The Journal of TRAUMA威 Injury, Infection, and Critical Care
Case Report
Colorectal and Vaginal Injuries in Personal Watercraft
Passengers
Sashil Singh Kapur, BA, and Lonnie Warren Frei, MD, FACS, FCCM
P
ersonal watercraft (PWC) usage has grown in the past
15 years. The increase in activity during this time has
been accompanied by an increase in injuries. A partic-
ular group of PWC-related injuries, rectal and vaginal inju-
ries, are being recognized with increasing frequency. We
report two cases of female passengers sustaining perineal
(rectal and vaginal) injuries after falling off the back of their
vehicles, and a review of the literature of these injuries.
CASE 1
A 15-year-old female passenger was thrown off the back
of a PWC as it accelerated. She landed on her back with her
legs thrown up in the air. She experienced perineal discom-
fort, but was able to swim over to the dock. She was noted by
her family to have bloody drainage on her legs as she climbed
onto the dock. She was brought to an emergency room, where
her main complaint was perineal discomfort and numbness.
She was given antibiotics. Rectal examination revealed a
patulous sphincter and obliteration of the anorectal junction.
A deep laceration in her perineum extended up to the vaginal
fourchette.
She was taken to the operating room, where vaginal
examination revealed no internal gynecologic injuries. The
perineal laceration extended deep into the pelvic soft tissues;
the anterior wall of the rectum was easily identified in the
depths of the wound. The anoderm was completely dissected
off the underlying muscular layers and had retracted up into
the distal colon. Rigid sigmoidoscopy could be performed
and, except for some mild ecchymotic areas of the rectal wall,
was normal. The anoderm and the rectum were reapproxi-
mated after the sphincter mechanism was repaired. The soft
tissues were drained. Because of concerns about continence,
a sigmoid colostomy was performed. Within 24 hours of
surgery, she noted some mild increase in sensation in the
perineum and rectal examination showed slight sphincter
Submitted for publication December 2, 2004.
Accepted for publication April 7, 2005.
Copyright © 2007 by Lippincott Williams & Wilkins
From the Department of Surgery, Saint Louis University, St. Louis,
Missouri.
Address for reprints: Lonnie W. Frei, MD, Department of Surgery,
3635 Vista at Grand, St. Louis, MO 63110; email: freilw@slu.edu.
DOI: 10.1097/01.ta.0000222533.97505.4e
Volume 63 • Number 5
J Trauma. 2007;63:1161–1164.
tone. She was discharged home after the colostomy began
functioning. She subsequently underwent colostomy closure
and is continent of both stool and flatus.
CASE 2
A 19-year-old female passenger was thrown off the back
of her PWC. She immediately experienced severe perianal
and diffuse abdominal pain. She was taken to a local com-
munity hospital where an abdominal and pelvic computed
tomography scan showed free air and fluid in the peritoneal
cavity. She was transferred to a trauma center. The patient
was mildly anxious and in moderate distress. She had mild
dyspnea, severe suprapubic and rectal pain, and diffuse ab-
dominal pain with rebound tenderness. Her vital signs were:
blood pressure, 110/52; heart rate, 88 bpm; respiratory rate,
20; temperature, 97.9°C; SaO2, 97% on room air. The rectal
examination revealed a 3-cm laceration of the posterior rectal
wall and a hematoma. She was given intravenous antibiotics
and was taken to the operating room for examination under
anesthesia and emergent exploratory laparotomy.
In the operating room, two rectal lacerations were iden-
tified, one posterior (Fig. 1) and the other posterolateral. The
larger laceration interrupted the external anal sphincter. Care-
ful examination found no lacerations communicating with the
vagina. Laparotomy revealed free air, with murky fluid in the
pelvic cul-de-sac. After careful examination, a rectosigmoid
perforation was found (Fig. 2). An end-colostomy was cre-
ated. Antibiotics were continued postoperatively. The patient
was discharged on the sixth postoperative day with subse-
quent colostomy closure planned.
DISCUSSION
There were a total of 1,070 PWC-related injuries reported
in the literature from 1985–2000 (table 1). Most studies
showed that the most common injuries from PWC accidents
were superficial blunt trauma (lacerations, contusions, sprains,
etc.).1– 8 Fractures were the second most common injury, fol-
lowed by head (brain) injuries and internal injuries (splenic
lacerations, liver lacerations, etc.). There was some variation in
the incidence of injuries among the studies, however.9,10 Not
including the case reports, there was only one reported vaginal
injury and one reported rectal injury, an incidence of 0.09%
each. In addition to the above referenced reports of injuries, six
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 The Journal of TRAUMA威 Injury, Infection, and Critical Care

