eMedicine Specialties > Clinical Procedures > Gastrointestinal Procedures
Foreign Body Removal, Rectum
Updated: Mar 29, 2009
Introduction
Anorectal foreign bodies are usually inserted transanally for sexual or medicinal purposes. Rectal foreign bodies may also be observed with body packing/stuffing or after prior oral ingestion of the object. Anorectal foreign bodies are more common in men than in women.
Rectal foreign bodies may include such objects as bottles, vibrators, fruit, vegetables, and balls. Cylindrical objects are common. In addition, thermometers may accidentally break while a rectal temperature is being obtained.
Be aware that patients have usually made multiple attempts to remove the object prior to presentation in the emergency department. Patients may create unusual stories to explain how the object became lodged in the rectum.
Indications
Indications for bedside rectal foreign body removal in the emergency department include the following:
- Object palpable on digital rectal examination
- Object less than 10 cm proximal to the anal verge
Contraindications
Relative contraindications to bedside rectal foreign body removal in the emergency department include the following:
- Severe abdominal pain
- Object not palpable on digital rectal examination
- Object more than 10 cm proximal to the anal verge
- Broken glass present in the anus or rectum
- Fragile object (eg, light bulb) present
- Extended time since insertion
- Inexperienced clinician
- Uncooperative patient
- Peritonitis
- Perforation
Anesthesia
- Intravenous relaxation medications and analgesia are usually required.
- The extent of sedation required depends on the anticipated difficulty of the procedure and the patient’s tolerance. For more information, see Procedural Sedation.
- Intravenous benzodiazepines allow for patient sedation and muscle relaxation.
- Intravenous narcotics should be used for pain control.
- Perianal block with lidocaine or longer-acting bupivacaine may be considered, although this is not commonly used.
Equipment
Equipment used may vary based on availability in the emergency department or hospital.
- Light source
- Retractor-type instrument for visualization
- Anal or rectal speculum
Rectal speculum (closed).
Rectal speculum (open).
Rectal speculum (closed).
Rectal speculum (open).
- Vaginal speculum
Vaginal speculum (closed).
Vaginal speculum (open).
- Hill-Ferguson retractor
Hill-Ferguson retractor.
- Anoscope, proctoscope, or rigid sigmoidoscope
- Anal or rectal speculum
- Grasper-type instrument for removal (These should be used only under direct visualization of the foreign body because of the increased risk of perforation.)
- Ring forceps
Ring forceps.
- Tenaculum forceps
Tenaculum forceps.
- Ring forceps
- Foley catheter
Positioning
- Placement in the lithotomy position allows for palpation of the object in the lower abdomen to assist in retrieval.
- Another option for patient positioning is the left lateral decubitus position, with the right lower extremity partially flexed at the hip and knee.
- Patients may be positioned prone, such as in the knee-to-chest position.
Technique
- Evaluation of the patient with a rectal foreign body begins with a thorough history.
- Many patients mention the presence of a rectal foreign body as part of the chief complaint. However, some patients may not mention the foreign body; they may only describe unusual histories with vague reports of abdominal pain, rectal pain, or rectal bleeding.[1 ]
- The history obtained should focus not only on signs and symptoms of perforation or complications but also on possible indications that removal in the emergency department may be difficult. Items to include in the history include the following:
- Fever
- Severe abdominal pain
- Rectal bleeding
- Systemic illness
- Time elapsed since insertion
- Type and size of object
- Methods attempted to remove foreign body prior to arrival
- The physical examination should include the following:
- Abdominal examination to evaluate for peritonitis
- External anal and perineal examination to evaluate for trauma
- Digital rectal examination (DRE) to determine if the foreign body is palpable (DRE should not be attempted if the object is sharp.)
- Radiographic evaluation includes an abdominal series to attempt visualization of the object and to evaluate for signs of complications.
Rectal foreign body that is difficult to observe on radiography.
Rectal foreign body readily visible on radiography.
- Consider a lateral view for further delineation of the object's orientation and location.
- If the foreign body is not radiopaque, an abnormal gas or stool pattern may be visualized around the external surface of the object. Air may be observed inside a hollow object.
- Specifically note the presence or absence of free intraperitoneal air.
- Look for an obstructive bowel gas pattern.
- Intravenous pain control and benzodiazepines should usually be administered.
- A perianal block may be considered.
- Formal procedural sedation may also be considered.
- Continuous electrocardiographic and vital sign monitoring should be performed.
- Instruct the patient to assume a preferred position (see Positioning).
- The object can often be removed with digital manipulation.
- If the patient is kept alert enough, he or she can perform the Valsalva maneuver to assist with the procedure.
- If the object cannot be successfully removed with digital manipulation, insert a retractor or speculum device.
- If the object is visible, grasp the edge of the object under direct visualization.
