Complete anal sphincter complex disruption from intercourse: A case report and literature review

[Tom]

Please note that this has been published under the Obama
administration, and that the subject in this case report is
black.

Enjoy.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437385/figure/fig00
10/

Abstract
INTRODUCTION

Anal sphincter injuries are uncommon injuries outside of
obstetric practice – but they may cause disastrous complications.

PRESENTATION OF CASE

We present a case of complete anal sphincter disruption from
anal intercourse in a 25 year old woman. Clinical management is
presented and technical details of the repair are discussed. She
had an uneventful post-operative course and good continence
after 154 days of follow up.

DISCUSSION

This is one of a handful of reported cases of anal sphincter
disruption secondary to anal intercourse. The established risk
factors in this case included receptive anal intercourse coupled
with alcohol use. We review the pertinent surgical principles
that should be observed when repairing these injuries, including
anatomically correct repair and appropriate suture choice. There
is little evidence to support simultaneous faecal diversion for
primary repair of acute perineal lacerations.

CONCLUSION

Acute post-coital sphincter injuries should be treated
operatively on an emergent basis, without diversion because they
are low energy injuries with minimal tissue loss and excellent
blood supply. Although repair of each injury should be
individualized, the majority of these injuries do not require
concomitant protective colostomy creation.

Keywords: Anal sphincter injury, Severe perineal laceration,
Colostomy
Go to:
1. Introduction
Anal sphincter injuries may cause disastrous complications
including perineal cellulitis, enteric fistulae and faecal
incontinence. These are uncommon injuries in civilian practice
so there is little evidence upon which to base management
decisions. We present a case in which anal intercourse led to
complete anal sphincter complex disruption and discuss the
management of these injuries.

Go to:
2. Case presentation
A 25 year old woman presented to the Emergency Department
complaining of severe perineal pain and bleeding after
intercourse. She reported that her partner was inebriated and
aggressively pursued un-protected anal intercourse despite
resistance. Her vital signs were normal upon presentation. The
abdomen was soft and non-tender. Examination of the perineum
revealed the presence of a laceration at the anal mucosa,
extending through the entire thickness of the anal sphincter
complex into the vagina (Fig. 1). The ends of the sphincter
complex had retracted laterally. There was minor bleeding
originating from the lacerated edges of the perineal muscles.
Apart from the laceration at the introitus, the vaginal
examination was normal.

Fig. 1

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437385/figure/fig00
05/

Fig. 1
The mucosa at the vaginal introitus has been lacerated (arrows)
and the laceration extends posteriorly through the sphincter
complex.
The patient consented to examination and repair under
anaesthesia. One gram of intravenous Cefuroxime was administered
for prophylactic at induction of anaesthesia. The sphincter ends
were not visualized as they had retracted laterally. Lateral
dissection beneath flaps of anal mucosa was required to identify
and retrieve the sphincter ends (Fig. 2). The sphincter ends
were mobilized (Fig. 3), the edges overlapped for 2 cm (Fig. 4)
and then apposed with three 1/0 polypropylene (Prolene®)
mattress sutures (Fig. 5). The perineal muscles were
individually repaired with 2/0 polyglactin (Vicryl®) sutures and
this was followed by repair of the rectal and vaginal mucosa
with 3/0 polyglactin (Vicryl Rapide®) sutures (Fig. 6). A
diverting colostomy to protect the repair was not employed in
this case.

Fig. 2
Fig. 2
The vaginal laceration has been extended and the anal flaps
developed laterally to allow identification of the retracted
sphincter ends (arrows).
Fig. 3
Fig. 3
The sphincter ends have been identified. They are grasped with
forceps to allow mobilization.
Fig. 4
Fig. 4
The sphincter muscle is completely mobilized to allow for a 2 cm
overlap at the midline (arrows).
Fig. 5
Fig. 5
Overlapped repair of sphincter muscles with three interrupted
mattress type sutures (arrows).
Fig. 6
Fig. 6
Repair of the vaginal mucosa over the sphincter complex
reconstruction.
Post-operatively, the area was cleaned daily with sitz baths.
Since this injury was detected and repaired early, no
therapeutic antibiotics were administered. This patient's post-
operative recovery was normal and she reported a Cleveland
Clinic Incontinence Score of 1 at the time of hospital discharge.

At 154 days follow up, the area had healed uneventfully and
there was good continence, with a Cleveland Clinic Incontinence
Score of 0. She was discharged from surgical care at this point.

Go to:
3. Discussion
Injuries to the anal sphincter are not uncommon in obstetric
practice, reportedly occurring in up to 6% of women after
vaginal delivery.1 However, anal sphincter injuries outside of
obstetric practice are much less common. Medical literature
contains few case reports2 and small case series3–5 documenting
civilian non-obstetric anal sphincter injuries from a variety of
causes.