Most of these involved a PWC colliding with another PWC,

Fig. 1. Posterior laceration through anal verge.
Fig. 2. Full-thickness perforation of rectosigmoid in pelvis.
case reports of PWC-related vaginal (three) or rectal (three)
injuries were found in the literature (table 2).11–13
Fatalities were uncommon among the population of
PWC-related injuries, occurring at a rate of 2.0% (21/1,070).
a stationary object, or a swimmer. The mean age of victims of
PWC injuries was in the mid-20s. Males were involved in
PWC-related injuries more than twice as often as females.
A personal watercraft is defined as a vessel that uses an
inboard motor powering a water jet pump as its primary source
of motive power, is less than 16 feet in length, and is designed
to be operated by a person sitting, standing, or kneeling on the
vessel. They are powered by two- or four-stroke engines (the
latter being the same type of engine used in cars) with up to 185
horsepower.14
Sales of PWC (s) reached an all-time high in the mid-1990s.
Units sold have been declining steadily since that time.15 Despite
the diminishing sales figures, the number of PWCs owned in the
United States has increased annually.16 From 1990 to 1995,
there was an estimated fourfold increase in the number of PWC-
related injuries, with a threefold increase in the number of PWCs
in operation.4 Increased popularity in PWC during this time and
increased usage led to a higher frequency of injuries.
Rectal and vaginal injuries have been uncommonly re-
ported in the literature, at 0.09%. Multiple authors suggest the
underreporting of PWC injuries.2–5,17 Case reports on rectal
injuries have been increasing recently, including this report
which presents two cases that occurred over a 2-year period.
The seriousness of these injuries mandates a high degree of
clinical suspicion to diagnose and appropriately treat them.
Rectal and vaginal injuries related to PWCs are very
serious injuries that can be potentially life-threatening. The
mechanism of this type of injury is due to a high-pressure jet
which can achieve pressures exceeding 800 PSI, approaching
the force of industrial pressure washers.18 If a driver or
passenger of a PWC falls off the rear of the vehicle in a
supine position with their legs splayed while the throttle is

Table 1 Literature Review of Personal Watercraft–Related Injuries

Injuries
Total Mean Male:
Deaths Superficial Closed
Study Year Injuries Fractures Internal Rectal Vaginal Age Female
Blunt Head

Vernberg et al.1 9/1985–8/1988 6 2 4 2 0 0 15.7

Hamman et al.2 1989–1991 94 0 31 17 10 1 0 0 65:21
Francis and 6/1991–10/1992 37 0 23 10 4 0 0 20.7 23:14
Vize3
Branche et al.4 1/1990–12/1995 624 * 50% 12% 0 0 25 442:182
Jeffery et al.10 1991 6 0 1 4 2 2 0 0 30
Swinburn11 1992–1996 6 1 1 4 2 0 0 31
Shatz et al.8 9/1991–6/1996 37 12 6 15 6 3 0 0 24 27:10
White and 1/1993–12/1997 68 0 70% 28% 13% 8% 0 0 26 45:23
Cheatham5
Jones6† 1994–1997 106 5 15 14 4 0 0 24 79:27
Haan et al.9‡ 8/1996–1/2001 24 0 0 1 30
Kim et al.7 1984–1997 62 1 51 32 8 9 1 0 23 41:21
Total 1070 21 1 1 722:298
Blank fields indicate values not assessed in respective study. Multiple injuries to a single patient are common.
* Study did not include fatalities; trauma.
† 53% of injuries in study were unspecified.
‡ Types of injuries not specified.

