Surg Clin N Am 82 (2002) 1253–1260

Anal trauma and foreign bodies

Michael D. Hellinger, MD*
Division of Colon and Rectal Surgery, DeWitt Daughtry Family Department of Surgery,
University of Miami School of Medicine, Miami, FL 33136, USA

Foreign bodies
Anorectal foreign bodies can either be ingested orally or inserted anally.
Although the vast majority are inserted for autoerotic purposes, they may
have been placed iatrogenically, or as a result of assault or trauma. Ingested
objects are rarely a cause of entrapped foreign bodies. Most often these are
bones that become impaled in the anal canal. Iatrogenic foreign bodies include
thermometers, enema tips, and catheters. Objects placed as a result of assault,
trauma, or eroticism represent a diverse collection, including sex toys; tools
and instruments; bottles, cans, and jars; poles; pipes and tubing; fruits and
vegetables; stones; balls; balloons; umbrellas; light bulbs; and flashlights.
Classification of the level of entrapment has helped stratify the likelihood
of transanal extraction. Those in the low or mid rectum, up to a level of 10
cm., most often can be removed transanally. Those above this level, in the
upper rectum, may require laparotomy for retrieval [1]. An alternative clas-
sification system reflects the extent of injury caused by the object. This sys-
tem stratifies injury into four categories. Categories one, retained foreign
body without injury; and two, nonperforative mucosal laceration, are the
most straightforward. Sphincter injury and rectosigmoid perforation repre-
sent categories three and four, and are much more serious injuries [2].

Evaluation
A history and physical examination should be followed by biplanar
abdominal films. These films will help ascertain the position of the object
and the presence or abscess of free intra-abdominal air. Digital rectal exam-
ination and anoscopic evaluation can reveal an injury to the anal canal or

* University of Miami/Sylvester Comprehensive Cancer Center, 1475 NW 12th Avenue,

Room 3550 (310-T), Miami, FL 33136.
E-mail address: mhelling@med.miami.edu

0039-6109/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 9 - 6 1 0 9 ( 0 2 ) 0 0 0 6 4 - 6
1254 M.D. Hellinger / Surg Clin N Am 82 (2002) 1253–1260

sphincter mechanism. Proctoscopic evaluation to rule out rectal injury is

imperative after extraction. If more than a superficial injury is found or if
there is persistent bleeding, patients need to be admitted to the hospital for
observation and possible surgical intervention. A water-soluble contrast
enema study may be useful in evaluating for radiolucent objects, and when
perforation is suspected.

Management
The majority of objects are easily removed in the emergency department.
Relaxation is essential and sedation is often necessary to retrieve these for-
eign bodies, however. Admission with a period of observation may allow an
object to drop down lower in the rectum, allowing for bedside extraction.
Local anesthetic injected into the anal sphincters can assist with relaxation
and extraction. The awake patient may be able to assist with a valsalva
maneuver. Less commonly, spinal or general anesthesia is necessary to re-
move an impacted foreign body. Extremely rarely, laparotomy is neces-
sary to remove an object. This may allow for trans-abdominal manipulation
and transanal extraction. It may be necessary to perform a colotomy to
remove the object, however. Ingenuity and patience are essential when deal-
ing with these patients [1,3–8].
Numerous instruments have been used to assist with extraction, including
obstetrical forceps, tenaculum, ring forceps, and a vacuum extractor. Snares
have been utilized to loop an object. Often the vacuum created as the object
is pulled distally precludes removal. A Foley catheter passed proximally will
break the seal. With the balloon inflated, traction on the Foley may assist in
removal. Even a Sengstaken-Blakemore tube has been used. Authors have
reported filling a hollow object with plaster of Paris and placing a tongue
blade into it as a handle, drilling holes in objects to release the seal, placing
screws in to them for traction, and even sectioning objects. Use of a large-
bore operative proctoscope may assist in removal [1–6,8].
Anal dilation may be necessary, and in rare instances, anal sphinctero-
tomy may be required. Lateral internal sphincterotomy may be safely
performed without any long-term alteration in continence. It may also
be safer and more controlled a procedure than aggressive dilation. A complete
anal sphincterotomy with immediate repair has also been reported with
success when all else fails [1,4,7].
Following extraction, the anorectum must be thoroughly evaluated to
rule out an occult injury that requires further intervention. Superficial non-
bleeding rectal injuries may be left alone. Those that are bleeding or that
involve the muscular wall require repair. Perforative injuries to the rectum
should be managed as any other traumatic rectal perforation. These injuries
may require primary repair or resection, diversion, presacral drainage, or
rectal irrigation. Management of injuries to the anus is discussed in the
following section on anal trauma [1–3,7,8].
 M.D. Hellinger / Surg Clin N Am 82 (2002) 1253–1260 1255

