The signs of peritonitis, intrapelvic or transabdominal missile path, and intraperitoneal free air warrant immediate celiotomy. Proctosigmoidoscopy can be a great aid in the diagnosis of a rectal injury, and should be performed in the ED. To evaluate the lower GU tract, a cystourethrogram should be performed. This can be performed either as a separate study or in conjunction with CT scanning, with rectal and intravenous contrast and clamping the urethra catheter to obtain a CT cystogram. If the CT scan demonstrates a pelvic hematoma, angiography or venography may be indicated to document a significant vascular injury. Also, appropriate consultation should be obtained. Local wound exploration is of limited value in penetrating buttock injuries. For those patients who present with peritonitis, or if there is a concern of a rectal injury, broad spectrum intravenous antibiotics should be initiated in the ED. Operative therapy for rectal injuries should be directed at proximal colostomy, presacral drainage, and distal washout. Genitourinary tract injuries are repaired with appropriate drainage and often a suprapubic cystostomy.
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