Anorectal Trauma and Injuries

  • Andrew H. Miller
  • Carlos V. R. Brown
  • Matthew J. Martin


The management of trauma to the rectum and anus has a complicated past rooted in military and battlefield experiences. Rectal trauma management varies widely based on the anatomic location and degree of the injury. Intraperitoneal rectal injuries are generally treated much like left colon injuries. Numerous factors play into the complicated operative algorithm for extraperitoneal rectal injuries. This chapter discusses the literature, reasoning, and scenarios for proximal fecal diversion, presacral drain placement, primary rectal repair, and the use of distal rectal washout. Rectal foreign body extraction is explained. The evaluation and acute management of traumatic anal sphincter injury, including a brief overview of outpatient incontinence options, is reviewed.


Rectal trauma/injury Anal trauma/injury Intraperitoneal rectal injury Extraperitoneal rectal injury Anal sphincter injury/trauma Rectal foreign body Blunt rectal trauma Penetrating rectal trauma Presacral drain placement Distal rectal washout 


  1. 1.
    The holy bible. New international version. Grand Rapids: Zondervan Publishing House; 1993.Google Scholar
  2. 2.
    Perry BW, Brooks JP, Muskat PC. The history of military colorectal trauma management. Sem Colon Rectal Surg. 2004;15(2):70–9.CrossRefGoogle Scholar
  3. 3.
    Welling DR, Duncan JE. Stomas and Trauma. Clin Colon Rectal Surg. 2008;21(1):45–52.CrossRefGoogle Scholar
  4. 4.
    Imes PR. War surgery of the abdomen. Surg Gynecol Obstet. 1945;81:608–16.PubMedGoogle Scholar
  5. 5.
    Stone HH, Fabian TC. Management of perforating colon trauma: randomization between primary closure and exteriorization. Ann Surg. 1979;190:430–6.CrossRefGoogle Scholar
  6. 6.
    Strada G, Raad L, Belloni G, Carraro P. Large bowel perforations in war surgery: one-stage treatment in a field hospital. Int J Color Dis. 1993;8:213–6.CrossRefGoogle Scholar
  7. 7.
    George SM Jr, Fabian TC, Voeller GR, Kudsk KA, Mangiante EC, Britt LG. Primary repair of colon wounds: a prospective trial in nonselected patients. Ann Surg. 1989;209:728–34.CrossRefGoogle Scholar
  8. 8.
    Velmahos GC, Gomez H, Falabella A, Demetriades D. Operative management of civilian rectal gunshot wounds: simpler is better. World J Surg. 2000;24(1):114–8.CrossRefGoogle Scholar
  9. 9.
    Williams MD, Watts D, Fakhry S. Colon injury after blunt abdominal trauma: results of the EAST Multi-Institutional Hollow Viscous Injury Study. J Trauma. 2003;55:906–12.CrossRefGoogle Scholar
  10. 10.
    Steele SR, Maykel JA, Johnson EK. Traumatic injury of the colon and rectum: the evidence vs dogma. Dis Colon Rectum. 2011;54(9):1184–201.CrossRefGoogle Scholar
  11. 11.
    Levine JH, Longo WE, Pruitt C, Mazuski JE, Shapiro MJ, Durham RM. Management of selected rectal injuries by primary repair. Am J Surg. 1996;172(5):575–9.CrossRefGoogle Scholar
  12. 12.
    Thomas DD, Levison MA, Dykstra BJ, Bender JS. Management of rectal injuries. Dogma versus practice. Am Surg. 1990;56(8):507–10.PubMedGoogle Scholar
  13. 13.
    Cho SD, Kiraly LN, Flaherty SF, Herzig DO, Lu KC, Schreiber MA. Management of colonic injuries in the combat theater. Dis Colon Rectum. 2010;53:728–34.CrossRefGoogle Scholar
  14. 14.
    Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007;50:25–33.CrossRefGoogle Scholar
  15. 15.
    Porter JM, Ursic CM. Digital rectal examination for trauma: does every patient need one? Am Surg. 2001;67:438–41.PubMedGoogle Scholar
  16. 16.
