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Foreign Bodies, Rectum
Updated: Sep 28, 2009
Introduction
Background
The treatment of rectal foreign bodies has been discussed in the medical literature for many years.1 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 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.
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.2
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.
- 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 28:1.3,4
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.5
Clinical
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.3
- 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.2
- 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.4,5
- 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.6,7
- 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.8
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.
- 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.4 The main purpose of the rectal examination is to check for the presence of blood and the position of the foreign body.
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References
Wagner J. Foreign bodies in the rectum. Am J Surg. 1937;36:266-269. [Medline].
Smith MT, Wong RK. Foreign bodies. Gastrointest Endosc Clin N Am. Apr 2007;17(2):361-82, vii. [Medline].
Clarke DL, Buccimazza I, Anderson FA, Thomson SR. Colorectal foreign bodies. Colorectal Dis. Jan 2005;7(1):98-103. [Medline].
Stack LB, Munter DW. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. Aug 1996;14(3):493-521. [Medline].
Rodriguez-Hermosa JI, Codina-Cazador A, Ruiz B, Sirvent JM, Roig J, Farres R. Management of foreign bodies in the rectum. Colorectal Dis. Jul 2007;9(6):543-8. [Medline].
Janicke DM, Pundt MR. Anorectal disorders. Emerg Med Clin North Am. Nov 1996;14(4):757-88. [Medline].
Rosser C. Colonic foreign bodies. JAMA. 1929;39:368-369. [Medline].
Hellinger MD. Anal trauma and foreign bodies. Surg Clin North Am. Dec 2002;82(6):1253-60. [Medline].
Lake JP, Essani R, Petrone P, et al. Management of retained colorectal foreign bodies: predictors of operative intervention. Dis Colon Rectum. Oct 2004;47(10):1694-8. [Medline].
Further Reading
Keywords
object in rectum, rectal foreign body, rectal foreign object, rectal foreign bodies, rectal pain, rectal bleeding, rectal lacerations, rectal perforations, foreign body in the rectum