Anal trauma
Traumatic injuries to the anus and anal sphincters are extremely rare.
Abundant ischiorectal and gluteal soft tissues generally protect the sphinc-
ters and pudendal nerves from all but the most severe of traumatic injuries.
In addition, the abundant blood supply to the region promotes healing and
diminishes the risk of tissue necrosis. In fact, it is not uncommon to see deep
injuries to the perineum without anal sphincter injury. When traumatic
forces are strong enough, however, perineal injury may be so extensive that
the anus can separate from surrounding tissues.

Etiology
By far the most frequent causes of anal trauma are iatrogenic sources.
These include obstetrical injuries, as well as injuries caused by anorectal
procedures. Other less common potential causes include injury from enema
tips and rectal thermometers, as well as foreign bodies, and blunt or pene-
trating trauma.
Traumatic injuries may be caused by impalement, straddle injuries, lacer-
ations, blast or gunshot wounds, and even fist fornication. Blunt trauma to
the perineum can result in extensive tissue loss and even disruption of the
levator sling. Associated pelvic fracture certainly can contribute to anal
canal or sphincter injury.
Various anorectal procedures have been complicated by anal sphincter
injury. Partial lateral internal sphincterotomy is obviously a procedure
designed to incise a portion of the internal sphincter. The procedure may
lead to varying degrees of partial incontinence, which is temporary in na-
ture. Inadvertent incision of external sphincter is possible, however, and
may lead to adverse long-term sequellae.
Anal sphincter injury following hemorrhoid surgery is also extremely
rare. It may be possible if the anal sphincters are inadvertently injured. Anal
fistula surgery is the anorectal procedure most often followed by fecal
incontinence. Minor degrees of incontinence may occur with division of
minimal amounts of sphincter, especially in the anterior location. As long
as the anorectal ring remains intact, however, major incontinence should
be avoidable. Anal dilatation for the treatment of various anorectal dis-
orders has been shown to result in varying degrees of fecal incontinence
as well.
Transanal stapling procedures have been shown to result in anal sphinc-
ter injuries. The vast majority of these are fragmentation injuries to the
internal anal sphincter. External sphincter damage has been reported, how-
ever. In one study, 27% of patients suffered internal sphincter injury, and
11% were found to have external sphincter injuries identified by endoscopic
ultrasound following transanal stapling procedures. None of the patients
with internal sphincter injuries suffered an alteration in continence, however.
1256 M.D. Hellinger / Surg Clin N Am 82 (2002) 1253–1260

Both patients with external sphincter defects had occasional incontinence

for liquid stools [9].
By far the most common causes of anal sphincter injury are complica-
tions of vaginal delivery. Perineal tears are extremely common. Laceration
to the anal sphincters or anal canal may be the result of deep tears or an
extensive episiotomy, however. Factors associated with an increased risk
of injury include high birth weight babies, primigravidas, previous tears,
instrumentation, and midline versus mediolateral episiotomy. Estimated
rates of sphincter injury range from 0.25% to 23%, and up to 75% of these
may develop varying degrees of fecal incontinence [10–12]. In one study, the
use of instrumentation to assist in delivery increased the rate of sphincter
injury to nearly 50% [11]. The use of the vacuum extractor increases the risk
of injury nearly threefold, and forceps increases the risk up to sevenfold [12].
With regard to sphincter injury and episiotomy, the rate of disruption is
0.25% to 2.6% without an episiotomy, 0% to 4% with a mediolateral episiot-
omy, and 4.5% to 23% for midline episiotomy [12].

