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102
S.B. Dharap
Table 8.1 Rectal injury grade
Grade Type of injury Description of injury
I Hematoma Contusion or hematoma
without devascularization
Laceration Partial-thickness laceration
II Laceration Laceration <50% of
circumference
III Laceration Laceration >50% of
circumference
IV Laceration Full-thickness laceration with
extension into the perineum
V Vascular Devascularized segment
Moore et al. (
1990 )
Laparoscopy: Laparoscopy is done to rule out
intraperitoneal injury in penetrating rectal
trauma, and in its absence, diverting sigmoid
colostomy alone can be carried out (without
formal laparotomy) to treat the extraperitoneal
rectal injury (Navsaria et al. 2001 ) .
8.4 Grade of Injury
Table 8.1 enlists different grades of rectal injury
as described by the Eastern Association of
Surgery for Trauma. However, practical decisions also depend on the site: intraperitoneal,
extraperitoneal, or anorectal.
8.5 Surgical Strategy
Surgical decisions for anorectal injuries depend
upon:
Hemodynamic stability: In an unstable patient,
damage control surgery is recommended and
should be limited to clearing immediate threats
to life, i.e., diverting the fecal stream by proximal colostomy, debriding the devitalized tissue, and drainage of the presacral space.
Condition of local tissues: If there is local tissue
loss with devitalization, edema, and gross
contamination, anastomotic leak is likely. In
such cases, proximal diversion is advisable. If
the local tissues are healthy, primary closure
can be attempted.
Anatomic location: Intraperitoneal (IP) rectal inju-
ries are managed like colonic injuries, and the
current evidence is in favor of primary closure
without diversion. Extraperitoneal (EP) rectal
wounds are diffi cult to access and therefore dif-
fi cult to close and hence theoretically can lead
to intra-abdominal sepsis, particularly in the
presacral area due to contamination from the
rectal contents, and thus evolved the concept of
routine use of proximal diversion, presacral
drainage, and distal rectal washouts (DRW).
This was extensively practiced in military set-
tings and later also applied to civilian settings
(Brunner and Shatney
1987 ; McGrath et al.
1998 ). But today, four points are often debated
in management of rectal injuries: (1) routine
use of proximal diversion, (2) primary closure
without diversion, (3) presacral drainage, and
(4) distal rectal washouts (DRW).
There is a theoretical risk of contamination of
the prerectal space with distal washouts (Tuggle
and Huber 1984 ). Ivatury et al. 1991 reported
safety of primary closure in rectosigmoid wounds
and usefulness of diversion and presacral drainage,
but did not fi nd evidence to support the use of
DRW (Ivatury et al. 1991 ). McGrath reported that
intraperitoneal injuries can be treated by primary
closure (McGrath et al. 1998 ). In those extraperito-
neal rectal tears which can be accessed and sutured
satisfactorily, presacral drain is probably not
required. But for those extraperitoneal tears which
are not accessible and diffi cult to suture, presacral
drainage is advisable to prevent presacral abscesses.
Gonzalez et al. also dismiss the utility of presacral
drain placement in preventing local septic complications (Gonzalez et al.
1998 ). Laparoscopy has
been advocated by Navsaria et al. to rule out intraperitoneal injury in penetrating rectal injury. They
have reported successful use of diverting sigmoid
colostomy without formal laparotomy for managing the extraperitoneal rectal injury without presacral drainage and DRW (Navsaria et al. 2001 ;
Navsaria et al. 2007 ). Weinberg et al. ( 2006 ) have
suggested a pathway based on anatomical location
of rectal injury (IP or EP) and have suggested that
omission of colostomy in most IP injuries and
selected EP injuries and judicious use of presacral
drainage to reduce the risk of retrorectal abscess in
8 Anorectal Injuries
103
Intra-peritoneal
Low velocity
primary closure, No
drain
Fig. 8.1 Algorithm showing management of rectal injuries, distal rectal washout ( DRW )
Hartmann’s
EP injuries (Weinberg et al. 2006 ). However,
Anorectal
Injury
High velocity
Tissue Loss
Extra-peritoneal
No tissue Loss
Diversion,
Presacral drainage
enough evidence was not found to categorically
support the practice of colostomy in open pelvic
fracture cases with rectal injury to prevent septic
complications (Lunsjo and Abu- Zidan 2006 ).
