Case Presentation A 33-year-old male, HIV-positive, sought emergency care for enterorrhagia and abdominal
pain after engaging in fisting seven days before admission. He was hospitalized, underwent
tests, and was treated with antibiotics while being observed, but he left the hospital
after four days of treatment. He required readmission due to anal pain associated
with bowel movements, though the bleeding complaint improved. Upon admission, there
were no abnormalities in the abdominal physical exam. A proctological examination
revealed a laceration in the right posterolateral region, extending 7 cm from the
anal border. Abdominal CT scan showed irregular wall thickening in the middle and
lower thirds of the rectum, with mesorectal fat densification and small adjacent gas
foci. A flexible sigmoidoscopy was performed, revealing a deep transmural linear laceration
starting at the pectinate line and extending about 8 cm cranially. The emergency department
team recommended surgery: suturing the laceration, presacral drainage, and loop sigmoidostomy.
The patient progressed well and was discharged on the seventh postoperative day.
Discussion The treatment of traumatic rectal injuries has evolved. Initially, it was based on
injuries occurring during armed conflicts, such as landmine explosions in the Vietnam
War. Traditionally, the treatment of extraperitoneal rectal injuries had four main
pillars: intestinal diversion, presacral drainage, distal rectal lavage, and local
repair. However, recent guidelines have abandoned presacral drainage due to higher
rates of local infections, as well as distal rectal lavage, which has not shown proven
benefits. Currently, despite controversy, ostomy is still recommended for patients
with full-thickness extraperitoneal rectal lacerations, as it reduces the rate of
infectious complications, even without affecting mortality. Surgical indications should
consider each case and the risk-benefit ratio of the morbidity associated with ostomy.
In the specific case described, the coloproctology team suggested conservative management,
given the time since the trauma (15 days) and the lack of systemic repercussions,
but the emergency team opted for surgical intervention.
Conclusion The practice of fisting is becoming increasingly popular, highlighting the need for
updated management approaches for post-traumatic rectal injuries.
