Background: Presentation of rectal injuries in the civilian setting is often delayed due to patient denial or assault and requires a high index of suspicion for diagnosis. The standard of care in dealing with such injuries has evolved from mandatory fecal diversion to emphasis on avoidance of colostomy whenever possible. Case Report: A 17 year old male presented to the emergency department with complaints of severe lower abdominal pain, high grade fever and bloody stool following a fall at swimming facility. CT scan abdomen and pelvis confirmed presence of a well organized hematoma in right side of vesicorectal pouch with no active leak. Proctoscopy under anesthesia confirmed rectal perforation on the anterior wall on the right side and a small ulcer after blood clots were evacuated. This was sutured in the same setting and patient was kept on oral liquids and responded well to treatment with follow up ultrasound scans confirming reduction in hematoma size. He was discharged on 7 th day and remained healthy on immediate follow up. Conclusion: Primary repair of low rectal perforation during proctoscopy under anesthesia can be safely carried out without colostomy as an alternative in patients presenting with hemodynamic stability and limited sepsis. The optimum approach should be individualized and fecal diversion should be avoided where possible to reduce morbidity.