- Never attempt to grasp an unseen object because of the risk of pinching the rectal mucosa, which can cause further injury.
- If the object cannot be visualized with a retractor instrument in place, consultation with a surgeon is indicated.
- If a glass object is being grasped, pad the ends of the forceps to avoid breakage.
- Apply steady, gentle traction on the forceps to withdraw the object.
- Suprapubic pressure may assist with object removal.
- The object may need redirection around the sacral curve.
- Have the patient bear down, which may aid in removal.
- The foreign body and the speculum may need to be removed as a single unit if the object is too large to be withdrawn through the speculum.
- If suction created by the rectal mucosa is hindering withdrawal, a Foley catheter may be advanced proximal to the object and the balloon inflated to break the suction. The Foley catheter can then be used as an additional traction device to aid in removal.
- If the foreign body cannot be removed safely, obtain a consultation with a surgeon or gastroenterologist. The patient may require an examination under general anesthesia for removal, an endoscopic removal, or a laparotomy for removal.[2 ]
- Once the object is removed, consider sigmoidoscopy/colonoscopy to detect possible mucosal injury. If more severe injury or perforation is suspected, surgical consultation is needed.
- If no injury is found, the patient may be discharged home after observation in the emergency department.
- If injury is discovered, a surgeon should be consulted for likely admission.
- If only superficial mucosal injury is found, consider discharging the patient in conjunction with a surgical consultation.
- Discharge instructions should include warning signs for perforation, infection, and bleeding. The patient should understand that he or she needs to return to the emergency department if these signs or symptoms develop.
Pearls
- Consider assault as an etiology for an anorectal foreign body.
- Delayed removal of rectal foreign bodies can lead to severe complications, including the following:
- Perforation
- Peritonitis
- Infection or sepsis
- Mucosal ulcerations, lacerations, or edema
- Obstruction
- Bleeding
- Enemas, laxatives, and cathartics should not be used routinely to aid in removal of a foreign body.
- Objects proximal to the rectum are more likely to require operative intervention for removal.
- Orally ingested foreign bodies that traverse the GI tract without difficulty do not commonly become lodged in the colorectum. Small pointed objects, especially toothpicks or fish bones, may become impacted in the anal crypts.
- A few uncommon methods have been used to successfully remove rectal foreign bodies, including the use of a vacuum-extractor device, plaster of Paris, and obstetric forceps.
Complications
- Inability to remove the object or retained foreign body
- Perforation
- Mucosal injury
- Bleeding
Multimedia
Media file 1: Ring forceps.
Media file 2: Tenaculum forceps.
Media file 3: Vaginal speculum (closed).
Media file 4: Vaginal speculum (open).
Media file 5: Rectal speculum (closed).
Media file 6: Rectal speculum (open).
Media file 7:
Rectal speculum
(closed).
Media file 8: Rectal speculum (open).
Media file 9: Hill-Ferguson retractor.
Media file 10: Rectal foreign body that is difficult to observe on radiography.
Media file 11: Rectal foreign body readily visible on radiography.
References
Rodríguez-Hermosa JI, Codina-Cazador A, Ruiz B, Sirvent JM, Roig J, Farrés R. Management of foreign bodies in the rectum. Colorectal Dis. Jul 2007;9(6):543-8. [Medline].
Lake JP, Essani R, Petrone P, Kaiser AM, Asensio J, Beart RW Jr. Management of retained colorectal foreign bodies: predictors of operative intervention. Dis Colon Rectum. Oct 2004;47(10):1694-8. [Medline].
Management of rectal foreign bodies. In: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th. Philadelphia, PA: WB Saunders Company; 2004:875-7.
Hellinger MD. Anal trauma and foreign bodies. Surg Clin North Am. Dec 2002;82(6):1253-60. [Medline].
Koornstra JJ, Weersma RK. Management of rectal foreign bodies: description of a new technique and clinical practice guidelines. World J Gastroenterol. Jul 21 2008;14(27):4403-6. [Medline].
Management of specific anorectal problems. In: Marx JA, Hockberger RS, Walls RM. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th. St Louis, MO: Mosby; 2002:1356-1358.
Keywords
rectal foreign body, object in rectum, gastrointestinal tract, GI tract, foreign body, anus, anal foreign body, rectum, digital rectal examination, DRE, foreign body removal
Contributor Information and Disclosures
Author
Victoria L Hogan, MD, Assistant Professor, Department of Emergency Medicine, University of Alabama at Birmingham
Victoria L Hogan, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Andrew R Edwards, MD, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, University of Alabama at Birmingham; Co-Director, Department of Resuscitation, University of Alabama at Birmingham Hospital; Medical Director of Jefferson County SWAT Team, Jefferson County Sheriff's Department
Andrew R Edwards, MD is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
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Medical Editor
Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
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Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
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CME Editor
Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
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