Gonzalez et al. reported that extraperitoneal nondestructive, penetrating rectal injures could be managed successfully without diversion and, however,
stated the need for a randomized controlled trial
(RCT) (Gonzalez et al. 2006 ).
Suggested algorithm for management of rectal
injury is shown in Fig. 8.1 .
Tissue Loss
DRW, Debridement
Diversion/Hartman
Presacral drainage
8.5.1 Technical Points in Surgery
Various controversial issues sometimes make
surgical decisions challenging. Burch et al. have
discussed the following technical points to
improve surgical outcome in these patients
(Burch et al. 1989 ).
Colostomy: The purpose of colostomy is com-
plete diversion of fecal stream from the
injury site. Cecostomy, “tube” colostomy, and
“window” colostomy or a sunken colostomy
are suboptimal and ineffective.
Site of colostomy: The sigmoid colon is preferred
unless there is severe destruction of the
Fig. 8.2 Spur of a loop colostomy
rectosigmoid, in which case transverse colostomy is carried out.
Type of colostomy: Loop colostomy is the sim-
plest to perform and also to close, but it is
important to make an adequate spur supported
by a rod which will ensure complete diversion
of fecal stream (Fig. 8.2 ). Proximal colostomy
with mucous fi stula is preferred if a segment
of sigmoid colon needs to be resected. End
colostomy with closure of distal stump
(Hartmann’s procedure) is preferred when
104
S.B. Dharap
Fig. 8.3 Site of insertion of a
presacral drain
there is destruction of the part of the rectum
and sigmoid. Abdominoperineal excision with
end colostomy may be done when there is
destruction of the sphincter as well.
Presacral drain: The drain is placed between
Waldeyer’s fascia and the rectum and is
brought out through the perineum through a
curvilinear incision between the anus and coccyx (Fig. 8.3 ).
Distal rectal washouts: This is usually carried
out after creation of the colostomy and closure
of the laparotomy wound. Lithotomy position
is given. Rectal stump is irrigated transabdominally through the distal stoma, while the
assistant stretches the anal canal to facilitate
evacuation of contents.
8.5.2 Anorectal Foreign Bodies
A variety of foreign bodies like sticks, bottles,
glasses, and cans have been reported. DRE
and plain X-ray of the abdomen and pelvis
usually clinch the diagnosis. It is important
not to embarrass the patient further by repeatedly asking as to how the foreign body went
in! Clinical examination to rule out signs of
peritonitis (abdominal tenderness, guarding,
and rigidity) is a must. In such a case, laparotomy will be required. Removal is challenging and various innovative methods have been
Rectum
Retrorectal
space
Waldeyer’s
fascia
Presacral drain
Levator ani
Anococcygeal
ligament
reported for the safe extraction of the foreign
body. Lithotomy position, good lighting, good
sedation to relax the sphincters, suprapubic
pressure, and use of appropriate devices for
extraction may help in removal of the foreign
body. In diffi cult cases general anesthesia with
muscle relaxation may be of help in achieving safe retrieval. If transanal manual extraction fails, endoscopy-guided retrieval may be
attempted. Laparoscopy-guided removal has
also been described (Coskun et al.
2013 ). At
times laparotomy and colotomy may be needed
for removal of the impacted or inaccessible foreign body (Cologne and Ault 2012 ).
It must be remembered that patient undergoing successful transanal extraction of foreign
body needs to be closely watched for signs of
full-thickness rectal tear in spite of the apparently
safe extraction, and if perforation is suspected,
CECT may be performed to rule out the same
(Cologne and Ault
2012 ).
