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Rectal foreign bodies

Rectal foreign bodies
Literature review current through: Jan 2024.
This topic last updated: Aug 11, 2022.

INTRODUCTION — Rectal foreign bodies can present a difficult diagnostic and management dilemma. They can be caused by a wide variety of objects, lead to variable degrees of local trauma to the surrounding tissues, and can be associated with perforation or delayed injury. Further complicating management is the variable degree to which patients are willing to disclose the underlying cause leading to their presentation, the frequently long delay before they seek medical attention, and in some cases, acknowledgment that a foreign body is present. As a result, recognition and management require a systematic approach.

EPIDEMIOLOGY — Published experience with rectal foreign bodies is based mainly on single-center case series (table 1). Studies of adults have suggested that most patients are men (65 to 100 percent) who are in their thirties or forties (range 16 to 94 years) [1-4].

The incidence is not known precisely, but rectal foreign bodies are seen regularly in most large hospitals. As an example, in a report from the University of California of patients seen between 1993 and 2002, approximately one patient per month received care for a rectal foreign body [5].

CLASSIFICATION — Placement has been categorized as voluntary versus involuntary (eg, rape, assault) and sexual versus nonsexual.

Involuntary nonsexual foreign bodies often involve children or patients who are mentally ill. They have also resulted from medical instruments such as thermometers or enema tips and, uncommonly, from peroral ingestion of objects that become lodged in the colon (eg, bones, toothpicks, and small objects such as erasers or broken plastic utensils).

Voluntary nonsexual placement includes such practices as "body-packing" of latex condoms or plastic bags of cocaine and other illicit drug paraphernalia. Although impaction and bowel obstruction can result from this practice, more devastating outcomes occur with rupture of the containers leading to drug absorption resulting in overdose or even death [6].

More commonly, foreign bodies are introduced through the anal canal voluntarily during sexual practices.

The American Association for the Surgery of Trauma has proposed a Rectal Organ Injury Scale [7]:

Grade 1 – Contusion or hematoma without devascularization, or partial-thickness laceration

Grade 2 – Laceration ≤50 percent circumference

Grade 3 – Laceration >50 percent circumference

Grade 4 – Full-thickness laceration with extension into the perineum

Grade 5 – Devascularized segment

Most injuries due to rectal foreign bodies are grade 1.

TYPES OF FOREIGN BODIES — Foreign bodies consist of all types and sizes, with the most common items including phallic-shaped items. As will be discussed below, the shape and size of the object may influence subsequent management.

A partial list documented in the literature along with the authors' experience includes balloons, barium enema tips, batteries, a billy club, bones, bottles, broomsticks, crab shell, a curtain rod, dentures, drugs (eg, marijuana, cocaine, amphetamines), fish hooks, flotation devices, garden tools, glue, a hosepipe, light bulbs, markers, match sticks, money, nails, ornaments, a paintbrush, a penknife, pets' toys, a pill bottle, a spray can, stones, a stove, stuffed animals, thermometers, a toothbrush, tumbler, toy cars, a trailer hitch, a turkey baster, utensils, a vacuum hose, wire, and a variety of fruits and vegetables. There have been also retained foreign bodies from medical procedures [8]. The wide variety of items underscores the need for an approach that considers the optimal methods and risks associated with removing the object.

CLINICAL MANIFESTATIONS AND DIAGNOSIS — Recognition and diagnosis of rectal foreign bodies depends upon an appropriate history and physical examination and radiological evaluation as needed.

History and physical examination — Patients are often reluctant to fully disclose their situation and instead may complain of anorectal or abdominal pain, blood per rectum, or mucus discharge, while not volunteering the presence of a foreign body [1,5]. In our experience, many patients will only admit to a rectal foreign body when directly asked about it.

Many patients present hours or even days after placement following repeated failed attempts at removal. In some cases, patients present following successful removal of the object but with secondary manifestations from local trauma (eg, mucosal tears, sphincter disruption or perforation).

In rare instances, presentation has been delayed for years. One report, for example, described a patient with a rectal perforation due to a thermometer who remained asymptomatic for seven years before the thermometer was discovered incidentally on a plain abdominal radiograph [9].

