Journal of Pediatric Surgery 49 (2014) 349352

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Fecal continence following complex anorectal trauma in children

Katie W. Russell , Elizabeth S. Soukup, Ryan R. Metzger, Sarah Zobell, Eric R. Scaife, Douglas C. Barnhart,
Michael D. Rollins
Division of Pediatric Surgery, Primary Childrens Medical Center, University of Utah, Salt Lake City, UT

a r t i c l e

i n f o

Article history:
Received 16 October 2013
Accepted 16 October 2013
Key words:
Rectal injury
Anal injury
Anorectal injury
Pediatric trauma
Penetrating trauma
Colostomy
Impalement

a b s t r a c t
Background: Complex injuries involving the anus and rectum are uncommon in children. We sought to
examine long-term fecal continence following repair of these injuries.
Methods: We conducted a retrospective review using our trauma registry from 2003 to 2012 of children with
traumatic injuries to the anus or rectum at a level I pediatric trauma center. Patients with an injury requiring
surgical repair that involved the anal sphincters and/or rectum were selected for a detailed review.
Results: Twenty-one patients (21/13,149 activations, 0.2%) who had an injury to the anus (n = 9), rectum
(n = 8), or destructive injury to both the anus and rectum (n = 4) were identied. Eleven (52%) patients
were male, and the median age at time of injury was 9 (range 114) years. Penetrating trauma accounted for
48% of injuries. Three (14%) patients had accompanying injury to the urinary tract, and 6 (60%) females had
vaginal injuries. All patients with an injury involving the rectum and destructive anal injuries were managed
with fecal diversion. No patient with an isolated anal injury underwent fecal diversion. Four (19%) patients
developed wound infections. The majority (90%) of patients were continent at last follow-up. One patient
who sustained a gunshot injury to the pelvis with sacral nerve involvement is incontinent, but remains
articially clean on an intense bowel management program with enemas, and one patient with a destructive
crush injury still has a colostomy.
Conclusions: With anatomic reconstruction of the anal sphincter mechanism, most patients with traumatic
anorectal injuries will experience long-term fecal continence. Follow-up is needed as occasionally these
patients, specically those with nerve or crush injury, may require a formal bowel management program.
2014 Elsevier Inc. All rights reserved.

Injuries involving the anus and rectum in children are rare and are
often associated with injuries to the bony pelvis and genitourinary
system. Limited data exist regarding the long-term fecal continence
following management of these injuries. Much of the literature to date
relates to selective fecal diversion and immediate postoperative
complications. We reviewed our experience specically examining
long-term fecal continence.
1. Methods
After obtaining approval from the institutional review board, we
conducted a retrospective review of all children with injury to the
anus or rectum treated at our level 1 pediatric trauma center from
January 2003 through December 2012. Patients were identied
using our trauma registry and the electronic charts were reviewed to
select only patients who required operative repair of the injury.
Injuries to the anus not involving the anal sphincters were excluded.
Patient information including demographics, mechanism of injury,
associated injuries, Injury Severity Score (ISS), diagnostic studies,
surgical treatment, postoperative complications and long-term
Corresponding author. Tel.: +1 801 662 2950; fax: +1 801 662 2980.
E-mail address: [email protected] (K.W. Russell).
0022-3468/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2013.10.015

bowel function were collected from inpatient records and outpatient

follow-up charts.
2. Results
The prevalence of anorectal injury at our center during the 10-year
period was 0.2% (21/13,149). The median age at the time of injury of
was 9 years (range 114 years), and 11 patients (52%) were male.
Nine (43%) patients had an injury involving the anus, 8 (38%) had
rectal injuries and 4 (19%) had destructive injuries to both the anus
and rectum (Table 1). Ten (83%) patients with a rectal injury had an
extraperitoneal component and only two (17%) were isolated
intraperitoneal injuries. Forty-eight percent of the injuries were the
result of penetrating mechanisms. The blunt mechanisms were
separated into blunt trauma (33%) and straddle injury (19%). The
straddle injuries all had sphincter involvement by blunt force but
were isolated and thus considered separately from high-force blunt
mechanisms (motor vehicle crash, pedestrian rollover, all-terrain
vehicle crash) that resulted in more destructive anorectal injuries and
accompanying injury to other organ systems. The median ISS was 13
(range 142), and was generally higher in patients who had blunt
trauma (median 26), in contrast to those with straddle injuries
(median 3) and penetrating trauma (median 13). Common associated

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K.W. Russell et al. / Journal of Pediatric Surgery 49 (2014) 349352

Table 1
Summary of patient characteristics, management and outcomes.
Injury location

ISS median (range)

Mechanisms

Penetrating

Associated injuries

Fecal diversion

Fecal continence

Anus (n = 9)

4 (134)

22%

Vagina (n = 4)
Pelvis fx (n = 2)
Tibia fx (n = 1)
Pulmonary contusion (n = 1)