This patient sustained sphincter injury during anal intercourse.
Only a handful of reported cases have been secondary to anal
intercourse, usually after sexual assault.2,4,5 There is a
greater propensity to develop injuries during anal compared to
vaginal penetration because the ano-rectal mucous membranes do
not provide sufficient lubrication for sexual intercourse.6
Injuries are usually heralded by anodyspareunia – pain during
receptive anal intercourse.6 The risk increases without use of
condoms6 and with the use of alcohol and other recreational
drugs,6 both of which were present in this case.

There are several potential dangers with anal intercourse
including transmission of communicable diseases,7,8 mucosal
lacerations,6 faecal incontinence6 and injury to the anal
sphincters.2–5 We expect the incidence of anal injuries to
increase parallel to the rising prevalence of anal intercourse
in homosexual6 and heterosexual relationships.9,10 It is
estimated that up to 40% of men and 35% of women engage in
heterosexual anal intercourse.9,10 Of course the prevalence of
this activity varies by demographics and nationalities, ranging
from a low of 3.5% of survey respondents in South Korea11 to a
high of 18.5% of survey respondents in France.12

Most genito-anal injuries are minor and only require symptomatic
treatment. Rectal perforations and sphincter injuries, while
much less common, demand emergent operative intervention. This
patient sustained a severe perineal laceration. These
lacerations can be graded according to their depth, with fourth
degree lacerations being the most severe and representing
completely transected anal sphincters and overlying anal
mucosa.1 These injuries are accompanied by serious morbidity in
over 50% of cases, even after early detection and repair.1 This
emphasizes the need for appropriate surgical treatment.

This case illustrates the pertinent surgical principles that
should be observed when repairing these injuries. It is
important for experienced staff to perform anatomically correct
repair.1 The mucosa should be approximated with absorbable sub-
mucosal sutures.13,14 And slowly absorbable or non-absorbable
sutures should be used to repair the anal sphincter,1,13,15
preferably by the overlap technique.15,16

The need for simultaneous diversion of feces is an area that is
under researched. Colostomies have been traditionally used to
reduce infectious morbidity by diverting faeces away from the
perineal repair. Loop sigmoid colostomies allow full diversion
of feces away from the distal bowel limb,17 are rapidly
constructed and easily closed without laparotomy. They are
readily accepted for secondary repairs and when patients develop
frank recto-vaginal fistulae,1 but the decision becomes less
clear for primary repair of acute perineal lacerations.

The medical literature contains only a few case reports and
small series with reports of colostomies during repair of acute
injuries, but the indications are elusive and its performance is
not standard.19,20 There is also a marked difference in expert
opinion, with 30% of coloproctologists but no obstetricians
recommending diversion for third or fourth degree tears in a
recent practice survey.1 Colostomies may also impair healing by
altering collagen metabolism in the de-functionalized
rectum.20,21 With attenuated mucosal defense and integrity,
there is increased microbe translocation and infectious
morbidity.22 Finally, there is a further 20% risk of potential
morbidity at the time of colostomy closure20–22 to consider.

We believe that post-coital anal sphincter disruptions should be
repaired without diversion because they are low energy injuries
with minimal tissue loss and excellent blood supply.
Furthermore, the trans-anal approach affords excellent exposure
of these injuries, abolishing the problem of difficult exposure
in the pelvis at laparotomy.

Go to:
4. Conclusion
Post-coital anal sphincter injuries are uncommon injuries. They
should be treated operatively on an emergent basis. Although
repair of each injury should be individualized, the majority of
these injuries do not require concomitant protective colostomy
creation.

Go to:
Conflict of interest
The authors have no financial and/or personal relationships to
declare as conflicts of interest that could inappropriately
influence their work.

Go to:
Funding
This work was completed without any external source of funding
and/or study sponsors.

Go to:
Ethical approval
Written informed consent was obtained from the patient for
publication of this case report and accompanying images. A copy
of the written consent is available for review by the Editor-in-
Chief of this journal on request.

Go to:
Authors’ contributions
Shamir O. Cawich contributed to study design, data collections,
data analysis and writing. Leslie Samuels contributed to study
design and writing. Ian Bambury and Cherian J. Cherian
contributed to study design, data collections and writing.
Loxley R. Christie and Santosh Kulkarni contributed to study
design and writing.