Evaluation
Initial evaluation should focus on the primary survey of the trauma vic-
tim. Once all life-threatening injuries have been identified and attended to,
the secondary survey may be completed. At this point, identification of anal
injuries can be undertaken. A detailed history and physical should allow for
identification of these injuries and associated complaints. Specifically,
aspects of sphincter function and continence should be addressed. A past
history regarding anorectal surgery and obstetrical issues should be docu-
mented. The number and site of previous episiotomies should be docu-
mented.
In addition, the extent of incontinence for solid and liquid stool and gas
should be ascertained. In the acute traumatic situation, the injury is usually
fairly evident. Sphincter injuries may go unrecognized, however. Digital rec-
tal exam is obviously essential in assessing the extent of injury. Actual
sphincter integrity should be assessed, as well as sphincter tone and con-
tractility. In the acute situation the anorectal physiology laboratory is
often unavailable, but studies such as anal ultrasonography, electromyo-
graphy (EMG), and manometry may be essential in the ultimate evalua-
tion of patients. Iatrogenic injury is most often identified at the time of the
surgical procedure, and should be addressed accordingly.
In blunt or penetrating trauma, the initial evaluation should document
the extent of soft tissue injury and loss and the degree of contamination.
Associated pelvic and perineal injuries should be identified. This may
require urological or gynecological evaluation. Assessment of sphincter
integrity and mucosal/anodermal laceration is imperative in the evaluation
of these patients. Anoscopy is essential, and proctosigmoidoscopy should
be undertaken to rule out associated rectal injury.
 M.D. Hellinger / Surg Clin N Am 82 (2002) 1253–1260 1257

Management
Initial management should focus on debridement of all devitalized tissue
and open drainage to prevent perineal sepsis. Nonbleeding superficial lacer-
ations may be left open. Deeper mucosal or anodermal lacerations, espe-
cially those that are bleeding, may require suture repair. Most patients
with isolated superficial injuries who are otherwise stable may be discharged
after examination and treatment in the emergency facility.
If sphincter injury is identified, a decision must be made as to whether or
not to perform an immediate repair. Internal sphincter or limited external
sphincter injuries may be safely left unrepaired without risking subsequent
fecal incontinence. In an otherwise stable patient with minimal tissue loss,
primary sphincter repair may be undertaken. To accomplish a tension-free
repair after tissue debridement, overlapping sphincteroplasty is not usually
possible and end-to-end repair should be performed. Closure of the anal
mucosa should assist in orienting perineal structures.
The use of a diverting stoma and drains depends on the extent of perineal
tissue damage. Creation of a diverting stoma is not usually necessary in iso-
lated anal trauma, but should be considered if there is extensive perineal
injury or rectal injury. It can be especially advantageous when the anus is
floating free of surrounding structures. It may also be easier for a patient
to manage a stoma rather than deal with severe fecal incontinence.

Anal sphincter repair

Numerous approaches to direct anal sphincter repair have been described,
including sphincter plication, end-to-end repair, the Park’s postanal repair,
and overlapping sphincteroplasty. By far the most effective technique has
been shown to be the overlapping repair. Other techniques have been associ-
ated with a high rate of failure, especially in the delayed setting, and have been
largely abandoned. Due to tearing of sutures and splaying of muscle ends, a
failure rate of up to 42% has been noted for direct end-to-end repair [13].
Overlapping sphincteroplasty is most often the procedure of choice for
patients with obstetrical injury or limited anal sphincter trauma. In the elec-
tive situation, anorectal physiology laboratory evaluation is helpful to deter-
mine the extent of sphincter injury and associated pudendal nerve injury. A
mechanical bowel preparation and intravenous antibiotics should be given
to all patients preoperatively.
Sphincteroplasty is performed via a curved perineal incision between the
anus and vagina. The rectovaginal septum is separated to a depth above the
anorectal ring. The sphincter ends are then identified laterally in the ischior-
ectal fossae. It is imperative not to excise the scar tissue, because it will hold
the sutures for the repair. Dissection is continued to free the sphincter later-
ally so that the edges may be overlapped anteriorly around the anus. Care
must be taken not to dissect too far posteriorly, because the pudendal nerves
traverse the ischiorectal fossae slightly posterior to the horizontal midline.
1258 M.D. Hellinger / Surg Clin N Am 82 (2002) 1253–1260

Once the dissection is complete, if there is continuity via scar tissue of the
muscle ends, this should be transected. At this point the ends are wrapped
around the anus as far around as possible so that the resultant anal orifice
just allows placement of an examining finger. The overlapping repair is per-
formed with interrupted horizontal mattress sutures using the retained scar.
This should prevent the sutures from pulling through. Most often, three to
four sutures are used on each side of the repair. Either a long lasting or non-
absorbable monofilament suture should be used for this repair. Anterior
levatoroplasty may be performed at the time of sphincter repair to further
lengthen the anal canal. This should be performed before suturing the edges
of the sphincter into position.
Following this, the perineal body should be reconstructed and the soft tis-
sues approximated. The skin edges can either be left open or closed primar-
ily. Most often the initial horizontal incision must be closed vertically or in
a Y fashion, as the reconstructed perineal body has greatly increased the
distance between anus and vaginal introitus. Tension on this repair may
preclude skin closure in some instances.
This technique provides good to excellent results in the majority of
patients; however, success depends on adequate residual muscle mass, an
intact neuromuscular bundle with detectable sphincter contraction, and
retention of scar tissue from the severed muscle ends [13–16]. Although not
a contraindication to repair, bilateral, or in some studies unilateral, puden-
dal neuropathy is a predictor of poor outcome [13,15]. Good to excellent
results have been reported in 70% to 90% of patients [15,16]. In general,
this translates into a 75% to 80% reduction in incontinence episodes, but
success may diminish over time [15].