8.5.3 Obstetric Anal Sphincter
Injuries (OASIS)
Perineal tears are common during delivery. Thirdand fourth-degree perineal tears involve the sphincter and the anal canal, respectively. It is associated
with primiparity, induced labor, epidural analgesia,
persistent occipito posterior position, prolonged
8 Anorectal Injuries
105
Fig. 8.4 Clinical photograph of an obstetric perineal
injury presenting several years later
second stage of labor, forceps delivery, and large
baby. In India, unattended home delivery could
be a factor. Diversion is generally not warranted
(Cawich et al. 2007 ). Identifi cation and primary
repair by a trained operator is the best option. Endto-end or overlapping repair of the external anal
sphincter is recommended using monofi lament or
braided delayed absorbable sutures. Postoperative
physiotherapy, laxatives, and antibiotics active
against both aerobic and anaerobic organisms are
advised (Royal college of Physicians of Ireland
2014 ). If untreated, patients may suffer from fecal
incontinence, fecal urgency, dyspareunia, and
perineal pain (Fowler 2010 ). Clinical examination
(Fig. 8.4 ) along with endoanal ultrasound is diag-
nostic. Surgical repair of the sphincter by overlapping sphincteroplasty is the treatment of choice.
8.5.4 Iatrogenic Anorectal Injuries
Although preventable in principle, iatrogenic
injuries do occur, The key issues which determine management are time of diagnosis (during
the procedure or later), size of the perforation,
state of preparation of the colon (for colonoscopy), extent of fecal contamination, and state of
the injured rectum (diseased or otherwise). If
diagnosed during the procedure, primary repair
can be done if there is no contamination. Small
puncture wounds can be treated conservatively.
Larger wounds have to be closed; which can be
achieved by endoscopic clipping, laparoscopic
suturing, or open surgical repair. Delayed diagnosis will usually need diversion due to sepsis
(Lohsiriwat
2010 ). Iatrogenic injury to infl amed
or diseased rectum will usually need diversion.
Extraperitoneal rectal injuries during extraperitoneal radical prostatectomy have been reported to
be successfully treated conservatively (Khoder
et al. 2009 ). Anal sphincter injuries have been
encountered during surgery for anal disorders
particularly for high fi stula-in-ano. If recognized
during surgery, primary repair has been advocated. In others who present later with incontinence, muscle transposition and artifi cial
sphincters are options (Sheikh 2008 ).
8.5.5 Closure of Colostomy
Diverting colostomy done for anorectal injuries
needs closure or reversal when the sphincters are
intact. The common practice is to close the colostomy by 4–8 weeks of its formation after confi rming the healing of the wound by distal
cologram.
The issues which are debated are: (1) optimal
time for closure, (2) preoperative distal cologram
for confi rming healing of rectal injury, and (3)
preventing morbidity after closure of colostomy.
A number of complications have been reported
after reversal of colostomy. More morbid complications are anastomotic leak with fi stula or peritonitis, anastomotic stricture, and postoperative
intestinal obstruction. Bern et al. have reported
signifi cantly higher morbidity after closure of
colostomy done for colonic injuries than that for
rectal injuries (Berne et al.
morbidity was also associated with delayed closure after initial surgery. This report thus favors
primary closure for colonic injuries and proximal
colostomy for rectal injuries and also supports
early reversal. Renz BM et al. have advocated
same admission colostomy closure (SACC) after
confi rming radiological healing of rectal wound
by contrast enema at 5–10 days after initial surgery (Renz et al. 1993 ). They practiced delayed
closure after 2 months in those who showed contrast leak. Pittman DM and Smith LE have recommended delayed closure of colostomy beyond
1998 ). The higher
106
S.B. Dharap
4–8 weeks in specifi c group of patients – those
with colonic injuries and those with associated
surgical complications at the time of creation of
colostomy (Pittman and Smith 1985 ). The rou-
tine use of distal cologram prior to colostomy
closure has been reported to have a low yield
(Madiba et al. 2000 ).
8.6 Outcome
8.6.1 Complications
Apart from sepsis and MODS which are often
encountered following major trauma, complications specifi c to anorectal injury are as follows:
infections, surgical site infection, buttock
abscess, buttock necrosis, pubic ramus osteitis,
septic arthritis, and pelvic abscess have been
reported (Navsaria et al. 2007 and Ivatury 1991 ).
Wound infection and pelvic sepsis are associated
with shock at presentation and more than 6 h
delay in treatment. Drain and washouts do not
seem to reduce the incidence of pelvic sepsis
(Shatnawi and Bani-Hani 2006 ). Rectocutaneous
and rectovesical fi stulae have been reported
(Navsaria et al. 2007 ). Anal stenosis can occur
following anorectal avulsion injuries and requires
appropriate treatment (Ibn Majdoub Hassani
et al. 2013 ).
