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The Journal of Trauma: Injury, Infection, and Critical Care

Issue: Volume 47(2), August 1999, pp 385-388


Copyright: © 1999 Lippincott Williams & Wilkins, Inc.
Publication Type: [Case Reports]
ISSN: 0022-5282
Accession: 00005373-199908000-00031

Rectal Blowout by Personal Watercraft Water Jet: Case Report and Review of Liter
ature
Philpott, Jonathan M. MD; Ng, Peter C. MD; Wixon, Christopher L. MD; Haisch, Car
l E. MD; Hoey, Brian A. MD; Kiesnowski, Brian MD, MPH; Crombie, Courtney H. MD;
Walker, Jamie S. MSN; Meade, Paul G. MD; Foil, M. Beth MD
From the Department of Surgery, East Carolina University, School of Medicine, an
d the University Health Systems of Eastern North Carolina, Greenville, North Car
olina.
Carl E. Haisch, MD, Professor of Surgery, Trauma & Critical Care, Department of
Surgery, East Carolina University School of Medicine, Greenville, NC 27858.
Injuries sustained from personal watercraft are becoming more frequent as the po
pularity of the watercraft increases. [1-9] This is the first report of a trauma
tic disruption of the external anal sphincter and a full thickness perforation o
f the rectosigmoid colon caused by the water jet of a personal watercraft. This
case emphasizes the potentially destructive force generated by these craft and r
eiterates warnings from the United States Coast Guard (USCG) and industry manufa
cturers recommending wet suit pants for personal watercraft occupants.

CASE REPORT
A 15-year-old female passenger on a personal watercraft (Waverunner; Yamaha Moto
r Corp., Cypress, Calif) fell off the rear as the craft accelerated from rest. S
he landed supine in the water and immediately experienced severe abdominal pain.
As she was pulled into a nearby boat, her family noted her bathing suit wedged
between her buttocks and watery, bloody stool running down her legs. She was tak
en to a local hospital, where she underwent a brief period of resuscitation, and
was then transferred to our regional Level I trauma center by air ambulance. On
arrival, she complained of severe, diffuse abdominal and rectal discomfort. Phy
sical examination revealed a rigid abdomen with rebound tenderness and guarding.
Visual inspection of the perineum revealed perianal lacerations and watery, blo
ody stool coming from the anus. Digital rectal examination demonstrated negligib
le sphincter tone.
The patient was taken to the operating room for examination under anesthesia. Sp
eculum and bimanual examination revealed no obvious gynecological injuries. Rigi
d sigmoidoscopy was attempted, but was unsuccessful because of an inability to k
eep the rectum insufflated with air. As the examination continued, her abdomen b
ecame increasingly distended and tympanic.
We proceeded with exploratory laparotomy and encountered massive fecal contamina
tion of the peritoneal cavity. Exploration revealed a 1 x 8 cm perforation of th
e anterior rectum above the peritoneal reflection and a small 2 x 2 cm hematoma
at the base of the mesentery. The rectal perforation was debrided and closed in
two layers, and a proximal diverting colostomy was performed. No other injuries
were noted, but peritoneal soilage was extensive. Stool was impacted under both
hemidiaphragms and into the mesentery, omentum, and bowel wall. Despite 16 liter
s of irrigation and vigorous scrubbing with laparotomy pads, stool remained impr
egnated in the peritoneal tissues. At the end of the case, the rectosigmoid was
irrigated with Betadine solution, and the presacral space was drained.
The patient's postoperative course was uncomplicated. By day 3, she was ambulato
ry, her colostomy was functional, and she was begun on a progressive diet. Becau
se of the extensive contamination, 7 days of antibiotics were administered; fort
unately, she demonstrated no infectious complications. At discharge, anal sphinc
ter tone and anal rectal reflex remained markedly abnormal.
Outpatient manometric anorectal physiologic testing was performed on postoperati
ve day 17. Resting sphincter pressure was 10 to 20 mm Hg (normal 60-90 mm Hg), a
nd squeeze pressure was 25 to 70 mm Hg (normal 1.5-2.0 times the rest pressure).
A rectal balloon could be sensed at 20 cc of air insufflation. Bilateral pudend
al nerve terminal motor latency was normal (2.0 +/- 0.2 ms). Endorectal sonograp
hy demonstrated a complete disruption of the external sphincter anteriorly.
After 6 weeks, her perineal laceration was nearly healed, and her resting sphinc
ter tone normalized. She was started on an intermittent enema-training program.
After 4 months of training, she was able to remain continent to instilled water,
and a repeat endorectal sonogram revealed that the external sphincter muscles h
ad healed. She underwent colostomy takedown, and 5 months after injury, she was
continent to both stool and flatus, and she resumed normal activity.