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 Personal Watercraft Injuries

Table 2 Case Reports of Personal Watercraft–Related Rectal and Vaginal Injuries

Passenger
Author Year Age/Sex Injuries Treatment
or Driver

Wein et al.12 1990 29/F Passenger 5-cm midline perineal tear, 10-cm tear Suturing of broad ligament, suturing
posterior vaginal fornix extending in layers of the vagina and
into the base of the left broad peritoneum
ligament, 5-cm defect in the
peritoneum of the pouch of Douglas
Haefner et al.13 1991 17/F Passenger 4-cm laceration right vaginal fornix Right hypogastric artery ligation
extending into broad ligament,
retroperitoneal hematoma
Muller14 1993 22/F Passenger 7-cm right vaginal laceration, 4- to Ligation of arteries, suturing of
5-cm left vaginal laceration, bilateral lacerations, placement of Penrose
pudendal artery lacerations, right drain
vaginal artery laceration
Parsons et al.15 1999 30/F Passenger 4-cm laceration posterior rectum Loop sigmoid colostomy with
12-cm from the anal verge transanal drainage of presacral
space
Philpott et al.16 1999 15/F Passenger Peritoneal fecal contamination, 8-cm Proximal diverting colostomy, 16-L
laceration of anterior rectum, 2-cm irrigation, Betadine irrigation
mesenteric hematoma
Descottes et al.17 2003 16/M Passenger 5-cm laceration anterior sigmoid None, death from multisystem
colon, dissection up rectal wall, failure
distal perforation of anterior rectal
mucosa

still activated, their perineum is exposed to the effects of
hydrostatic injury. The energy that these jets create is more
than enough to create mucosal injuries and full-thickness
perforations into the peritoneal cavity.
The reduced potential for rectal and vaginal injuries to
produce systemic effects makes proper diagnosis critical. Pa-
tients with such injuries may present with only vague abdominal
pain. Even with a more obvious presentation of abdominal pain
and rectal bleeding, a lesion can be fatally missed at emergency
laparotomy.19 Therefore, these types of injuries necessitate a
high degree of clinical suspicion.
The initial examination should include a thorough rectal,
perineal, and vaginal examination. If the patient is stable
enough, an abdominal and pelvic computed tomography scan
may be indicative of signs of perforation if peritoneal signs
are absent. Intravenous antibiotics should be started. If the
patient’s clinical picture and examination warrant surgery, a
more thorough examination under anesthesia must be per-
formed. This includes rigid proctoscopy and pelvic examina-
tion with careful inspection for communication of lacerations
to the vagina in females. An open laparotomy is recom-
mended to enable a full inspection of the abdomen and distal
colon in appropriate cases. Surgical treatment may include
standard colonic fecal diversion techniques. A combined ap-
proach between gynecology and general surgery is advocated
when diagnosing and treating these types of injuries in
females.
To minimize rectal and vaginal as well as other PWC-
related injuries, prevention is key. The majority of PWC
accidents and injuries are attributable to inexperience, reck-
lessness, and excessive speed.1–3,5– 8,9,20 Many riders do not
know how to react to dangerous situations such as a near
collisions, high wakes, and choppy weather. Many states did
not have requirements for written tests, hours logged, or even
licensure when many of the articles reviewed were written.
Therefore, the primary mode of prevention should be educa-
tion of the consumer, spearheaded by manufacturers, organi-
zations such as the Personal Watercraft Industry Association,
and state regulatory agencies.
Since the mid to late 1990s, many states have enacted
legislation to improve PWC safety. Many states currently re-
quire some kind of testing and documentation to legally operate
a PWC; minimum age requirements have also been added.
There are multiple online exams available for consumers which
are accepted by many states.21–23
Other types of measures are needed to prevent rectal
and vaginal injuries. These injuries appear to occur to
passengers rather than drivers.24 Passengers may be more
susceptible to these injuries because of a lack of a handle-
bar for maintaining stability during a ride. Passengers may
not be paying attention to the path of their vehicle and may
not be ready to brace themselves for a sudden jolt, causing
a loss of balance. Most importantly, passengers do not
have an auto-shutoff switch on most PWCs. Drivers will
automatically shut off the throttle if they fall off their
vehicle. When passengers fall off, the throttle can still
operate, allowing the jet to continue, potentially leading to
injury. Also, in none of the cases was there a report of the
patient wearing a neoprene suit (“wet suit”) or any other
type of protective clothing. These suits are essential in
directly protecting soft tissue from hydrostatic injury.

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care
CONCLUSION
In conclusion, rectal and vaginal injuries may not be as
rare as previously reported. Appropriate medical interven-
tions will prevent further morbidity and mortality when these
cases present, especially with the female PWC passenger.
Preventive interventions include education, the standardiza-
tion of auto-shutoffs for passengers or restricting passengers,
and wearing protective gear such as wet suits when riding
PWCs.
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November 2007