What is the treatment for a rectal tear?

Management of Rectal Tears

For rectal tears, the treatment approach depends on the severity, location, and associated complications, with conservative management recommended for uncomplicated tears and surgical intervention for complicated cases.

Assessment and Diagnosis

• A focused medical history and complete physical examination, including digital rectal examination, should be performed for all patients with suspected rectal injury 1
• Laboratory tests should include complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactates) to assess the patient's clinical status 1
• In hemodynamically stable patients, contrast-enhanced abdomino-pelvic CT scan should be performed to detect associated complications, without delaying appropriate treatment 1
• Imaging should not delay management in hemodynamically unstable patients 1

Treatment Algorithm

Conservative Management

• For uncomplicated rectal tears without signs of ischemia or perforation:
  • Attempt gentle manual reduction under mild sedation or anesthesia 1
  • Position patient in Trendelenburg position during reduction attempts 1
  • Conservative measures may include:
    • Topical application of granulated sugar or hypertonic solutions to reduce edema 1
    • Submucosal infiltration of hyaluronidase to decrease edema 1
    • Elastic compression wrap to force edema fluid out of the prolapse 1

Surgical Management

• Immediate surgical intervention is required for patients with:

  • Signs of shock 1
  • Gangrene or perforation of rectal tissue 1
  • Hemodynamic instability 1

• Urgent surgical intervention is indicated for:

  • Bleeding 1
  • Acute bowel obstruction 1
  • Failure of conservative management 1

Surgical Approach Selection

• For patients without peritonitis or hemodynamic instability, the choice between abdominal and perineal procedures should be based on patient characteristics and surgeon expertise 1
• For patients with peritonitis, an abdominal approach is suggested 1
• For hemodynamically unstable patients, an abdominal open approach is recommended 1
• In patients requiring resectional surgery, the decision between primary anastomosis (with or without diverting ostomy) and terminal colostomy should be based on the patient's clinical condition and risk of anastomotic leakage 1

Pharmacological Management

• Empiric antimicrobial therapy should be administered in cases with strangulated tissue due to risk of intestinal bacterial translocation 1
• The antibiotic regimen should be tailored based on:
  • Patient's clinical condition 1
  • Individual risk for multi-drug resistant organisms 1
  • Local resistance epidemiology 1

Important Considerations and Pitfalls

• Failure to recognize or repair rectal tears increases the risk of fistula formation and incontinence 2
• The failure rate of conservative management for complicated rectal tears is high; therefore, conservative measures should not delay surgical treatment when indicated 1
• Systematic examination of the rectum should be performed after all procedures to assess for occult damage 2
• Traditional practices such as presacral drainage and distal rectal washout for extraperitoneal injuries have been associated with increased abdominal complications and should be avoided 3
• Timing of surgical intervention after failed conservative management remains controversial, but surgery should not be delayed in cases with overt gangrene, perforation, or shock 1