Muscle transposition
In circumstances where there is extensive injury to either the sphincters,
perineum, or pelvic floor, or pudendal nerve damage has occurred, it may
not be feasible to primarily reconstruct the anal sphincters. In this circum-
stance, transposition of either the gluteal or gracilis muscles may be feasible.
Transposition may be used to fill a large soft-tissue defect, or for actual
sphincter reconstruction.
Gracilis muscle transposition involves harvesting the gracilis muscle and
forming a wrap around the anal canal. This may be stimulated or nonstimu-
lated. The stimulated or dynamic graciloplasty converts a fast-twitch muscle
to a slow-twitch muscle capable of sustained activity. This stimulation gives
the gracilis muscle properties required to maintain sustained contraction
and function as a sphincter. Initial success has been achieved in 60% to
85% of patients in reported trials [16–19]. Due to device failure, device ero-
sion, or infection, however, the long-term success rate is in the range of 40%
to 45% [18–20]. The most common risk for failure is major infection, which
has been reported in 13% to 29% of patients. In addition, approximately
 M.D. Hellinger / Surg Clin N Am 82 (2002) 1253–1260 1259

20% of patients may suffer from constipation or obstructed defecation,

which usually can be managed conservatively [18].
The gluteal muscle has the advantage of being a large, strong, well-vascu-
larized muscle in close proximity to the anal canal. This eliminates the need
for disfiguring thigh incisions. In addition, the gluteal muscle functions as an
accessory muscle in maintaining continence [21]. The dual neurovacular sup-
ply makes this muscle suitable for partial transposition. Bilateral flaps of the
gluteal muscle are taken, based on the inferior gluteal vessels and nerves.
The flaps are split and passed anterior and posterior to the anal canal from
each side and sutured in an overlapping position. The opposing pull from
both muscles creates a valve-like sling around the anus. In reported trials,
good to excellent results have been achieved in 60% to 90% of patients
[21,22]. Because this muscle is only partially transposed, there is no adverse
effect on hip and thigh mobility. Infectious complications are most common,
and have been reported in 35% to 43% of patients [21].

Artificial sphincter
Christiansen and Lorentzen first reported implantation of an artificial
device for anal sphincter reconstruction [23]. Their initial patients under-
went implantation of a modified artificial urinary sphincter. Since that time,
a dedicated artificial anal sphincter has been developed. This device, the
Acticon Neosphincter (American Medical Systems, Minnetonka, MN), has
emerged as a viable option for anal sphincter replacement in patients who
have failed primary repair, suffer from concomitant neuropathy, or have lost
too much sphincter to undergo such repair. The system consists of a cuff
that is wrapped around the anal canal just below the top of the anorectal
ring, a pressure-regulating balloon placed within the pelvis, and a control
pump located in the scrotum or labia. Relative procedural simplicity makes
this an attractive option over the technically more demanding muscle trans-
position procedures.
Recent reviews of small clinical trials have shown a successful outcome in
60% to 75% of patients implanted. The rate of explantation due to infection,
erosion, or malfunction is in the range of 15% to 32%. Reimplantation
may be successful in up to 50% of these patients, however [24–26]. Long term
follow-up will be necessary to determine the longevity of success.

Summary
Although anal trauma is rare, iatrogenic injury is not uncommon. Imme-
diate recognition is vital to a successful outcome and may obviate the need
for a diverting stoma. Evaluation must include a search for involvement of
other structures and an evaluation of the anal sphincters. Foreign bodies
most often do not cause significant anorectal injuries. Extraction of these
diverse objects requires ingenuity. Superficial injuries may be left open or
sutured closed. There are number of options for repair of anal sphincter
1260 M.D. Hellinger / Surg Clin N Am 82 (2002) 1253–1260

injuries, either immediately or in a delayed fashion. A review of the clinical

environment will dictate the procedure chosen.

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