Findings on physical examination are variable. The abdominal examination can be normal or show tenderness, a palpable mass, or diffuse peritonitis if perforation has occurred. Rectal examination may be completely normal or demonstrate bright red blood or melena, depending upon the timing of presentation. Although the foreign body is typically found in the mid- or distal rectum, the absence of a palpable foreign body on digital examination does not exclude its presence. The object may either be located proximally in the high rectum or colon.

Laboratory findings — Laboratory examination is often unremarkable. The presence of leukocytosis and/or metabolic acidosis is concerning for extensive injury.

Radiological evaluation — A radiological evaluation is often helpful. We generally begin with a plain film radiograph (an abdominal flat plate to identify the object and an upright film to evaluate for pneumoperitoneum) (image 1). In patients in whom there is concern related to a radiolucent object and in those who have concerning findings on initial evaluation, we suggest a computed tomography (CT) scan.

MANAGEMENT — Patients should initially be assessed for signs of perforation. Hypotension, abdominal pain, or increasing deep pelvic pain in the setting of rectal foreign body placement mandates an evaluation for full-thickness injury; we usually obtain plain films to rule out free air (as quickly as possible) or a CT scan in more stable patients. Patients with peritoneal signs or obvious perforation require urgent surgical evaluation and treatment. Such patients should be kept nil per os and resuscitated with intravenous fluid, and appropriate laboratory evaluation should be obtained (ie, complete blood count, chemistries, and a coagulation panel).

If the foreign body is still in place, it should ideally be removed in an emergency department or an outpatient setting (see below). Clinically stable patients with foreign bodies that are located proximally can be observed to see if the object will progress to the distal rectum, which facilitates transanal removal. We suggest against using enemas or stimulant suppositories in this setting, although such an approach has been described. Use of these approaches theoretically risks forcing the foreign body into a more proximal location or causing more extensive injury (especially with sharp objects).

Transanal approach — The majority of rectal foreign bodies can be removed transanally [5]. One of the most important factors required for success is adequate patient relaxation, which can be accomplished with intravenous sedation and perianal nerve blocks:

Intravenous sedation allows patients to relax, decreases anal spasm, and permits improved exposure and visualization of the object.

Perianal blocks with local anesthesia similar to that used for elective anorectal surgery can also facilitate patient comfort and should be used as needed. We use a mixture of lidocaine and bupivacaine to perform both a pudendal nerve and intersphincteric block. (See "Pudendal and paracervical block".)

The patient can be placed in any position, depending upon the clinician's preference. We prefer the lithotomy position, especially when an assistant is present, since it can facilitate abdominal pressure for stabilization and downward pressure on the object.

We initially perform a digital rectal examination to confirm the object's presence, size, and location. Various retractors and clamps commonly used in routine anorectal surgery should be available. We frequently use a tenaculum or Kocher clamp to grasp and maintain control of the object throughout rectal removal.

Standard implements for anorectal surgery may not always be sufficient, depending upon the size, shape, and composition of the object. A variety of improvised methods have been described in such settings (see below).

Following successful removal, we routinely perform rigid proctoscopy or flexible sigmoidoscopy to evaluate the mucosa for local damage, active bleeding, perforation, or additional retained objects. We generally repeat plain film to look for free air from perforations that may have occurred during the course of the object's removal and those that were not identified via direct visualization.

Blunt objects — Many different methods have been described for removal of blunt objects. Probably the best approach is grasping the object; success depends upon the operator's hand size and the adequacy of anal relaxation. Patients often have a history of repetitive anal insertion leading to sphincter laxity, which facilitates manual removal of the object. Awake, albeit sedated, patients can help by performing a Valsalva to attempt to propel the smooth blunt object toward the rectum. When this does not provide the ability to grab the object, clamps such as those described above are needed.

However, smooth objects like bottles cannot always be grasped, while objects such as fruits and candles can break with repetitive attempts at clamp removal. In such cases, we have used a technique of breaking full apples and vegetables into smaller pieces that can be grasped and more easily removed (picture 1A-B).