Fecal incontinence following pelvic and perineal trauma should be assessed using clinical
examination, manometry, concentric needle electromyography, and endoanal ultrasound. Engel
et al. identifi ed external sphincter defects in 56 of
65 patients with posttraumatic (non-obstetric)
fecal incontinence and reported good outcome in
36 of 52 patients who underwent overlapping
sphincter repair (Engel et al.
1994 ).
8.6.2 Mortality
Brunner RG and Shatney CH have reported
higher morbidity and mortality for blunt rectal
injury due to higher number and severity of associated injuries (Brunner and Shatney 1987 ). In
general, mortality is related to shock at presentation, associated injuries, and more than 6 h delay
in treatment (Shatnawi and Bani-Hani 2006 ).
Conclusion
Although a relatively uncommon injury, the
management of anorectal injuries is challenging. Apart from the bleeding and sepsis
in an acute setting, anorectal injuries may
also cause delayed morbidity due to anal
incontinence and stenosis. Early diagnosis
and expeditious treatment is necessary for
control of hemorrhage which is an immediate threat to life and control of contamination which could prove life threatening due to
septic complications. Anorectal injuries are
more common after penetrating trauma than
blunt trauma. Rectal foreign bodies, obstetric
injury, and iatrogenic injury are other causes.
Inspection of the perineum and DRE in major
trauma patients can achieve early recognition
of injury. Thorough clinical examination is
mandatory as rectal injury is often associated with injuries not only to the pelvis, urethra, vagina, and lower abdomen but also to
other body parts. In a stable patient, anorectal
injury can be further confi rmed by proctoscopy and CECT scan (with rectal contrast).
All full-thickness rectal injuries need surgical management. Historically diversion,
debridement, drainage, and distal rectal
washouts have been advocated. However,
current evidence suggests that intraperitoneal rectal injuries can be safely managed by
primary closure alone. Diverting colostomy
is recommended in all unstable patients, in
the presence of contamination, in local tissue devitalization, and in case of inaccessible
extraperitoneal rectal tears. Patients with
rectal foreign bodies need to be observed for
rectal injury after the removal of the foreign
body. Obstetric injuries need early diagnosis and sphincter damage identifi cation and
repair by a trained person. Morbidity of iatrogenic injury can be minimized by recognizing it during the procedure or operation
itself; however, it is best to prevent it by taking appropriate precautions.
8 Anorectal Injuries
107
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Anal Incontinence
P. N. Joshi , Ashok Kumar , and Kiran Shah
9
9.1 Introduction
Continence may be defi ned as the ability to retain
solid or liquid stools and fl atus not only in various positions but also during physical exercise,
coughing, and sneezing. It is an acquired capacity to suppress the natural urge to defecate. Fecal
incontinence is the inability to control feces and
to expel it at a proper place and at a proper time.
It is a very distressing symptom which interferes
severely with social life. It is a socially and psychologically devastating condition for the family
and the patients. In India, its exact prevalence is
not known; however, in western population, the
prevalence is reported to be as high as 2.2 % in
the general population. According to one of the
survey in the USA, 14 % of the adult patients visiting their primary physician had experienced
P. N. Joshi (*)
Department of Proctology ,
Grant Medical College , Mumbai , India
drpnjoshi@rediffmail.com
e-mail:
A. Kumar
Department of Surgical Gastroenterology ,
Sanjay Gandhi Post Graduate Institute of Medical
Sciences , Lucknow 226014 , India
doc.ashokgupta@gmail.com
e-mail:
K. Shah
Proctologist, Department of General Surgery,
Saifee Hospital, Maharshi Karve Road,
Charni Road, Mumbai , India
alkiranshah@yahoo.in
e-mail:
fecal incontinence, and 10.5 % of them had
restricted their activity due to the condition
(Gupta 2007 ).
9.2 Anatomy of the Anal Sphincter Complex
Internal Anal Sphincter (IAS) It is the contin-
uation of the smooth muscle of the rectum and is
under control of the involuntary nervous system.
IAS is tonically contracted and contributes 80 %
of the resting pressure.
External Anal Sphincter (EAS) It is a striated
muscle, which is under voluntary control. The
muscle is innervated by the pudendal nerve (S2,
S3, S4), which remains partially contracted at rest.
