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Emergency Medicine > GASTROINTESTINAL
Foreign Bodies, Rectum
Article Last Updated: Jul 13, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: David W Munter, MD, MBA, Assistant Clinical Professor of Emergency Medicine, Medical Director and Chair, DePaul University Medical Center; Partner, Emergency Physicians of Tidewater, LPC; President of the DESA Consulting Group
David W Munter is a member of the following medical societies: American College of Emergency Physicians, American College of Physician Executives, Medical Society of Virginia, and Norfolk Academy of Medicine
Editors: Edmond A Hooker II, MD, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eugene Hardin, MD, FACEP, FAAEM, Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
rectal foreign bodies, rectal pain, rectal bleeding, rectal lacerations, rectal perforations, object in the rectum, foreign body in the rectum
Background
Controlled studies of patients with rectal foreign bodies have not been conducted, and the literature is largely anecdotal. These patients usually present to the ED because of pain, often after multiple attempts to remove the object. Presentation is often delayed because of embarrassment. The keys to adequate care for these patients are respect for their privacy, evaluation of the type and location of the foreign body, determination if removal can be performed in the ED or if operative referral is needed, and use of appropriate techniques for removal. Caregivers should refrain from making disparaging or comical remarks concerning the nature of the problem and prevent invasions of the patient's privacy by curious hospital staff.
Pathophysiology
Rectal foreign bodies usually are inserted, with the vast majority of cases as a result of erotic activity. In these cases, the objects are typically dildoes or vibrators, although almost any object can be seen, including light bulbs, candles, shot glasses, and odd or unusually large objects such as soda bottles, beer bottles, or other large objects.
Less commonly, rectal foreign bodies are inserted in an attempt to conceal the object, typically weapons such as knives, or drug packets.
Some rectal foreign bodies are initially swallowed and then transit through the GI tract. Examples of the latter include toothpicks, popcorn, bones, and sunflower seeds.
Rectal foreign bodies can be classified as high-lying or low-lying, depending on their location relative to the rectosigmoid junction. This distinction is important. Objects that are above the sacral curve and rectosigmoid junction are difficult to visualize and remove, and they are often unreachable by rigid proctosigmoidoscope. Low-lying rectal foreign bodies are normally palpable by digital examination and are candidates for ED removal. Frequently, delay in presentation and multiple attempts at self-removal lead to mucosal edema and muscular spasms, further hindering removal. Rectal lacerations and perforations may occur but are less common than other complications.
Frequency
United States
No reliable data exist regarding the frequency of rectal foreign bodies. Older literature consists of occasional case reports, but, more recently, case series and descriptions of evaluation and extraction techniques have been documented. It is likely that the use of various objects for anal eroticism is increasing, resulting in an increased incidence of retained rectal foreign bodies.
Mortality/Morbidity
- Mortality is rare and results from bleeding, rectal perforation or laceration, and infectious complications.
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- Morbidity is somewhat more common and primarily the result of rectal laceration or perforation.
Race
The few published series that list race note no significant differences.
Sex
Prevalence is higher in males than in females by a ratio of approximately 28:1.
Age
Age distribution is bimodal, with peaks in the 20s (anal erotism) and 60s (thought to be secondary to the use of foreign objects for prostatic massage). Most patients are in the age range of 20-30 years.
History
- Patients with rectal foreign bodies are usually aware of their presence and often present requesting removal. They may also present with rectal pain or bleeding, and less often, abdominal pain.
- Patients who have ingested foreign bodies that become lodged in the rectum may present with rectal pain or bleeding, constipation, pain with defecation, pruritus, or diffuse abdominal pain. Symptoms of peritonitis or bowel obstruction also may be present. The usual etiologic objects are sunflower seeds, toothpicks, or bones, and the ingestion is typically unknown.
- Patients with rectal foreign bodies may be too embarrassed to mention the foreign body at triage but usually admit the etiology to the physician. Maintain a high suspicion index of rectal foreign body in psychiatric patients or prisoners who present with rectal pain or bleeding.
- The vast majority of patients with rectal foreign bodies present because of an inability to remove the object. Some patients claim to have sat or fallen on the object. Older patients may state they were engaged in therapeutic prostatic massage or breaking up fecal impactions when the object was lost. Occasionally, objects such as thermometers or enema tips may become lost. Most patients, however, admit to the history of insertion by self or a partner.
- Typically, multiple failed attempts at self-removal have occurred. Ascertaining whether the patient attempted any instrumentation in these attempts is important because this increases the risk of perforation or laceration. Length of time since insertion and presence of rectal or abdominal pain, fever, or rectal bleeding are important elements of the history. The type of object should be determined because fragile or sharp foreign bodies deserve special consideration.
- Patients should be asked if the foreign body is the result of assault because this is more likely to result in a serious injury. Notify the legal authorities if the patient has been assaulted.
Physical
- Assess vital signs and general appearance. Fever or hypotension may indicate infection or bleeding. Perform an abdominal examination. Absent bowel sounds, rigidity, or peritoneal signs suggest perforation. The foreign body, especially if large or in a high-lying position, can occasionally be palpated.