Go to:
References
1. Fernando R.J., Sultan A.H., Radley S., Jones P.W., Johanson
R.B. Management of obstetric anal sphincter injury: systematic
review and national practice survey. BMC Health Services
Research. 2002;2(9):1472–6963. [PMC free article] [PubMed]
2. Kirov G.K., Losanoff J.E., Kjossev K.T. Zoophilia: a rare
cause of traumatic injury to the rectum. Injury, International
Journal of Care of the Injured. 2002;33:367–368. [PubMed]
3. Jones J.G., Worthington T. Genital and anal injuries
requiring surgical repair in females under 21 years of age.
Journal of Pediatric and Adolescent Gynecology.
2008;21(4):207–211. [PubMed]
4. Hwa H.L., Chen S.C., Wu M.Z., Shun C.T., Liu S.K., Lee J.C.
Analysis of cases of sexual assault presenting at a medical
centre in Taipei. Taiwanese Journal of Obstetrics and
Gynecology. 2010;49(2):165–169. [PubMed]
5. Hilden M., Schei B., Sidenius K. Genitoanal injury in adult
female victims of sexual assault. Forensic Science
International. 2005;154(23):200–205. [PubMed]
6. Damon W., Rosser B.R. Anodyspareunia in men who have sex with
men: prevalence, predictors, consequences, and the development
of DSM diagnostic criteria. Journal of Sex & Marital Therapy.
2005;31(2):129–141. [PubMed]
7. Pauk J., Huang M.L., Brodie S.J., Wald A., Koelle D.M.,
Schacker T. Mucosal shedding of human herpesvirus 8 in men. New
England Journal of Medicine. 2000;343(19):1369–1377. [PubMed]
8. Huan X.P., Yin Y.P., Fu G.F., Jiang N., Zhang Q.Q., Zhang
X.N. High prevalence of sexually transmitted diseases among men
who have sex with men in Jiangsu Province, China. Journal of the
American Academy of Child and Adolescent Psychiatry.
2006;33(2):118–123. [PubMed]
9. Leichliter J.S., Chandra A., Liddon N., Fenton K.A., Aral
S.O. Prevalence and correlates of heterosexual anal and oral sex
in adolescents and adults in the United States. Journal of
Infectious Diseases. 2007;196(12):1852–1859. [PubMed]
10. Leichliter J.S. Heterosexual anal sex: part of an expanding
sexual repertoire? Sexually Transmitted Diseases.
2008;35(11):910–911. [PubMed]
11. Yi U.H., Sin J.S., Choe H.G. Sexual behaviour of Korean
women. Daehan Namseong Gwahak. 1999;1(3):177–185.
12. Sell R.L., Wells J.A., Wypdij D. Prevalence of homosexual
behaviour and attraction in the United States, United Kingdom
and France: results of national population based samples.
Archives of Sexual Behavior. 1995;24(3):235–248. [PubMed]
13. Grant A. The choice of suture and techniques for repair of
perineal trauma: an overview of evidence from controlled trials.
British Journal of Obstetrics and Gynaecology.
1989;96:1281–1289. [PubMed]
14. Kettle C., Johanson R.B. Absorbable synthetic versus catgut
suture material for perineal repair. Cochrane Database of
Systematic Reviews. 2010;6:CD000006. [PMC free article] [PubMed]
15. Fernando R., Sultan A.H., Kettle C., Thakar R., Radley S.
Methods of repair for obstetric anal sphincter injury. Cochrane
Database of Systematic Reviews. 2006;3:CD002866. [PubMed]
16. Fernando R.J., Sultan A.H., Kettle C., Radley S., Jones P.,
O’Brien P.M.S. Repair techniques for obstetric anal sphincter
injuries: a randomized controlled trial. Obstetrics &
Gynecology. 2006;107(6):1261–1269. [PubMed]
17. Morris D.M., Rayburn D. Loop colostomies are totally
diverting in adults. American Journal of Surgery.
1991;161(6):668–671. [PubMed]
19. Young C.W., Mathur M.N., Evers A.A., Solomon M.J. Successful
overlapping anal sphincter repair: relationship to patient age,
neuropathy, and colostomy formation. Diseases of the Colon and
Rectum. 1998;41(3):344–349. [PubMed]
20. Cook T.A., Deane D., Mortenson N.J.M. Is there a role for a
colorectal team in the management of severe third degree vaginal
tears? Colorectal Disease. 1999;1:263–266. [PubMed]
21. Kudsk K.A. Current aspects of mucosal immunology and its
influence by nutrition. American Journal of Surgery.
2002;183:390–398. [PubMed]
22. Khalid M.S., Moeen S., Khan A.W., Arshad R., Khan A.F. Same
admission colostomy closure: a prospective, randomized study in
selected patient groups. Surgeon. 2005;3(1):11–14. [PubMed]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437385/