    Esposito TJ, Ingraham A, Luchette FA. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005;59:1314–9.CrossRefGoogle Scholar
  17. 17.
    Herzig DO. Care of the Patient with Anorectal Trauma. Clin Colon Rectal Surg. 2012;25:210–3.CrossRefGoogle Scholar
  18. 18.
    Anderson SW, Soto JA. Anorectal trauma: the use of computed tomography scan in diagnosis. Semin Ultrasound CT MR. 2008;29(6):472–82.CrossRefGoogle Scholar
  19. 19.
    Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJ, Scalea TM. Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury—a prospective study in 200 patients. Radiology. 2004;231:775–84.CrossRefGoogle Scholar
  20. 20.
    Arthurs Z, Kjorstad R, Mullenix P, Rush RM Jr, Sebesta J, Beekley A. The use of damage-control principles for penetrating pelvic battlefield trauma. Am J Surg. 2006;191:604–9.CrossRefGoogle Scholar
  21. 21.
    Pereira BM, Reis LO, Calderan TR, de Campos CC, Fraga GP. Penetrating bladder trauma: a high risk factor for associated rectal injury. Adv Urol. 2014;2014:386280.CrossRefGoogle Scholar
  22. 22.
    Russell KW, Soukup ES, Metzger RR, Zobell S, Scaife ER, Barnhart DC, Rollins MD. Fecal continence following complex anorectal trauma in children. J Pediatr Surg. 2014;49:349.CrossRefGoogle Scholar
  23. 23.
    Aihara R, Blansfield JS, Millham FH, LaMorte WW, Hirsch EF. Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures. J Trauma. 2002;52(2):205–8. discussion 208-9PubMedGoogle Scholar
  24. 24.
    Moore EE, Cogbill TH, Malangoni M, Jurkovich GJ. Scaling system for organ specific injuries. Available at: Accessed 22 Feb 2016.
  25. 25.
    Hoyt DB, Lekawa ME. Trauma of the colon and rectum. In: Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD, editors. The ASCRS textbook of colon and rectal surgery. 2nd ed. New York: Springer; 2007.Google Scholar
  26. 26.
    Chappuis CW, Frey DJ, Dietzen CD, Panetta TP, Buechter KJ, Cohn I Jr. Management of penetrating colon injuries. A prospective randomized trial. Ann Surg. 1991;213:492–8.CrossRefGoogle Scholar
  27. 27.
    Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: is it necessary? J Trauma. 1996;41:271.CrossRefGoogle Scholar
  28. 28.
    Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: a prospective randomized study. J Trauma. 1995;39:895.CrossRefGoogle Scholar
  29. 29.
    McGrath V, Fabian TC, Croce MA, Minard G, Pritchard FE. Rectal trauma: management based on anatomic distinctions. Am Surg. 1998;64:1136.PubMedGoogle Scholar
  30. 30.
    Maxwell RA, Fabian TC. Current management of colon trauma. World J Surg. 2003;27:632–9.CrossRefGoogle Scholar
  31. 31.
    Berne JD, Velmahos GC, Chan LS, Asensio JA, Demetriades D. The high morbidity of colostomy closure after trauma: further support for the primary repair of colon injuries. Surgery. 1998;123:157–64.CrossRefGoogle Scholar
  32. 32.
    Demetriades D, Pezikis A, Mellssas J, Parekh D, Pickles G. Factors influencing the morbidity of colostomy closure. Am J Surg. 1988;155:594–6.CrossRefGoogle Scholar
  33. 33.
    Park JJ, Pino AD, Orsay CP, Nelson RL, Pearl RK, Cintron JR, Abcarian H. Stoma complications: the Cook County Hospital experience. Dis Colon Rectum. 1999;42:1575–80.CrossRefGoogle Scholar
  34. 34.
    Franko ER, Ivatury RR, Schwalb DM. Combined penetrating rectal and genitourinary injuries: a challenge in management. J Trauma. 1993;34:347.CrossRefGoogle Scholar
  35. 35.
    Burch JM, Feliciano DV, Mattox KL. Colostomy and drainage for civilian rectal injuries: is that all? Ann Surg. 1989;209:600–11.CrossRefGoogle Scholar
  36. 36.
    Lavenson GS, Cohen A. Management of rectal injuries. Am J Surg. 1971;122:226–30.CrossRefGoogle Scholar