It generates approximately 20 % of the resting
pressure in the anal canal. Inhibition of the EAS
during defecation allows the passage of stool.
Puborectalis Muscle (PRM)
sling around the anorectal junction with an angle
of approximately 90°, which closes the outlet and
prevents the passage of solid stool. It also remains
partially contracted at rest and derives nerves
from S2, S3, and S4. During normal defecation
with relaxation of the PRM and descent of pelvic
fl oor, the anorectal angle widens approximately
to 135° which facilitates the passage of stool.
It is a U-shaped
© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_9
109
110
P.N. Joshi et al.
Continence results from the interaction of a great
number of functions: consistency of stools, coordinated activity of the smooth and striated muscle in
the anorectum and pelvic fl oor, anatomic integrity
of these structures, integrity of autonomic innervations, anal spinal and cerebral refl exes.
9.3 Causes of Incontinence
There are various causes of incontinence; some
of them can be prevented while others can be corrected with reasonably good results.
9.3.1 Trauma
It can be secondary to obstetrical injury, accidental
injury, and anorectal surgery like fi stulotomy, hemorrhoidectomy, lateral internal sphincterotomy, etc.
The risk of fecal incontinence in obstetric injury
increases with the number of vaginal deliveries,
delivery of large baby, prolonged second stage of
labor, use of forceps, and episiotomy. The mechanism of incontinence is twofold: fi rst is the disruption of the sphincter muscle with neuropathy
(cause for early fecal incontinence), and second
is isolated pudendal neuropathy (late manifestation). Stretching of the pudendal nerve is one of the
important reasons for the idiopathic incontinence
in the middle-aged women. EMG and histopathology study have shown 80 % of denervation of
puborectalis muscle and external anal sphincter.
syndrome. In diarrhea, it is because of increased
volume of stool, rapid transit, and impaired rectal
sensation.
9.3.4 Congenital Disease
Megarectum and Hirschsprung’s disease
9.3.5 Pelvic Floor Denervation
It can be secondary to chronic straining at stool,
descending perineum syndrome, rectal prolapse,
and vaginal delivery.
9.3.6 Aging
It can lead to sclerosis of the IAS, increased fi ber
density in the EAS, and weakening of the pelvic
fl oor muscle, which are the causes of incontinence. In elderly and hospitalized patients, anatomical and functional outlet obstruction can lead
to incontinence.
9.3.7 Miscellaneous
Like laxative abuse
9.4 Clinical Evaluation
9.3.2 Neurological Conditions
Diseases like diabetes, multiple sclerosis, congenital anomalies, and tumors of the brain and
spinal cord can lead to autonomic dysfunction,
bacterial overgrowth, ingestion of hexitols, and
pancreatic insuffi ciency.
9.3.3 Diarrheal States
These occur secondary to infectious diarrhea,
infl ammatory bowel disease, and short gut
9.4.1 Medical History
The medical history gives an idea about how
severe the effect of incontinence is on social
activity and work. Past history of diffi cult childbirth and history of trauma and previous anorectal surgical operations should be listed. The
duration of the symptoms and their aggravation,
bowel habits, frequency, consistency of stool,
diet, rectal prolapse, gynecological and urinary
problems, associated neurological disease, metabolic disease, and radiotherapy should be asked
in detail.
9 Anal Incontinence
Table 9.1 Cleveland Clinic incontinence score
Type of
incontinence
Solid 0 1 2 3 4 4
Liquid 0 1 2 3 4 4
Gas 0 1 2 3 4 4
Wears pad 0 1 2 3 4 4
Lifestyle changes 0 1 2 3 4 4
0 perfect continence, 20 complete incontinence
Rarely <1/month, sometimes less than 1/weak, usually <1/day, always >1/day
Frequency
Never Rarely Sometimes Usually Always Always
111
Obstetric injuries are the major cause of
incontinence and psychosocial inhibitions in
developing countries delay the treatment.
The Cleveland Clinic (Wexner) fecal incontinence score takes into account fi ve parameters
that are scored on a scale from zero (absent) to
four (daily); frequency of incontinence to gas, liquid, and solids; the need to wear pad; and lifestyle
changes (Table 9.1 ) (Jorge and Wexner 1993 ).
