Anal Trauma And Foreign Bodies

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 classification system reflects the extent of injury caused by the object. This system 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 represent 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 examination 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: [email protected] 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

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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 foreign 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 remove an impacted foreign body. Extremely rarely, laparotomy is necessary 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 dealing 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 largebore operative proctoscope may assist in removal [1–6,8]. Anal dilation may be necessary, and in rare instances, anal sphincterotomy 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 nonbleeding 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].

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Anal trauma Traumatic injuries to the anus and anal sphincters are extremely rare. Abundant ischiorectal and gluteal soft tissues generally protect the sphincters 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 penetrating trauma. Traumatic injuries may be caused by impalement, straddle injuries, lacerations, 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 nature. 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 disorders has been shown to result in varying degrees of fecal incontinence as well. Transanal stapling procedures have been shown to result in anal sphincter injuries. The vast majority of these are fragmentation injuries to the internal anal sphincter. External sphincter damage has been reported, however. 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.

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Both patients with external sphincter defects had occasional incontinence for liquid stools [9]. By far the most common causes of anal sphincter injury are complications 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 episiotomy, and 4.5% to 23% for midline episiotomy [12]. Evaluation Initial evaluation should focus on the primary survey of the trauma victim. 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 documented. The number and site of previous episiotomies should be documented. 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 rectal exam is obviously essential in assessing the extent of injury. Actual sphincter integrity should be assessed, as well as sphincter tone and contractility. In the acute situation the anorectal physiology laboratory is often unavailable, but studies such as anal ultrasonography, electromyography (EMG), and manometry may be essential in the ultimate evaluation 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.

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Management Initial management should focus on debridement of all devitalized tissue and open drainage to prevent perineal sepsis. Nonbleeding superficial lacerations may be left open. Deeper mucosal or anodermal lacerations, especially 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 isolated 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 associated 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 elective situation, anorectal physiology laboratory evaluation is helpful to determine 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 ischiorectal 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 laterally 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.

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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 performed 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 nonabsorbable 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 tissues approximated. The skin edges can either be left open or closed primarily. 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, pudendal 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 circumstance, 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 nonstimulated. 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 erosion, 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

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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-vascularized 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 supply 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 underwent 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 transposition 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. Immediate 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

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injuries, either immediately or in a delayed fashion. A review of the clinical environment will dictate the procedure chosen. References [1] Kingsley AN, Abcarian H. Colorectal foreign bodies: management update. Dis Colon Rectum 1985;28:941–4. [2] Barone JE, Yee J, Nealon TF. Management of foreign bodies and trauma of the rectum. Surg Gyn & Obstet 1983;156:453–7. [3] Barone JE, Sohn N, Nealon TF. Perforations and foreign bodies of the rectum. Ann Surg 1976;184(5):601–3. [4] Busch DB, Starling JR. Rectal foreign bodies: case reports and a comprehensive review of the world’s literature. Surgery 1986;100(3):512–9. [5] Crass RA, Tranbaugh RF, Kudsk KA, et al. Colorectal foreign bodies and perforation. Am J Surg 1981;142:85–8. [6] Elam AL, Ray VG. Sexually related trauma: a review. Ann Emerg Med 1986;15:576–84. [7] Fry RD. Anorectal trauma and foreign bodies. Surg Clin N Amer 1994;74(6):1491–505. [8] Scholfield PF. Foreign bodies in the rectum: a review. J R Soc Med 1980;73:510–3. [9] Ho YH, Tsang C, Tang CL, et al. Anal sphincter injuries from stapling instruments introduced transanally. Dis Colon Rectum 2000;43:169–73. [10] Abramowitz L, Sobhani I, Ganansia R, et al. Sphincter defects the cause of anal incontinence after vaginal delivery? Dis Colon Rectum 2000;43:590–8. [11] Belmonte-Montes C, Hagerman G, Vega-Yepez PA, et al. Anal Sphincter injury after vaginal delivery in primiparous females. Dis Colon Rectum 2001;44:1244–8. [12] Warshaw JS. Obstetric anal sphincter injury: Incidence, risk factors, and repair. Semin Colon Rectal Surg 2001;12:90–7. [13] Ternent CA. Direct sphincter and pelvic floor repair. Semin Colon Rectal Surg 1997;8:93–102. [14] Fang DT, Nivatvongs S, Vermeulen FD, et al. Overlapping sphincteroplasty for acquired anal incontinence. Dis Colon Rectum 1984;27:720–2. [15] Gordon LL, Birnbaum EH. Fecal Incontinence: putting it all together. Semin Colon Rectal Surg 2001;12:131–7. [16] Jorge JMN, Wexner SD. Etiology and Management of fecal incontinence. Dis Colon Rectum 1993;36:77–97. [17] Baeten CG, Bailey HR, Bakka A, et al. Safety and efficacy of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 2000;43:743–51. [18] Buie WD. Dynamic graciloplasty for fecal incontinence: the current status. Semin Colon Rectal Surg 2001;12:108–14. [19] Whitehead WE, Wald A, Norton NJ. Treatment options for fecal incontinence. Dis Colon Rectum 2001;44:131–44. [20] Mavrantonis C, Wexner SD. Stimulated graciloplasty for treatment of intractable fecal incontinence. Dis Colon Rectum 1999;42:497–504. [21] Deveas JM, Fernandez JM. Bilateral gluteoplasty for anal incontinence. Semin Colon Rectal Surg 1997;8:103–9. [22] Fleshner PR, Roberts PL. Encirclement procedures for fecal incontinence. Perspect Colon rectal Surg 1991;4:280–97. [23] Christiansen J, Lorentzen M. Implantation of artificial sphincter for anal incontinence. Dis Colon Rectum 1989;32:432–6. [24] Aitola PT, Congilosi SM. Artificial anal sphincter: the current status. Semin Colon Rectal Surg 2001;12:115–20. [25] Lehur PA, Roig JV, Duinslaeger M. Artificial anal sphincter: prospective clinical and manometric evaluation. Dis Colon Rectum 2000;43:1100–6. [26] O’Brien PE, Skinner S. Restoring Control: the ActiconTM Neosphincter artificial bowel sphincter in the treatment of anal incontinence. Dis Colon Rectum 2000;43:1213–6.