  37. 37.
    Rombeau JL, Wilk PJ, Turnbull J, R B, Fazio VW. Total fecal diversion by the temporary skin-level loop transverse colostomy. Dis Colon Rectum. 1978;21:223–6.CrossRefGoogle Scholar
  38. 38.
    Gonzalez RP, Falimirski ME, Holevar MR. The role of presacral drainage in the management of penetrating rectal injuries. J Trauma. 1998;45:656.CrossRefGoogle Scholar
  39. 39.
    Weinberg JA, Fabian TC, Magnotti LJ, et al. Penetrating rectal trauma: management by anatomic distinction improves outcome. J Trauma. 2006;60:508–14.CrossRefGoogle Scholar
  40. 40.
    Burch JM. Injury to the colon and rectum. In: Feliciano DV, Moore EE, Mattox KL, editors. Trauma. 3rd ed. Stamford: Appleton and Lange; 1996.Google Scholar
  41. 41.
    Bosarge PL, Como JJ, Fox N, Falck-Ytter Y, Haut ER, Dorion HA, Patel NJ, Rushing A, Raff LA, McDonald AA, Robinson BRH, McGwin GJ, Gonzalez RP. Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2016;80(3):546–51.CrossRefGoogle Scholar
  42. 42.
    Lake JP, Essani R, Petrone P, Kaiser AM, Asensio J, Beart RW Jr. Management of retained colorectal foreign bodies: predictors of operative intervention. Dis Colon Rectum. 2004;47:1694–8.CrossRefGoogle Scholar
  43. 43.
    Glasgow SC, Heafner TA, Watson JDB, Aden JK, Perry WB. Initial management and outcome of modern battlefield anal trauma. Dis Colon Rectum. 2014;57:1012–8.CrossRefGoogle Scholar
  44. 44.
    Haas PA, Fox TA Jr. Civilian injuries of the rectum and anus. Dis Colon Rectum. 1979;22:17–23.CrossRefGoogle Scholar
  45. 45.
    Engel AF, Kamm MA, Hawley PR. Civilian and war injuries of the perineum and anal sphincters. Br J Surg. 1994;81:1069–73.CrossRefGoogle Scholar
  46. 46.
    Madiba TE, Moodley MM. Anal sphincter reconstruction for incontinence due to non-obstetric sphincter damage. East Afr Med J. 2003;80:585–8.PubMedGoogle Scholar
  47. 47.
    Mossadegh S, Tai N, Midwinter M, Parker P. Improvised explosive device related pelvi-perineal trauma: anatomic injuries and surgical management. J Trauma Acute Care Surg. 2012;73(2 suppl 1):S24–31.CrossRefGoogle Scholar
  48. 48.
    Jorge JMN, Habr-Gama A. Anatomy and embryology. In: Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD, editors. The ASCRS textbook of colon and rectal surgery. 2nd ed. New York: Springer; 2011.Google Scholar
  49. 49.
    Critchlow JF, Houlihan MJ, Landolt CC, Weinstein ME. Primary sphincter repair in anorectal trauma. Dis Colon Rectum. 1985;28(12):945–7.CrossRefGoogle Scholar
  50. 50.
    Martin MJ, Brown CVR. Colon and rectal trauma. In: Steele SR, Champagne BJ, Maykel JA, Orangio GR, editors. Complexities in colorectal surgery. New York: Springer; 2014.Google Scholar
  51. 51.
    Gordon PH, Schouten WR. Fecal incontinence. In: Gordon PH, Nivatvongs S, editors. Principles and practice of surgery for the colon rectum and anus. 3rd ed. New York: Informa Healthcare; 2007.Google Scholar
  52. 52.
    McCune WS. War wounds of the rectum and anal sphincter. Surgery. 1948;23:653–64.PubMedGoogle Scholar
  53. 53.
    Barisic G, Krivokapic Z, Markovic V, Popovic M, Saranovic D, Marsavelska A. The role of overlapping sphincteroplasty in traumatic fecal incontinence. Acta Chir Iugosl. 2000;47(4 suppl 1):37–41.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Andrew H. Miller
    • 1
  • Carlos V. R. Brown
    • 2
  • Matthew J. Martin
    • 3
  1. 1.Department of SurgeryThe University of Texas at Austin Dell Medical SchoolAustinUSA
  2. 2.University Medical Center BrackenridgeAustinUSA
  3. 3.ScrippsSan DiegoUSA

Personalised recommendations