9.4.2 Examination
Detailed anorectal examination is mandatory and
may reveal soiling of garments, scars of previous
surgery, size of a gaping patulous anus and
sphincter tone at rest and sphincter squeeze pressure, refl ex contraction when performing digital
examination, and fi brosis of the anal canal and
adjacent tissue. Also one should look for the
presence of a rectocele or a loose rectovaginal
septum, perineal descent in response to straining
or coughing with opening of the anal canal, and
complete rectal prolapse.
9.4.3 Investigations
Clinical evaluation as suggested by Hughes
should be adequate enough to assess the cause
and the severity of the condition allowing the
appropriate plan of action (Hughes et al. 1984 ).
9.4.3.1 Manometry
Manometry studies will confi rm the clinical fi ndings. They are useful in evaluating disorders
selectively affecting smooth or striated muscles.
These studies are useful particularly if biofeedback training is planned. Furthermore, they allow
precise evaluation of postoperative results. Anal
manometry determines the sphincter pressures,
sensation, rectal compliance, and anorectal
refl exes. It is measured by placing a balloon into
the rectum which detects the pressure changes.
Manometers use air, water perfusion systems, or
chips to sense the pressures.
Many different techniques are available,
including water-fi lled perfusion catheters, waterfi lled or air-fi lled balloons, sleeve catheter, and
pressure transducers. Microtransducers are the
most reliable catheters because they minimize
the distention of the anus; however the cost and
the fragility of these devices restrict their use.
The most commonly used sensory devices are 4
to 8 mm in diameter, water-perfused, soft, plastic,
and multichannel catheters with radial array.
Squeeze pressure can be measured by asking
the patient to contract the sphincter as the catheter is positioned in the pressure zone. Normal values of both resting and squeeze pressures vary
among patient population.
Rectal sensory testing includes volumetric
measurement of fi rst detectable sensation, sensation of fullness, and the maximum tolerated volume by balloon distension. Hypersensitivity can
be seen with infl ammatory conditions and poor
rectal compliance.
Compliance is measured by infl ating the rectal
balloon with increasing volume of air or water.
The result is expressed as the ratio of the pressure
to the volume ( C = P / V ). The compliance decreases
with infl ammation, fi brosis, drugs, or surgery.
The normal resting anal pressure is 40 mmHg,
and squeeze pressure is 80 mmHg, and these are
112
Fig. 9.1 Anal manometry
setup: high-resolution
impedance manometry
system. Electronic chips are
used for signal capture
(Diagram courtesy of
Dr. Uday C. Ghoshal)
P.N. Joshi et al.
Fig. 9.2 Saline perfusion system (Diagram courtesy of
Dr. Uday C. Ghoshal)
predominantly the functions of the internal and
external anal sphincters, respectively. The compliance refers to the change in volume of the rectum in relation to the change in p . Compliance
can change after surgical resection of the rectum
or irradiation.
The saline perfusion system has 16 channels
for sensing the pressure changes. The balloon is
infl ated manually to the desired volume (Figs. 9.1
and 9.2 ).
The lower part of the graph produced by the
saline perfusion system corresponds to the anal
canal, and the upper pressure corresponds to the
rectum (Fig. 9.3 ).
9.4.3.2 Measurement of Sphincter Strength
A method for quantitative evaluation of sphincter
strength has been described by Henriksen and
Huthouisen ( 1972 ). A 2 cm diameter ball is
inserted into the rectum. The force which is necessary to withdraw the ball is measured.
9.4.3.3 Anal Sphincter Electromyography (EMG)
It checks the health of the pelvic fl oor, muscles,
and the nerves that control the muscles. The average amount of electrical activity when the person
relaxes quietly, squeezes to prevent a bowel
movement, and strains to have a bowel movement shows whether there is damage to the nerve
that controls the external sphincter and pelvic
fl oor muscles are recorded by EMG (Fig.
9.4 ). It
measures the electrical activity of the striated
muscles, which includes the external anal sphincter and puborectalis. There are different methods
of performing EMG. It can be simultaneously
used with videoproctography to detect the electrical activity of the muscles.
The role of EMG in the treatment of anal
incontinence has reduced with the introduction of
EUS. The results of EMG do not really predict
the outcome of the sphincter repair. Today, EMG
seems to be relevant for sphincter mapping prior