Staged management of complete traumatic anorectal disruption following penetrating perineal gunshot injury in a child: A case report

Introduction: Complete traumatic disruption of the anorectal sphincter in children is rare and surgically challenging. High-grade penetrating injuries with delayed presentation and heavy fecal contamination carry significant risks of pelvic sepsis and long-term continence impairment. Case presentation: A previously healthy 12-year-old boy presented three days after a perineal gunshot injury due to delayed referral from a peripheral facility. Examination revealed extensive soft-tissue destruction with complete circumferential disruption of the anal canal and sphincter complex (fourth-degree perineal injury). He was hemodynamically stable. Contrast-enhanced CT demonstrated extensive perineal soft-tissue disruption with associated soft-tissue emphysema extending into the gluteal region and comminuted coccygeal fracture fragments, without evidence of intraperitoneal visceral injury. Initial management included intravenous antibiotics, conservative debridement preserving viable sphincter tissue, and sigmoid colostomy. Ten days later, delayed perineal reconstruction and anoplasty were performed with re-approximation of residual sphincter musculature. The large perineal skin defect was reconstructed using bilateral medial thigh V–Y advancement flaps. Six months later, colostomy closure was performed after a distal contrast study confirmed intact repair without leak or stricture. From the time of colostomy closure until two months of follow-up, the patient demonstrated voluntary sphincter contraction and continence for formed stool without soiling. Conclusion: In pediatric penetrating anorectal trauma with delayed presentation, early fecal diversion followed by delayed anatomical reconstruction is safe and effective. Preservation of all viable sphincter musculature is critical to the functional outcomes.