The treatment of rectal foreign bodies has been discussed in the medical literature for many years.[1, 2] Controlled studies of patients with rectal foreign bodies have not been conducted, and the literature is largely anecdotal or consists of patient series.[3, 4] The approach to the management of these patients has not changed in the last 10-20 years. These patients usually present to the emergency department (ED) because of pain, discomfort, or foreign body sensation, often after multiple attempts to remove the object. Presentation is almost always 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. This is not just a priority for patient respect and privacy, but also a medicolegal issue for the hospital and staff.
Rectal foreign bodies usually are inserted, in 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 or beer bottles.
Less commonly, foreign bodies are inserted rectally in an attempt at concealment. Typically, these objects are drug packets; less often, they are weapons, such as knives or guns. Some psychiatric patients will purposefully conceal sharp objects in their rectums in an attempt to injure the examining provider when he or she performs a rectal examination. Finally, more commonly in older patients, rectal foreign bodies are used for prostatic massage or to break up fecal impactions and are lost during this activity.
Some rectal foreign bodies are initially swallowed and then transit through the gastrointestinal (GI) tract. Examples of the latter include toothpicks, popcorn, bones, sunflower seeds,[5] and, in more recent years, camera pills used in gastrointestinal studies (see the image below). Rectal foreign bodies can also be the result of assault, including child abuse. The weapon used in the assault is typically a blunt object but may be any object.[6]
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The patient swallowed a camera pill that became lodged in the rectum at a prior surgical anastamosis site and had to be removed via sigmoidoscopy.
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 with rigid proctosigmoidoscopy. Low-lying rectal foreign bodies, however, are normally palpable on digital examination and are candidates for ED removal.
Frequently, delays in presentation and multiple attempts at self-removal lead to mucosal edema and muscular spasms, which further hinder removal. Rectal lacerations and perforations may occur but are less common than other complications.
There are no reliable data on the frequency of rectal foreign bodies. The older literature contains occasional case reports; more recently, several case series and descriptions of evaluation and extraction techniques have been published. It is likely that the use of various objects for anal eroticism is increasing, resulting in an increased incidence of retained rectal foreign bodies.
The age distribution is bimodal, with peaks in the 20s (thought to be due to anal eroticism) and 60s (thought to be secondary to the use of foreign objects for prostatic massage). Most patients are in the age range of 20-40 years.[6, 7] The prevalence is much higher in males than in females: the ratio is approximately 28:1.[8, 9] The few published series that list race note no significant differences between racial groups.
For the vast majority of rectal foreign bodies, the prognosis is excellent. For foreign bodies that result in perforation of the rectal or colon wall, the prognosis is also good with the use of antibiotics and operative intervention. Deaths in patients with rectal foreign bodies are rare and are almost always the result of perforation with prolonged delay until presentation for care.
Mortality is rare and results from bleeding, rectal perforation or laceration, and infectious complications.[6] Morbidity is somewhat more common and is primarily the result of rectal laceration or perforation.
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.[8, 10] More serious complaints indicative of perforation include fever, vomiting, or severe abdominal or rectal pain.[6, 11]
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.[5] Fecal impaction should be considered.
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.[9, 7]
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 a history of self-insertion or insertion by a partner.[1]
Typically, multiple failed attempts at self-removal have occurred. Ascertaining whether the patient attempted any instrumentation in these attempts is important because the use of instruments increases the risk of perforation or laceration. The length of time since insertion and the 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.[6, 10]
Patients should be asked if the foreign body is the result of assault because serious injury is more likely in this scenario. Depending on local laws, notify the legal authorities if the patient has been assaulted, and if local laws require this, the patient agrees to such notification.
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.
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.[9] The main purpose of the rectal examination is to check for the presence of blood and the position of the foreign body.
The most common complications of rectal foreign bodies are rectal laceration and perforation, which are diagnosed by direct visualization. Questionable cases should be referred to a general surgeon. Other complications that may be seen include infection with abscesses and sepsis.
