Rectal injury can occur in the upper rectum, located above the pelvic peritoneal reflection, or in the lower rectum, situated below the reflection. The clinical manifestations differ between these two regions. Injuries to the upper rectum present clinical features similar to those of colon rupture, while injuries to the lower rectum can lead to severe infections in the perirectal space. In the absence of symptoms of peritonitis, the diagnosis of lower rectal injury may be delayed.
Clinical manifestations of extraperitoneal rectal injury include:
- The passage of blood or urine from the anus.
- Fecal leakage from open wounds in the perineum, sacrococcygeal region, buttocks, or thighs.
- The presence of fecal debris in the urine.
A digital rectal examination may reveal positive findings, and occasionally the rupture site in the rectum can be palpated. If rectal injury is suspected but the digital examination is negative, a colonoscopic examination may be performed when necessary.
Surgical approaches for rectal and perineal injuries should be tailored to the location and severity of the injury. The general principles of rectal injury management are early and thorough debridement, repair of rectal lacerations, diversion with a colostomy, and comprehensive drainage of the perirectal space.
For ruptures in the upper rectum, an abdominal approach is used for repair. If the injury involves destructive damage, resection followed by end-to-end anastomosis is performed, along with a double-barrel colostomy in the sigmoid colon. The stoma is typically closed 2–3 months later.
For ruptures in the lower rectum, extensive drainage of the perirectal space is necessary to prevent the spread of infection. A sigmoid colostomy is performed to divert fecal flow until the rectal wound has fully healed.