Several other approaches have been reported, including [1-3,5,10-21]:

Placement of a Foley catheter above a smooth object to create a seal and pull the object down back towards the anus

Injection of air above the object to break the vacuum seal that can be present in the colon proximal to the object

Use of magnets to help extract metal objects

Inflation of the balloon from a Sengstaken-Blakemore tube inside the object (such as a jar) to provide traction and extract the object transanally

Use of an obstetrical vacuum device to provide suction to remove the foreign body

Sharp objects — Extraction of sharp objects is often more difficult than removal of blunt objects and is associated with an increased risk for local mucosal trauma and perforation. We suggest avoiding blind attempts at grasping the object; the object should be manipulated only when it can be visualized transanally or through a proctoscope or sigmoidoscope. Extra attention during and after removal will aid in preventing and identifying mucosal injury.

Body packers — Patients who inserted objects to conceal illicit drugs (such as cocaine) are a particular challenge since care must be made to avoid disrupting the outer barrier holding the drugs (image 2A-B). Most of these patients use condoms or other easily breakable material for the packets, which can be easily damaged with clamps and other sharp medical instruments; spillage of the contents into the colon can lead to systemic toxicity and death. As a result, these instruments should generally not be used.

If manual extraction is not successful and there is neither obstruction nor signs of systemic toxicity, admission may be warranted for a period of observation to attempt to allow the packets to pass closer to the rectum. A more aggressive approach (which may include surgery and treatment for drug toxicity) is required if this is not successful and in patients with clinical features of obstruction, perforation, or systemic absorption. (See "Internal concealment of drugs of abuse (body packing)".)

Endoscopy — Objects that lie more proximally in the rectum or distal colon are more challenging than objects in the distal rectum since they are often not accessible via typical transanal approaches. In a review of 87 cases, significantly more patients with a foreign body in the sigmoid colon ultimately required surgery compared with those in the rectum (55 versus 24 percent) [5].

Endoscopy provides an opportunity to avoid abdominal exploration. We generally perform flexible sigmoidoscopy to identify the object. Endoscopic snares commonly used for polypectomy or endoscopic retrograde cholangiopancreatography (ERCP) wires provide excellent tools to "lasso" the foreign body and remove it alongside the scope (picture 2 and picture 3). This approach also provides the ability to watch the complete removal of the object and repeat the endoscopy following removal to evaluate for local mucosal injury, perforation, or retained objects.

Surgery — The inability to remove objects in an outpatient setting does not always mandate a laparotomy. Improved relaxation and sedation can be accomplished in the operating room, often permitting successful transanal extraction. As noted above, perianal blocks in addition to intravenous sedation can facilitate removal. Palpation of the abdomen frequently permits caudal pressure and stabilization of the object, which may allow it to be removed transanally.

Surgery is generally required if this is not successful and in all patients with evidence of peritonitis or perforation. Although initial transanal extraction can be attempted, surgeons should avoid any unnecessary, prolonged attempts. Leaving the object in place may help identify the site of perforation for appropriate treatment. Transanal minimally invasive (TAMIS) approaches have been reported with successful outcomes when performed in stable patients with no signs of perforation by surgeons with appropriate experience [22]. (See "Transanal endoscopic surgery (TES)".)

Laparoscopy has been described to push the rectal foreign body from above to assist removal transanally [23,24]. Removal in patients requiring exploration in the absence of perforation may still be successful via the transanal route by milking the object distally in the rectum (analogous to squeezing a tube of toothpaste). Care must be taken to avoid further injury during this maneuver when dealing with sharp or breakable objects.

Colotomy with removal and primary closure is required if this is not successful. Proximal diversion is not necessary in the absence of perforation, gross spillage with excessive contamination during colotomy, or necrotic bowel.

Foreign body-induced perforation — Free perforation of the intraperitoneal rectum or colon mandates laparotomy with appropriate removal. Whether the patient should undergo primary repair or a diverting stoma depends upon the patient's condition, degree of injury, and extent of intra-abdominal fecal soilage.