All cases of suspected laceration or perforation should be treated by administering a broad-spectrum antibiotic such as piperacillin-tazobactam.
Laboratory studies generally do not add much useful information in the acute presentation. A hematocrit may be useful if bleeding is present. Obtain a white blood cell (WBC) count with differential when infection is suspected.
For patients who are operative candidates (eg, patients who show signs of peritonitis, sepsis, or perforation or who have rectal foreign bodies that cannot be removed in the emergency department), obtain routine preoperative laboratory studies.
A flat plate radiograph of the abdomen or pelvis is indicated. The foreign object can be identified and localized in most cases (see the images below). A lateral pelvic film sometimes gives additional information regarding the orientation of the foreign body, particularly whether its position is high- or low-lying. An upright chest radiograph is indicated if perforation is suspected. If concerns arise about perforation or abscess, computed tomography is indicated.
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Typical appearance of a vibrator in the rectum.
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Vibrator in the rectum. The patient attempted self-removal with a pair of salad tongs, which also became lodged, resulting in two rectal foreign bodie....
Many rectal foreign bodies can be removed in the emergency department (ED). Objects that are sharp or may break should be removed in the operating room (OR). Adequate analgesia and direct visualization are critical to success. Patient relaxation is key.
Arrange for evaluation and treatment of patients who are not candidates for ED removal and patients with suspected rectal lacerations or perforations. Patients with subsequent uncomplicated OR removal are typically discharged after recovery.
Transport the patient in a comfortable position. Fluid resuscitation is indicated in cases of hypotension caused by sepsis or hemorrhage.
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 mandates referral of the patient 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, unbreakable, and nonfriable, thus excluding thin glass objects such as light bulbs. Foreign bodies located in the sigmoid colon as opposed to the rectum are much more likely to require operative intervention.[11]
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 this attempt is successful, ED extraction can then be attempted.
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 (eg, with a mild sedative such as midazolam) and analgesia (eg, with morphine, hydromorphone, or fentanyl). Position the patient in a knee-chest position; alternatively, place the patient on a gynecology bed with stirrups.
Obtain direct visualization of the foreign body with an anoscope or proctoscope. Use direct lighting. Insert the lubricated scope. Grasp the visualized foreign body with forceps or snares (retractors may also be used), and slowly withdraw it. Minimize the cross-sectional size of the foreign body (turn it if necessary so that it is withdrawn the long-ways).
If the foreign body cannot be visualized, do not make blind attempts removal device; instead, apply gentle pressure on the lower abdomen in an attempt to move the foreign body into the field of vision. If the foreign body cannot be visualized even with abdominal pressure, consult a surgeon or a gastroenterologist.
Difficulties may be encountered in extracting larger objects around which the rectal mucosa has formed a seal. If the foreign body can be visualized and grasped but opposing suction forces hinder removal, insert a lubricated Foley catheter past the foreign body. This breaks the suction seal, creates an air channel, and facilitates removal.
As a rule, extraction attempts should be limited to 20-30 minutes. If the foreign body cannot be removed within this time frame, consult a surgeon or a gastroenterologist.
After successful removal of the foreign body, carefully reexamine the rectum through the anoscope or proctoscope to detect any bleeding or tearing or to identify any additional foreign bodies.
Other extraction techniques that have been described include balloon extraction, in which a pneumatic dilation balloon is inserted distal to the foreign body, inflated, and then withdrawn, pulling the foreign body out along with the inflated balloon.[12]
Discharge patients on oral analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotic medications, as indicated. Antibiotics generally are not indicated in patients discharged home from the ED.
Refer most patients who have undergone 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.
It is particularly important to ensure privacy and confidentiality for these patients. Out of embarrassment, patients with rectal foreign bodies may use false names or identification at admission or may elope from the ED after extraction. In some cases, patients do not want any bills to be generated and offer to pay in cash to prevent the creation of an insurance paper trail. Attempt to fulfill such requests.