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- A rectal examination should be deferred in patients with known or suspected rectal foreign bodies, especially in prisoners or psychiatric patients, until the location and type of foreign body has been ascertained radiographically. In some cases, dangerous objects such as guns or sharp objects (eg, needles, razor blades) are inserted rectally in an attempt to hide the object or, in the case of psychiatric patients, to injure the examiner. The main purpose of the rectal examination is to check for the presence of blood and the position of the foreign body.
Other Problems to be Considered
Rectal wall perforation
Rectal wall laceration
Fecal impaction
Lab Studies
- A hematocrit may be useful if bleeding is present. Obtain a white blood cell count with differential when infection is suspected. Obtain routine preoperative laboratory studies for patients who are operative candidates (eg, patients with signs of peritonitis, sepsis, or perforation, or with rectal foreign bodies that cannot be removed in the ED).
Imaging Studies
- A flat plate radiograph of the abdomen or pelvis is indicated. The foreign object can be identified and localized in most cases.
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- A lateral pelvic film sometimes gives additional information regarding orientation of the foreign body, particularly whether its position is high- or low-lying.
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- An upright chest radiograph is indicated if perforation is suspected.
Prehospital Care
Transport the patient in a comfortable position. Fluid resuscitation is indicated in cases of hypotension caused by sepsis or hemorrhage.
Emergency Department Care
- Perform a rectal examination if no dangerous or sharp foreign body is visible on radiographs. The presence of frank blood is an indication of laceration or perforation, and the patient should be referred to a surgeon for evaluation. If the foreign body is palpated on rectal examination, the object is considered to be low-lying and a candidate for ED removal. Objects that can be removed in the ED should be smooth, nonbreakable, and nonfriable, thus excluding thin glass objects such as light bulbs.
- Patients with rectal foreign bodies often develop rectal edema or spasm. Successful removal usually requires direct visualization, which is greatly facilitated by provision of adequate sedation and analgesia. Under direct visualization with an anoscope or proctoscope and adequate lighting, the object is grasped with forceps or snares. Retractors may also be used. Difficulties may be encountered in extracting larger objects around which the rectal mucosa has formed a seal. In these cases, inserting a Foley catheter beyond the foreign object breaks the suction seal and facilitates removal. Generally, limit extraction attempts in the ED to approximately 30 minutes.
- After removal, a repeat examination, preferably direct, using the anoscope or proctoscope is indicated to evaluate for rectal injuries.
- Occasionally, a high-lying rectal foreign body may be palpable on abdominal examination. If the patient is cooperative, a manual transabdominal attempt to manipulate the foreign body into a low-lying position can be made. If successful, ED extraction can then be attempted.
Consultations
- Consult a general surgeon in the following situations:
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- When laceration, perforation, or infection is evident
- High-lying objects that cannot be converted to low-lying
- Glass objects, with the possible exception of thick, sturdy unbroken objects
- Breakable or friable objects
- Sharp or nonsmooth objects
- Dangerous objects
- Those for which extraction attempts in the ED have been unsuccessful
- The usual treatment of these patients by surgery includes attempted visualization and removal under general anesthesia using flexible rectosigmoidoscopy. In rare cases, a laparotomy is needed.
Further Inpatient Care
- Arrange for evaluation and treatment of patients who are not candidates for ED removal. Patients with subsequent noncomplicated operating room removal are typically discharged after recovery.
Further Outpatient Care
- Refer most patients who have had ED extraction to a general surgeon for follow-up in 24-48 hours. Some patients with simple extractions can be reevaluated in the ED in 24-48 hours.
In/Out Patient Meds
- Discharge patients on oral analgesics, such as nonsteroidal anti-inflammatory drugs or narcotic medications, as indicated. Antibiotics generally are not indicated in patients discharged home from the ED.
Complications
- The most common complications are rectal laceration and perforation, which are diagnosed by direct visualization. Refer questionable cases to a general surgeon. Other complications include infection with abscesses and sepsis.
Patient Education
Medical/Legal Pitfalls
- Because of embarrassment, patients sometimes use false names or identification.
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- After extraction, patients with rectal foreign bodies sometimes elope from the ED.
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- Ensure privacy and confidentiality for the patient. In some cases, patients do not want any bills generated and offer to pay in cash to avoid an insurance paper trail. Attempt to fulfill their requests.
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- Do not perform a rectal examination, especially in prisoners or psychiatric patients, until number, type, and location of the rectal foreign body is ascertained radiographically. This helps to avoid patient or examiner injury from sharp or dangerous objects (eg, guns, needles, razors).
| Media file 1:
Typical appearance of a vibrator in the rectum. |
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Media type: X-RAY
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| Media file 2:
Vibrator in the rectum. The patient attempted self-removal with a pair of salad tongs, which also became lodged, resulting in two rectal foreign bodies. Multiple attempts at self-removal are typical in patients with rectal foreign bodies. |
 | View Full Size Image | |
Media type: X-RAY
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Foreign Bodies, Rectum excerpt Article Last Updated: Jul 13, 2007
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