Rectal Foreign Body Removal

Anorectal foreign bodies are usually inserted transanally for sexual or medicinal purposes.[1] Rectal foreign bodies may also be observed with body packing or stuffing or after previous oral ingestion of the object. Anorectal foreign bodies are more common in men than in women.[2] The incidence of the problem appears to be increasing.[3, 4, 5, 6]

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.

The clinician should be aware that patients have usually made multiple attempts to remove the object before presentation in the emergency department (ED). Patients may create unusual stories to explain how the object became lodged in the rectum. Assault must be considered as a possible etiology for an anorectal foreign body.[7]

Indications for bedside rectal foreign body removal in the ED include the following:

• An object that is palpable on digital rectal examination (DRE)
• An object that is less than 10 cm proximal to the anal verge

Prompt removal is advisable.[8, 9, 10]  Delayed removal of rectal foreign bodies can lead to severe complications, including the following:

• Perforation ^[11]
• Peritonitis
• Infection or sepsis
• Mucosal ulcerations, lacerations, or edema
• Obstruction
• Bleeding

Transanal removal is usually successful; however, some patients will require emergency surgical management.[12]

Absolute contraindications for bedside rectal foreign body removal in the ED include the following:

• Peritonitis
• Perforation

Relative contraindications for bedside rectal foreign body removal in the ED include the following:

• Severe abdominal pain
• An object that is not palpable on DRE
• An object that is more than 10 cm proximal to the anal verge
• Broken glass present in the anus or rectum
• A fragile object (eg, a light bulb)
• An extended time since insertion
• An inexperienced clinician
• An uncooperative patient

Anatomy

The rectum lies in the sacrococcygeal hollow and changes to the anal canal at the puborectal sling formed by the innermost fibers of the levator ani. It has a dilated middle part called the ampulla. (See Large Intestine Anatomy and Anal Canal Anatomy.)

The rectum is related anteriorly to the urinary bladder, prostate, seminal vesicles, and urethra in males and to the uterus, cervix, and vagina in females. Anterior to the rectum is the rectovesical pouch in males and the rectouterine pouch in females. The anal canal is related to the perineal body in front and the anococcygeal body behind; both of these are fibromuscular structures.

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:

• 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

Physical examination

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)

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 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:

• Anal or rectal speculum (see the first and second images below)
• Vaginal speculum (see the third and fourth images below)
• Hill retractor (see the fifth image below)
• 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.

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.

Before extraction is attempted, intravenous (IV) pain control medications and benzodiazepines should usually be administered. A perianal block may be considered. Formal procedural sedation may also be considered. Continuous electrocardiographic (ECG) and vital sign monitoring should be performed. Enemas, laxatives, and cathartics should not be used routinely to aid in removal of a foreign body.

Instruct the patient to assume the desired position (see Patient Preparation). First, attempt to remove the object by means of digital manipulation alone; this often proves possible. 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 then visible, grasp its edge under direct visualization. Never attempt to grasp an unseen object: doing so may pinch the rectal mucosa and thereby cause further injury. If the object cannot be visualized with a retractor instrument in place, consult a surgeon.

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 have to be redirected around the sacral curve. Have the patient bear down; this may facilitate removal. If the object is too large to be withdrawn through the speculum, the foreign body and the speculum may have to be removed en bloc.

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, consultation with a surgeon or gastroenterologist is warranted. The patient may require an examination under general anesthesia for removal, an endoscopic removal, or a laparotomy for removal.[15, 16, 17]  Cases in which the foreign body was removed with a transanal technique using a single port have been reported.[18, 19, 20]

A few less common methods have been used for successful removal of rectal foreign bodies, including the use of a vacuum-extractor device, plaster of Paris, and obstetric forceps. Balloon extraction is sometimes employed.[21]  The use of laparoscopic specimen extraction bags has been described.[22]

Once the object is removed, sigmoidoscopy or colonoscopy should be considered for detection of possible mucosal injury. If more severe injury or perforation is suspected, surgical consultation is needed. If only superficial mucosal injury is found, consideration should be given to discharging the patient in conjunction with a surgical consultation. If no injury is found, the patient may be discharged home after observation in the emergency department (ED).

Discharge instructions should include warning signs for perforation, infection, and bleeding. The patient should understand that he or she needs to return to the ED if these signs or symptoms develop.