Rectal Injury

What to do right away

• Call 911 or your local emergency number for any penetrating wound near the anus, buttocks or lower belly, or heavy rectal bleeding.
• Do not try to remove an object that is stuck in the rectum. Pulling can tear the wall. Go to the ER.
• Do not eat or drink in case surgery is needed.
• Apply firm pressure with a clean pad to visible external bleeding.
• After sexual assault, try not to wash or change clothes before being examined, so evidence can be collected, but do not delay care. In the US, the National Sexual Assault Hotline is 1-800-656-4673.

How rectal injuries happen

The rectum lies deep in the pelvis. Its upper part is covered by the peritoneum (the lining of the abdomen), while the lower part sits outside it, surrounded by fat. This matters because a tear in the upper rectum spills stool into the abdomen, causing peritonitis, while a tear lower down causes a deep pelvic infection that can be slower to show.

Main causes:

• Penetrating trauma: gunshot and stab wounds to the buttocks, hips or lower abdomen. These cause most rectal injuries seen in US trauma centers.
• Blunt trauma: a pelvic fracture from a crash or fall, where bone fragments tear the rectum.
• Foreign bodies: objects inserted into the rectum, whether intentionally or during assault.
• Medical procedures: colonoscopy, sigmoidoscopy, biopsies, enemas (especially with stiff tips), rectal thermometers, prostate surgery and hemorrhoid procedures. Perforation from colonoscopy is uncommon.
• Childbirth: severe perineal tears (fourth-degree tears) extend through the anal sphincter into the rectal lining.
• Sexual assault and forceful anal intercourse.
• Radiation therapy: can weaken the rectal wall over time.

Symptoms

• bleeding from the rectum, from streaks to heavy bleeding (see rectal bleeding)
• pain in the rectum, lower belly, pelvis or perineum
• pain that spreads and worsens over hours, with a tense belly
• fever, chills and a fast heartbeat, which suggest infection is spreading
• air under the skin of the perineum or buttocks that crackles when pressed
• blood in the urine if the bladder is also injured
• after childbirth or surgery, stool or gas leaking from the vagina (a rectovaginal fistula)

Symptoms of a small perforation can be mild at first. Increasing pain after a procedure is a warning sign, not something to wait out.

Diagnosis

Doctors look for injuries to nearby organs at the same time, because rectal injuries rarely occur alone after major trauma.

• Examination, including a gentle digital rectal exam for blood and defects
• CT scan of the abdomen and pelvis, often with contrast given into the rectum, to show leaks, free air and the path of a bullet or blade
• Proctoscopy or flexible sigmoidoscopy, often under anesthesia, to see the tear directly
• Blood tests for blood count, infection and blood group
• X-ray to locate a foreign object

Surgeons grade the injury from I (bruise or hematoma) to V (complete destruction of a segment).

Treatment

• Removal of foreign bodies, usually in the ER or operating room under sedation.
• Small, partial-thickness tears: may heal with bowel rest, IV antibiotics and close observation.
• Upper rectal perforations: usually repaired directly through abdominal or keyhole surgery, sometimes removing the damaged segment.
• Lower (extraperitoneal) injuries: often managed with a temporary diverting colostomy, which brings the bowel out to a bag on the belly wall so the rectum can heal. It is usually reversed after 2 to 3 months. Some small injuries can be repaired through the anus without a stoma.
• Obstetric tears: repaired immediately after birth by an experienced clinician, followed by antibiotics, laxatives and pelvic floor follow-up.
• Antibiotics to cover bowel bacteria in all full-thickness injuries.

Complications and recovery

Possible complications include pelvic abscess, sepsis, fistulas to the vagina, bladder or skin, narrowing (stricture), and damage to the anal sphincter leading to fecal incontinence. Most people recover well after prompt treatment. Physical therapy for the pelvic floor and, in some cases, sphincter repair help with continence problems. Injuries often occur with colon injury or bladder damage, which affects recovery time.

Frequently asked questions

What are the symptoms of a perforated rectum?

Typical symptoms are rectal bleeding, pain in the rectum, pelvis or lower belly that gets steadily worse, fever, chills and a fast heartbeat. Some people notice a crackling feeling under the skin near the anus. These symptoms after trauma, an inserted object or a procedure need emergency care.

Can a torn rectum heal on its own?

Small tears in the lining, like an anal fissure, often heal on their own. A full-thickness tear through the rectal wall does not heal safely without treatment, because stool leaks into surrounding tissue. Very small perforations may be managed with antibiotics in hospital, but most need surgery.

What should I do if an object is stuck in my rectum?

Go to the ER. Do not try to pull it out or push it further, and do not use enemas or laxatives, as these can tear the bowel. Doctors see this regularly and will remove it, usually under sedation, and check for injury.

Will I need a colostomy after a rectal injury?

Not always. Many injuries are repaired without one. A temporary colostomy is used for larger or lower injuries, heavy contamination or when the person is very unwell. It is usually reversed in a second operation after the rectum heals, often 2 to 3 months later.