DISCUSSION
From 1990 to 1995, there was a fourfold increase in injuries related to personal
watercraft use. Currently, the rate of occurrence of emergency department injur
ies attributable to personal watercraft use is 8.5 times higher than that attrib
utable to the use of motorboats. [1] The majority of these injuries involve coll
isions with bridges, docks, or other watercraft, but occasional high-speed water
impact injuries and water jet injuries have been described. This case represent
s two previously undescribed injuries from the water jet of a personal watercraf
t: a traumatic disruption of the external anal sphincter, and a full thickness r
ectal perforation with extensive intraperitoneal soiling. Although similar mecha
nisms of injury have previously been reported, they describe injuries to the uro
genital tract (Table 1). [10-13]
Graphic Table 1
The mechanism by which personal watercraft are propelled is a water jet generate
d by an impeller located within the watercraft. Although the engines are compose
d of two or three cylinders (65-135 horsepower), they generate enough thrust to
propel the craft to speeds of 50 to 70 mph. [3,14,15,] This requires considerabl
e force, given that a modern personal watercraft may weight between 300 and 600
pounds. [3,14,15] Although data available to consumers regarding the hydrodynami
cs of personal watercraft are limited because most companies consider this infor
mation to be professional "industry secrets," one company, Kawasaki Motor Corpor
ation, does publish thrust specifications. [16] The thrust listed for the Kawasa
ki line of crafts ranges between 595 and 800 psi, [16] a Figure justbelow the ra
nge commonly used for industrial cleaning (1000-10,000 psi).
The highly destructive potential of water jets has been previously well document
ed; it includes major gastrointestinal, vascular, and soft tissue trauma. [17-22
] The kinetic energy imparted by the water jet is equal to the product of the ma
ss of the water and the velocity squared (KE = mv2). Given the high velocity of
the water jets used in personal watercraft, it is not surprising that they can i
mpart significant kinetic energy to a patient and cause significant injuries.
The pattern of tissue damage described in industrial water jet case reports is a
lmost identical to that seen in cases of high velocity missile trauma. [17-22] A
lthough injuries typically involve small, innocent-appearing skin penetration si
tes, devastating deep tissue trauma occurs as the kinetic energy from the water
jet disperses. In contrast to a high velocity missile, however, is the continuou
s nature of the water jet. Injuries to the extent noted in this case are therefo
re entirely consistent with the force generated by these vehicles.
A highly similar pattern of injury to the one described in this case has been ob
served in high velocity water impacts-the most common mechanism being a fall whi
le water-skiing (Table 2). This event, also referred to as the "water skier's do
uche," describes a douche of water forcefully injected into the vagina or rectum
when a water skier falls backwards (typically while being pulled from a startin
g position) and the perineum crashes into the water. In both water-skiing and pe
rsonal watercraft jet injuries, the water is traveling at a high velocity relati
ve to the individual. Predictably, the patterns of injury are similar as water i
s forced into the vagina or the rectum. Twenty-three rectal and vaginal injuries
similar to the ones in this case have been reported from all forms of high velo
city water impacts [23-43] (Table 2). In no case was the victim wearing a wet su
it.
Graphic Table 2
As in the water impact cases, there are no reported cases of perineal or rectal
water jet injuries occurring with the use of a wet suit. A wet suit is recommend
ed during personal watercraft operation to provide protection against water jet
contact, traumatic high velocity water impact, and also to protect the skin agai
nst lacerations resulting from collisions with fixed objects. The Personal Water
craft Industry Association and the USCG both recommend that the minimal attire i
nclude a half or full wet suit and a USCG inherently buoyant Type II lifejacket,
which will turn an unconscious person face up; a Type III lifejacket will not.
[44-46] For maximum protection, they also recommend wearing gloves to protect fr
om cuts and lacerations, and goggles to protect from traumatic water impact inju
ries to the eyes. [44-47]
These safety recommendations, however, remain largely ignored by the public -- p
rimarily as a result of a serious degree of public ignorance of the potential da
ngers involved in personal watercraft use and inadequate regulation of personal
watercraft use. The recent explosive popularity of personal watercraft has made
effective public safety education and regulation extremely difficult.
The personal watercraft industry needs to promote public education of required s
afety equipment and the dangers of improper personal watercraft use. Although on
e owner's manual does specifically warn of potential "serious rectal or vaginal
injuries" that could result from the water jet, [47] the mention is brief, and t
he ultimate potential for injury is not clearly defined. In addition, we were un
able to locate any scientific reports detailing the capability of a wet suit to
protect against 800 pounds of thrust. Will all brands of wet suits provide adequ
ate protection, or just some of them? Personal watercraft manufactures and the P
ersonal Watercraft Industry Association should take a leading role in wet suit t
esting so that industry safety standards can be developed and promoted.

CONCLUSION
This is the fifth reported injury from a personal watercraft water jet. The inju
ry could have been prevented or minimized if the occupant had worn proper protec
tive equipment. Her lack of protective equipment is attributable to inexperience
and ignorance of the dangers involved in personal watercraft use, and is repres
entative of the fundamental lack of consumer knowledge regarding the potential d
angers involved in personal watercraft use. A wet suit should be required as min
imal equipment to guard against high velocity water impact and water jet injurie
s.
Acknowledgments
The authors acknowledge Dr. Jean Luc Scemaa, Gunda Smith, and Per K. Audresen, f
or their assistance with the translation of the French and Swiss articles cited
in the bibliography.

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