Anal Trauma - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

Injury in the anal and rectal region of the body comprises anal trauma. Most injuries are due to penetrating trauma, sex-related activities, foreign body injuries, and accidental traumas. It is reported that gunshot wounds account for almost 85 percent to 90 percent of cases and about 5percent of stab wounds. Rectal or anal trauma treatment has significantly evolved over the past 80 years. The recognition of rectal injuries may require a very high level of suspicion as the leakage and injury can be restricted or unexposed. The trauma symptoms include difficulty in bowel movements, blood in the stool, burning sensation, and leakage.

How Common Is Anal Trauma?

The chances of rectal trauma in civilians account for almost 1 to 3 percent of cases; military conflict accounts for up to 5 percent of cases. The injuries from military conflicts involve very high-velocity wounds, blast injuries, and burns.

What Are the Causes of Anal Trauma?

The causes of anal and rectal trauma can be due to the following conditions and traumas:

• Sex-Related Traumas: Forceful sexual activities or assaults can lead to anal or rectal injuries such as lacerations, pelvis fractures, or even intense cuts and bleeding.

• Penetration Trauma: Forceful penetration or even insertion of other objects inside the anus during intercourse may lead to anal trauma.

• Foreign Body Injuries: Intentional or accidental hits by foreign bodies may lead to severe anal injuries like cuts, colon perforations, and even fractures.

• Gunshot Wounds: These type of injuries account for almost 90 percent of cases of anal trauma and severely affects the anal and rectal region.

• Stab Wounds: Forceful stabbing in the anal region.

• Blunt Trauma: This type of injury affects almost 1 to 2 percent of pelvic fractures and anterior-posterior compression cases.

• Bowel Functions: Severe constipation or diarrhea may also lead to anal traumas in some cases. These conditions can lead to pain, irritation, and damage to the skin around the anus.

• Muscle Spasm: Sometimes, muscles around the anus get stiff and lead to a tightening of the sphincter, making stool passing tough and painful.

What Are the Symptoms of Anal Trauma?

The symptoms of anal trauma depend on the type and severity of the cause behind the injury. Some of the symptoms are:

• Severe Bleeding: Bleeding can be continuous and severe or may be along with stool during bowel movements.

• When the person cannot move or change position due to severe pain or stiffness, there might also be difficulty sitting or standing and going through bowel movements.

• Fainting: In some cases, severe bleeding or serious blowout injury may lead to fainting or the feeling of passing out.

• Obstruction of any foreign object in the anus, which might be any sex toy or external object, must be removed immediately.

How to Diagnose Anal Traumas?

• The Advanced Trauma Life Support (ALTS) Program outlines the evaluation of a patient in trauma. The concept proposed by ALTS includes systemic evaluation consisting of a primary survey, resuscitation, and a detailed secondary survey of the patient. It is important to do an initial assessment of the patient before focusing on the anal region of the patient. The initial evaluation includes the identification of any immediate life-threatening injuries. The specific order given by ALTS is airway maintenance, breathing (ventilation), circulation (including hemorrhage control), disability (neurologic status), and exposure. Airway assessment and management are given the highest priority in any injured patient, irrespective of wound location or mechanism of a wound.

• The primary survey includes an examination of the perineum, buttocks, anal or groin folds, and lower gluteal region.

• Examination and recognition anal injuries require a higher level of suspicion in patients with penetrating wounds. This suspicion gradually increases with any penetrating wound in the lower abdomen, pelvis, perineum, buttocks, or thigh region.

• Hemodynamically stable, oriented, and alert patients should be asked about the detailed history of the trauma and the surrounding events. It is also necessary to take the patient's past medical history, including any surgeries, injuries, or social history.

• The standard examination technique for anal trauma is FAST which is focused assessment with sonography for trauma.

• Evaluation of the injury to look for fluid leakage indicating intra-abdominal hemorrhage, hollow viscus injury, ascites, or hemoperitoneum.

• Patients with positive FAST and stable conditions are further evaluated with computed tomography, which helps to locate the severity of the injury. However, unstable patients are evaluated by the surgeons in the operating room.

What Is the Treatment for Anal Trauma?

The treatment of anal trauma depends on the type and severity of the injury and the patient's physiological and anatomical state.

• Patients who are hemodynamically stable or unstable with massive blood loss, hypothermia, acidosis, or coagulopathy directly go to the operating room, and a damage control operation is performed on them.

• For hemodynamically stable patients, the rectal injury is repaired depending on the anatomy and severity of the wound. As the anus and rectum are partially extraperitoneal and partially circumferential, the management depends majorly on the part of the injury. The repair of intraperitoneal wounds is similar to colon injuries consisting of primary repair, which may involve or not involve proximal diversion.

• The patients should also receive broad-spectrum antibiotics, covering gram-negative and anaerobes for almost 24 hours after the injury.

• If the injury is destructive, which means greater than 50 percent circumferential involvement, the anus or rectum may require resection and anastomosis of the tissue. However, if the injury is non-destructive, less than 50 percent of the circumferential region, it can be easily repaired.

• In some severe injuries to the anus, fecal diversion may be considered, which should be performed after taking into account all the possible complications of ostomies.

• Health professionals should manage cases of fractures surgically to stabilize the part of the pelvic region.

Conclusion:

Anal trauma is caused due to injury in the anal and rectal region due to several causes such as gunshot wounds (majority of cases), blunt traumas, bowel dysfunctions such as constipation or severe diarrhea, sexual assault, and foreign body penetration. The injury assessment is done by a standard method known as ALTS (the advanced trauma life support program). The injury treatment depends on the injury's anatomy and the patient's physiological state. It is important to treat the injury immediately as it may lead to further complications and infections in the anal region.