Chapter 12 — Anorectal Trauma, Sexual Assault, and Foreign Bodies

Purpose: anorectal injury is often hidden by embarrassment, intoxication, or fear — assess it like trauma, treat the person with dignity, and never let an extraction or examination cause more harm than the injury.

🎨 INFOGRAPHIC / VISUAL BLUEPRINT — CHAPTER 12

• Chapter colour palette: Charcoal Red (#7F1D1D) header bar, Pale Rose (#FEF2F2) panels, Near-Black Red (#450A0A) text.
• Hero graphic: Three parallel lanes: (1) trauma — primary survey, CT, surgeon; (2) foreign body — X-ray, relax the sphincter, break the vacuum, remove, inspect; (3) sexual assault — consent, injuries, forensic referral, and a prophylaxis bundle with a 72-hour clock (HIV PEP) and a 120-hour clock (emergency contraception).
• Icon set: Shield, X-ray film, Foley balloon, evidence bag with chain-of-custody tag, emergency contraception packet, HIV PEP bottle, heart (psychological support), padlock (confidentiality).
• Bedside aphorism banner: “Believe, protect, document — then treat. Relax the sphincter before you pull.”

1. Blunt and Penetrating Anorectal Trauma

Table 12.1 — Mechanisms, assessment, and principles

2. Rectal Foreign Bodies

Be non-judgemental: objects may have been inserted for sexual, therapeutic, or self-harm reasons, during intoxication, or by another person. Ask privately whether the patient was harmed or coerced.

Table 12.2 — Foreign body assessment and removal

3. Sexual Assault — Trauma-Informed Care

• Safety and privacy first: a quiet room, a chaperone, a clinician of the patient’s preferred gender where possible, and a professional interpreter (never a relative).

• Consent is separate for each step: examination, forensic sampling, photography, and sharing information. The patient may decline any part at any time; assess capacity.

• Treat injuries first. Then offer referral to a forensic or sexual-assault service where available; forensic evidence is most useful when collected early, but sampling windows differ — follow local forensic guidance [L]. Keep clothing in paper bags and maintain the chain of custody.

• Absence of injury does not mean absence of assault [C].

• Involving the police in adult cases depends on the patient’s consent and local law; children and vulnerable adults follow safeguarding law (Chapter 14) [L].

Table 12.3 — The post-assault medical bundle

4. Documentation Principles

Table 12.4 — Documentation after assault, injury, or foreign body

5. Who Else to Involve [L]

Algorithm 12.1 — Injury, foreign body, or disclosed assault

[ANORECTAL INJURY, FOREIGN BODY, OR DISCLOSED ASSAULT]
|
+-- PRIMARY SURVEY: airway, breathing, circulation;
|   peritonism, heavy bleeding, sepsis, toxidrome?
|     -> RED: resuscitate; senior surgeon (+ toxicology)
|
+-- FOREIGN BODY
|   -> X-rays (+ CT if perforation suspected); ask:
|      sharp? high? perforated? drug packets?
|      +-- yes to any -> theatre / senior surgeon /
|      |   toxicology pathway; never grasp packets
|      +-- low, smooth, intact -> analgesia + sedation +
|          perianal block -> break the vacuum -> remove
|          -> proctosigmoidoscopy for mucosal injury
|
+-- TRAUMA (blunt, penetrating, impalement)
|   -> CT; proctosigmoidoscopy if injury suspected;
|      sphincter and perineal assessment; surgeon decides
|      repair or diversion (EAST 2016)
|
+-- SEXUAL ASSAULT (disclosed or suspected)
    -> private room, consent for each step, chaperone
    -> injuries first; forensic referral if wanted
    -> HIV PEP within 72 h; emergency contraception
       up to 120 h; STI prophylaxis; hepatitis B and
       HPV vaccines; tetanus
    -> safeguarding (all minors), psychological support,
       follow-up; police only per consent and law

6. Dangerous Mimics

Table 12.5 — Hidden injuries and disguised presentations

7. Role-Targeted Action Boxes

🚑 ER DOCTOR ACTION BOX

• Never pull a foreign body against a contracted sphincter — relax it first, and take glass or sharp objects to theatre.
• Start HIV PEP early when indicated — every hour counts within the 72-hour window.
• Look for associated injuries (urethra, vagina, pelvis) in every anorectal trauma.

🩺 FAMILY MEDICINE / GP CLINIC BOX

• Ask gently and privately when anorectal injuries or unexplained bleeding do not fit the story.
• Arrange follow-up for PEP adherence, repeat HIV and syphilis testing, vaccines, and psychological support.