Consult a general or colorectal surgeon in the following situations:
Laceration, perforation, or infection is evident
The foreign body is a high-lying object that cannot be moved to a low-lying position
The foreign body is made of glass (with the possible exception of thick, sturdy objects that have not been broken)
The foreign body is breakable or friable
The foreign body is sharp or rough
The foreign body is otherwise dangerous
Extraction attempts in the ED have been unsuccessful
The usual treatment of these patients by a surgeon involves attempted visualization and removal by means of flexible rectosigmoidoscopy with the patient under general anesthesia. In rare cases, a laparotomy is needed. In some institutions, gastroenterologists manage rectal foreign bodies, except in cases of laceration or perforation and cases where operative intervention is necessary.
The goals of pharmacotherapy are to reduce morbidity and prevent complications. Agents used in patients with rectal foreign bodies include narcotic analgesics, benzodiazepines, and antibiotics.
Clinical Context:
Morphine is the drug of choice for analgesia in this setting because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various intravenous (IV) doses are used; the dose is commonly titrated until the desired effect is obtained.
Clinical Context:
Hydromorphone is a potent semisynthetic opiate agonist that is structurally similar to morphine. It is approximately 7-8 times as potent as morphine on a milligram-for-milligram basis, with a shorter or similar duration of action.
Clinical Context:
Fentanyl is a synthetic opioid that is 75-200 times more potent than morphine sulfate and has a much shorter half-life. It has less hypotensive effects than morphine and is safer in patients with hyperactive airway disease because there is minimal to no associated histamine release. By itself, fentanyl causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Fentanyl is highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process. Consider continuous infusion because of the short half-life of fentanyl.
The parenteral form of fentanyl is the drug of choice for conscious sedation analgesia. It is ideal for analgesic action of short duration during anesthesia and in the immediate postoperative period. It is an excellent choice for pain management and sedation, with a short duration (30-60 min), and is easy to titrate. It is easily and quickly reversed by naloxone. After the initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than every 3-6 hours thereafter.
The transdermal form of fentanyl is used only for chronic pain conditions in opioid-tolerant patients. When the transdermal form is used, pain is controlled in the majority of patients with 72-hour dosing intervals; however, some patients require 48-hour dosing intervals. Transdermal fentanyl is easily and quickly reversed by naloxone.
Clinical Context:
Midazolam is a shorter-acting benzodiazepine sedative-hypnotic that is useful in patients requiring acute or short-term sedation. It is also useful for its amnestic effects.
Benzodiazepines facilitate visualization and successful removal of the foreign body. By binding to specific receptor sites, these agents appear to potentiate the effects of gamma-aminobutyrate (GABA) and to facilitate inhibitory GABA neurotransmission, as well as other inhibitory transmitters.
Clinical Context:
Piperacillin-tazobactam is a combination of an antipseudomonal penicillin with a beta-lactamase inhibitor. It inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.
David W Munter, MD, MBA, Associate Clinical Professor of Emergency Medicine, Eastern Virginia Medical School; Associate Professor of Emergency Medicine, Edward Via Virginia College of Osteopathic Medicine; Partner, Emergency Physicians of Tidewater, PLC; President of the DESA Consulting Group
Disclosure: Nothing to disclose.
Chief Editor
Steven C Dronen, MD, FAAEM, Chair, Department of Emergency Medicine, LeConte Medical Center
Disclosure: Nothing to disclose.
Acknowledgements
Eugene Hardin, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.
Edmond A Hooker II, MD, DrPH, FAAEM Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine
Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
References
Rosser C. Colonic foreign bodies. JAMA. 1929. 39:368-369.
Wagner J. Foreign bodies in the rectum. Am J Surg. 1937. 36:266-269.
The patient swallowed a camera pill that became lodged in the rectum at a prior surgical anastamosis site and had to be removed via sigmoidoscopy.
Typical appearance of a vibrator in the rectum.
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.
Typical appearance of a vibrator in the rectum.
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.
The patient swallowed a camera pill that became lodged in the rectum at a prior surgical anastamosis site and had to be removed via sigmoidoscopy.
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