None

100%

Rectum (n = 8)
Intraperitoneal (n = 2)
Extraperitoneal (n = 5)
intra/extra (n = 1)

15 (442)

Straddle (n = 4)
AVP (n = 2)
Rope burn (n = 1)
Impalement (n = 1)
Sexual abuse (n = 1)
Impalement (n = 3)
MVC (n = 2)
Sexual abuse (n = 1)
ATV crash (n = 1)
Stab wound (n = 1)

63%

All

100%

Anus + rectum (n = 4)
Intraperitoneal (n = 0)
Extraperitoneal (n = 2)
Intra/extra (n = 2)

15 (922)

Bladder (n = 3)
Vagina (n = 2)
Pelvis fx (n = 2)
Leg laceration (n = 1)
Small Bowel (n = 1)
Pulmonary contusion (n = 1)
Pelvis fx (n = 1)
Sacrum fx (n = 1)
Leg laceration (n = 1)
Cecum (n = 1)

All

50%a

Gunshot (n = 1)
Impalement (n = 1)
Boat propeller (n = 1)
AVP (n = 1)

75%

AVP: automobile versus pedestrian, MVC: motor vehicle crash, ATV: all-terrain vehicle, fx: fracture.
a
One is articially clean with enemas and one still has a colostomy.

injuries included vaginal injury in 6 females (60%), injury to the

urinary tract in 3 patients (14%) and pelvic fracture in 5 patients
(24%). In the patients with urinary tract injury, all had an injury to the
bladder (2 intraperitoneal, 1 extraperitoneal). One patient also had a
urethral injury and 1 suffered a ureteral injury.
A preoperative CT scan of the abdomen and pelvis was performed
in 83% (n = 10) of patients with rectal injury, and 22% (n = 2) of
patients with an isolated anal injury. At our facility all patients with
suspected anorectal injury receive rectal contrast, but given the large
geographic area that we serve, patients are often transferred with
imaging from other facilities (40%) and these scans commonly do not
have rectal contrast. Two patients with an injury involving both the
anus and rectum underwent a damage control operation at the
referring facility prior to transfer. Rigid proctoscopy was used to
evaluate the extent of the injury in ve patients with rectal
involvement, and one patient with an isolated injury to the anus.
There were no missed injuries.
All patients with injury involving the anal sphincters underwent
immediate repair. No patient with an isolated, nondestructive anal
injury underwent fecal diversion. The four patients that had combined
anal and rectal injuries all had destructive injury to the sphincters and
were diverted at the time of primary repair. A muscle stimulator was
used to facilitate an anatomical repair in patients with destructive
injury to the anal sphincters. One patient who was impaled while
climbing a fence had good sphincter muscle contraction in three of
four quadrants following repair. Anorectal manometry performed
prior to colostomy closure was normal and he is now continent of
stool and atus.
All patients with an injury to the rectum were managed with fecal
diversion. Ten (83%) of these patients underwent primary repair of the
rectal injury and two patients with an extraperitoneal injury were
managed by drain placement and distal irrigation of the defunctionalized rectum. One patient was managed with an endorectal pull-through
(Swenson type) and a protective loop ileostomy after suffering a
destructive pelvic and spinal injury secondary to a gunshot wound. The
endorectal pull-through was performed several days after a damage
control laparotomy when the patient was physiologically stable. Three
(25%) patients underwent diagnostic laparoscopy for evaluation of an
intraperitoneal rectal injury. Two of these patients had the rectal injury
repaired laparoscopically followed by a laparoscopic assisted loop
sigmoidostomy. The third patient was diagnosed with a complex
genitourinary injury on laparoscopy that required open repair.
The median length of stay for patients with a rectal injury was
11 days (range 452 days), and 2 days (range b 110 days) in
patients with an isolated anal injury. Four patients (19%) developed

