The major complications include rectal bleeding, rectal perforation, and damage to the anal sphincter. Since the patient may very well have presented with these complications, it is important to document them or their absence on the initial (i.e., preprocedural) examination. Rectal bleeding is common after a difficult extraction. It is important to rule out a perforation. This can be performed with the rigid rectosigmoidoscope after the extraction. Most perforations occur at the rectosigmoid junction, approximately 15 to 16 cm from the anus. Perforation above the peritoneal reflection will result in peritonitis and free air noted under the diaphragm on upright plain radiographs. Perforation below the peritoneal reflection may take several days to manifest pelvic pain, signs of a pelvic abscess, or sepsis. If there is no evidence of perforation or significant mucosal damage, the patient may still be discharged. However, large amounts of bleeding or significant mucosal damage require observation at the least. A Gastrografin enema without the use of the balloon may be used to identify a perforation if there is significant concern that it exists. Patients with perforation of an unprepared rectum require surgical intervention and broad-spectrum intravenous antibiotics. Any evidence of acute sphincter damage requires a surgical evaluation for possible debridement. The majority of these lesions are observed, allowed to heal secondarily, and then repaired surgically.