Preprocedural Planning
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. [13]
Orally ingested foreign bodies that traverse the gastrointestinal (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.
History
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 (ED) may be difficult. Items to address in the history include the following:
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Fever
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Severe abdominal pain
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Rectal bleeding
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Systemic illness
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Time elapsed since insertion
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Type and size of object
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Methods attempted to remove foreign body prior to arrival
Physical examination
The physical examination should include the following:
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Abdominal examination to evaluate for peritonitis
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External anal and perineal examination to evaluate for trauma
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Digital rectal examination (DRE) to determine if the foreign body is palpable (DRE should not be attempted if the object is sharp)
Objects proximal to the rectum are more likely to require operative intervention for removal.
Imaging studies
Radiographic evaluation includes an abdominal series to attempt visualization of the object and to evaluate for signs of complications (see the images below). 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.
The use of endoscopic ultrasonography (US) for diagnosis of foreign bodies in the colon and rectum has been described. [14]
Equipment
Equipment used for removal of a rectal foreign body may vary, depending on availability in a particular ED or hospital.
An adequate light source is required. Retractor-type instruments are used to achieve visualization, including the following:
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Anal or rectal speculum (see the first and second images below)
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Vaginal speculum (see the third and fourth images below)
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Hill retractor (see the fifth image below)
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Anoscope, proctoscope, or rigid sigmoidoscope
Grasper-type instruments, such as a ring forceps (see the first image below) or a tenaculum forceps (see the second image below), are employed for removal of the foreign body. Because of the increased risk of perforation, these should be used only when direct visualization of the foreign body has been achieved. A Foley catheter should be placed.
Patient Preparation
Anesthesia
Intravenous (IV) 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. IV benzodiazepines provide patient sedation and muscle relaxation. IV narcotics should be used for pain control. Perianal block with lidocaine or the longer-acting bupivacaine may be considered, though this is not as commonly used.
Positioning
Placement in the lithotomy position allows 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 the knee. Patients may be positioned prone, as in the knee-to-chest position.
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Ring forceps.
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Tenaculum forceps.
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Vaginal speculum (closed).
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Vaginal speculum (open).
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Rectal speculum (closed).
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Rectal speculum (open).
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Rectal speculum (closed).
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Rectal speculum (open).
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Hill-Ferguson retractor.
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Rectal foreign body that is difficult to observe on radiography.
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Rectal foreign body readily visible on radiography.