wound infections. Three of these were supercial perineal infections

treated with local wound care and antibiotics. One patient, who had
extensive perineal soft tissue loss after being crushed by a dump truck
developed a deep infection that required a prolonged hospitalization,
which included multiple operative debridements and eventual wound
coverage with a muscle ap and skin graft.
Eleven of the 12 patients that had fecal diversion have undergone
stoma closure. Median time to stoma closure was 103 days (range
46 days to 8.1 years). Median follow-up for patients with rectal or
combined injuries was 134 days (69 days to 8.3 years) and 12 days
(0-43 days) for patients with an isolated injury to the anus. The
patient who underwent an endorectal pull-through after a gunshot
injury to the pelvis with sacral nerve involvement has had her
ileostomy closed and is incontinent of stool but is accident free with
an intense bowel management program using large-volume enemas.
The patient who suffered a crush injury from a garbage truck has not
had his stoma reversed because of absent rectal tone and a fragile, skin
grafted perineum. All other patients (90%) were continent of stool at
the last follow-up visit.
3. Discussion
Pediatric anorectal injuries are uncommon and preservation of
fecal continence is an important component of management in these
patients. This is one of the largest series in children with anorectal
injuries examining long-term fecal continence. With appropriate
management continence should be expected. It is also important to
recognize that there are frequently associated injuries to the
genitourinary tract [14].
Anorectal injuries should be evaluated with priorities focusing on
the location and extent of the injury (intraperitoneal vs. extraperitoneal) and identication of associated genitourinary injuries as
delay in diagnosis has been shown to lead to an increase in morbidity
and mortality [3,5]. Patients most commonly present with rectal
bleeding [1,3]. While proctoscopy has been advocated in the past, a
recent series suggests that triple-contrast CT (IV, oral, rectal) is highly
accurate in diagnosing rectal injuries in children [6]. In addition,
laparoscopy should be considered in the management of these
injuries as both a diagnostic and therapeutic tool [79]. Injury to the
urinary tract has been reported in up to 44% of children [10], and
vaginal injury in 54% to 100% of females [3,4]. In our series, 14% had
urinary tract injuries and 60% of female patients had vaginal injuries.
Evaluation of the urethra and bladder with either cystography or
cystoscopy is indicated in cases of high clinical suspicion [2,11,12],
and vaginoscopy should be performed in female patients [11].

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351

Suspected anorectal injury

-Penetrating mechanism
-Rectal bleeding

Triple contrast CT scan

(iv, oral, rectal)
-Consider urethrocystography

Injury identified

OR for evaluation and repair

-Consider proctoscopy
-Consider laparoscopy
-Consider vaginoscopy
-Consider urethrocystoscopy

Destructive injury to sphincters/rectum

-Primary repair
-Consider muscle stimulator
-Diversion

Nondestructive sphincter injury

-Primary repair

Rectal injury (intraperitoneal)

-Consider primary repair
-Consider no diversion (stable patient)

Fig. 1. Flow diagram for management of anorectal injuries.

Historically rectal injuries have been managed following recommendations that came from experiences in the Vietnam War with
proximal diversion, debridement, drainage, possible distal rectal
washout and primary repair when feasible [13,14]. However, recent
evidence suggests that selected rectal injuries can be managed
without a colostomy [14]. Repair without diversion is most commonly
recommended for intraperitoneal rectal injuries in hemodynamically
stable patients [14], but some authors, in both adult and pediatric
populations, promote the use of selective diversion even for
extraperitoneal injury [4,7,15]. Bonnard et al. [7] reported successful
primary repair of a rectal injury without diverting colostomy in three
pediatric patients (two intraperitoneal, one extraperitoneal). Oztrk
et al. [4] similarly treated 21 pediatric patients with anorectal injuries
without diversion. Two of these patients required a colostomy for
management of postoperative complications (1 rectovaginal stula, 1
wound infection) [4]. Based on our review, we recommend primary
repair with diverting colostomy in patients with destructive injuries
involving the anus and rectum. Patients with an isolated intraperitoneal
rectal injury or injury to the anus without signicant soft tissue loss or
sphincter destruction may be managed without a colostomy (Fig. 1).
Evidence pertaining to the management and long-term outcomes
of complex anorectal injuries in children is limited. Fecal incontinence
has been reported in up to 19% [16] and anal stenosis in 11% of
children [17]. Although most series report long-term continence, the
extent of anal and sphincter injury is not well described [13,7]. When
examining our patients with injury to the anus, we included only
those children with injury to the anal sphincters. The majority of anal
injuries (n = 9) in our series were partial tears of the sphincter
complex that underwent immediate repair without diversion, and
none of these patients were incontinent at follow-up. Four patients
had extensive full-thickness and destructive injuries to the sphincter
complex associated with rectal injuries leading to management by

fecal diversion in addition to sphincter repair. Two of the four patients

are totally continent of stool. One of the four patients is incontinent
because of sacral nerve damage but is kept articially clean with a
daily large-volume enema. The patient who suffered a crush injury
from a garbage truck still has a colostomy caused by absent rectal tone
and a fragile skin-grafted perineum. In the future, he may be a
candidate for colostomy closure if he is able to be compliant with a
bowel management program.
Limitations of this study include the retrospective design and
small number of patients. Also, the follow-up was limited to the last
outpatient visit and it is possible that some of our patients
may have subsequently developed some degree of defecation
dysfunction. While 90% of our patients were continent at last
follow-up, stronger conclusions could be drawn with formal longterm continence evaluation.
4. Conclusions
Anorectal trauma in children is rare and often involves injuries to
the genitourinary system. These patients require a thorough evaluation which may include laparoscopy. With meticulous reconstruction
of the anal sphincter mechanism, most children with traumatic
anorectal injuries will experience long-term fecal continence. Patients
with more severe injuries, including those with nerve and destructive
crush injury, may benet from a structured bowel management
program similar to that used in patients with anorectal malformations.
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