🏥 ER & WARD NURSE CARE AND SBAR BOX

• Trauma-informed nursing: explain every step, ask before touching, offer a chaperone, and let the patient stop at any time.
• Preserve evidence (paper bags, labelled and sealed samples) only with consent; maintain the chain of custody.
• SBAR escalation: peritonism, fever above 38.0 °C, heart rate above 110/min, or ongoing bleeding after foreign-body removal.

💊 CROSS-SPECIALTY PRESCRIBING TRAP

• HIV PEP interactions: check other medicines (for example, polyvalent cations reduce integrase-inhibitor absorption).
• Doxycycline in pregnancy: avoid — use pregnancy-appropriate regimens.
• Naloxone for opioid toxicity in body-packers may need repeated doses or an infusion.

⛔ NEVER DO THIS

• Never grasp, cut, or puncture drug packets.
• Never perform a blind DRE when glass or a sharp object may be present.
• Never examine, photograph, or collect samples from an assault survivor without specific consent.
• Never use judgemental language in notes or conversation.
• Never let forensic procedures delay treatment of serious injury.

📝 COMMON DOCUMENTATION ERROR

• Missing time stamps for PEP, emergency contraception, and samples.
• Opinions instead of observations, and paraphrase instead of the patient’s quoted words.

📨 REFERRAL URGENCY BOX

The Patient in Front of You — Chapter 12 Mini-Case

🧑‍⚕️ THE PATIENT IN FRONT OF YOU

A 25-year-old woman attends 30 hours after a sexual assault involving anal penetration. She has anal pain and bleeding, is frightened, and is unsure whether she wants police involvement. Observations are normal.

Step 1 Make her safe and in control: private room, chaperone, her preferred clinician gender, and consent for each step.

Step 2 Treat injuries: gentle examination with consent; document findings with a body diagram and her quoted words.

Step 3 Medical bundle now: HIV PEP (within 72 hours), emergency contraception (within 120 hours if vaginal exposure is possible), STI prophylaxis per CDC 2021, hepatitis B and HPV vaccination if needed.

Step 4 Forensic and support: offer forensic referral without pressure; police only with her consent (per local law); psychological support and follow-up at 24 hours, 4–6 weeks, and 12 weeks.

Board-Style Question — Chapter 12

A 34-year-old man presents 8 hours after inserting a glass bottle. He has mild pain, no peritonism, and X-rays show a low rectal object without free air. What is the best management?

• A. Blind digital extraction in the ER without sedation
• B. Oral laxatives to help it pass
• C. Removal under anaesthesia in theatre, followed by endoscopic inspection of the rectum
• D. A large-volume enema

Answer and explanation

• ❌ A Blind extraction against a contracted sphincter risks breaking the glass and lacerating the rectum and the examiner.
• ❌ B Laxatives can push a breakable object against the rectal wall.
• ✅ C Correct. Glass is breakable and sharp-edged if fractured, so removal should be under anaesthesia with full sphincter relaxation, followed by inspection for mucosal injury (WSES-AAST 2021).
• ❌ D Enemas may push the object higher or cause injury.

Ten-Item Rapid Revision Checklist — Chapter 12

• 01 I complete a primary survey before focusing on the anorectum.
• 02 I image foreign bodies before examining, especially if glass or sharp objects are possible.
• 03 I know the indications for theatre removal.
• 04 I relax the sphincter and break the vacuum before removal.
• 05 I inspect the rectum after removal.
• 06 I never handle drug packets and use the toxicology pathway.
• 07 I obtain consent separately for each step after sexual assault.
• 08 I give HIV PEP within 72 hours and emergency contraception within 120 hours when indicated.
• 09 I document objectively with time stamps and quoted words.
• 10 I involve safeguarding, psychology, and other teams appropriately.

Five Most Dangerous Mistakes — Chapter 12

1. ⚠️ Pulling a glass foreign body in the ER and breaking it.
2. ⚠️ Missing a perforation because the patient looked well after removal.
3. ⚠️ Delaying HIV PEP while waiting for forensic or police decisions.
4. ⚠️ Examining or photographing an assault survivor without explicit consent.
5. ⚠️ Puncturing a drug packet during attempted removal.

Suggested Figure and Table Captions for the Medical Illustrator — Chapter 12

• Figure 12.1. The three-lane pathway: trauma, foreign body, sexual assault.
• Figure 12.2. Foley catheter technique to break the vacuum behind a smooth foreign body.
• Figure 12.3. Post-assault prophylaxis timeline (72-hour and 120-hour clocks).
• Table 12.1. Anorectal trauma: mechanisms, assessment, and principles.
• Table 12.2. Foreign body assessment and removal.
• Table 12.3. The post-assault medical bundle.
• Table 12.4. Documentation principles.
• Table 12.5. Hidden injuries and disguised presentations.
• Algorithm 12.1. Injury, foreign body, or disclosed assault.