Table/Fig 7). After four months of definitive repair, the anal continence was good, vaginal patency was satisfactory (Table/Fig 8) and colostomy closure was done.

The vaginal trauma patient of this case series (case number 3 of (Table/Fig 4)), on whom, the primary repair of the wound was done, encountered many complications like secondary wound infection, fibrosis, and narrowing of common urethrovaginal opening requiring repeated dilatation. A thorough exploration of rectal injuries is customary in the management of these cases. The traditional therapeutic strategies recommend faecal diversion in severe anorectal injury patients, comprising a diverting colostomy, cleaning of the perineal wound with rectal irrigation (20),(21). However, in recent years there are plenty of studies supporting primary reconstruction in patients with non severe injury, and selective faecal diversion reserved for patients with haemodynamic instability, profuse bleeding, damage to abdominal organs associated with colon injury (22),(23),(24). But in the geographical areas having a poor and rural population like the present study, there are some important factors to consider for faecal diversion as a safe initial procedure in lower grade AGI involving anorectum. These factors are delays in presentation, grossly infected wounds, and poor nutritional status of patients, as apparent from the present retrospective study.

Limitation(s)

The study was a retrospective observational study, so recommendation of any management strategy cannot be claimed.

Conclusion

It seems a safe practice to perform faecal diversion, not only in grade III to V anogenital injuries, but also in lower grade injuries having wound contamination, late presentation, and other systemic morbidities like malnutrition which may affect healing. In the current scenario, there is also an urgent need to provide community education in schools and different organisations regarding the safety of children at home and outside. A large scale case control study is recommended in future to investigate about the benefits of staged procedure of diversion colostomy in this subset of population.

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DOI and Others

10.7860/JCDR/2021/47257.15306

Date of Submission: Oct 19, 2020
Date of Peer Review: Dec 17, 2020
Date of Acceptance: May 21, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 20, 2020
• Manual Googling: May 20, 2021
• iThenticate Software: Jun 03, 2021 (6%)

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