Successful primary repair and avoidance of proximal diversion have been reported in trauma patients, but the approach needs to be individualized at the time of exploration [25,26]. Small extraperitoneal perforations in hemodynamically stable patients have been successfully treated with admission, complete bowel rest, and intravenous antibiotics alone [27]. However, patients should be observed in the hospital for progression of disease, which mandates surgical exploration. There remains some difficulty in differentiating partial-thickness from full-thickness rectal injuries, which has led to some patients with partial thickness undergoing operative intervention [28].

POSTREMOVAL MANAGEMENT — The length of period of observation following removal of the retained object is variable. It depends in part upon the clinical status of the patient, the size of the object removed and any resultant trauma associated with it, the status of the rectal wall (ie, degree of mucosal ischemia or injury), and the method used for removal (ie, spontaneous versus transanal versus laparotomy).

Postextraction endoscopy with either a proctoscope or flexible sigmoidoscope should be performed to evaluate the anorectal mucosa for injury and assure that no other retained objects remain. In addition, an upright chest radiograph may be warranted to look for free air to assure that perforation did not occur from a foreign body or during extraction.

Continuation of perioperative antibiotics is not necessary following simple extraction without any complications.

All patients should remain for a period of observation and repeat examinations. Before discharge, all patients should be offered the opportunity for psychological support, while avoiding casting judgment or belittling them.

COMPLICATIONS — Serious complications related to rectal foreign bodies are infrequent.

The most common complication involves tearing of the rectal mucosa during insertion or erotic behavior. The associated bleeding is often self-limited, although more pronounced ongoing bleeding may require examination under anesthesia and suture ligation.

Traumatic disruption of the sphincteric complex often results in varying degrees of fecal incontinence, especially with repetitive damage [29]. This may not manifest acutely.

Perforation is associated with higher degrees of morbidity and may result in rare cases of mortality. Factors such as underlying comorbidities, time of presentation, and degree of peritoneal soilage (ie, established fecal peritonitis versus walled-off abscess) all have a role in determining the degree of physiological insult. Case reports have documented the development of systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome, leading to multisystem organ failure and death [30]. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis" and "Acute respiratory distress syndrome: Epidemiology, pathophysiology, pathology, and etiology in adults".)

In patients who require a laparotomy and colotomy with removal or proximal diversion, most complications are due to wound infections and incisional hernias (table 1).

SUMMARY AND RECOMMENDATIONS

Rectal foreign body – Rectal foreign bodies can present a difficult diagnostic and management dilemma. They can be caused by a wide variety of objects, lead to variable degrees of local trauma to the surrounding tissues, and can be associated with perforation or delayed injury. Further complicating management are the variable degrees to which patients are willing to disclose the underlying cause leading to their presentation and the frequently long delay before they seek medical attention.

Assessment and diagnosis – Recognition and diagnosis of rectal foreign bodies depends upon an appropriate history and physical examination and radiological evaluation as needed. In our experience, many patients will only admit to a rectal foreign body when directly asked about it. (See 'Clinical manifestations and diagnosis' above.)

Patients should be assessed for signs of perforation. Patients with peritoneal signs or obvious perforation and those with obstruction require urgent surgical evaluation and treatment.

Management – If the foreign body is still in place, it should ideally be removed in an emergency department or an outpatient setting. Clinically stable patients with foreign bodies that are located proximally can be observed to see if the object will progress to the distal rectum, which facilitates transanal removal. We suggest not using enemas or stimulant suppositories in this setting (Grade 2C).

Transanal approach – The majority of rectal foreign bodies can be removed transanally, depending upon the object's size, characteristics, and location (see 'Transanal approach' above). We suggest the approaches below, which are based mainly on clinical experience (Grade 2C).

-In patients with blunt objects, we suggest attempts at manual removal after adequate sedation (intravenous and perianal nerve block). Other approaches can be attempted depending upon the object's characteristics and location. (See 'Blunt objects' above.)

-In patients with sharp objects, we suggest avoiding blind attempts at grasping the object; the object should be manipulated only when it can be visualized transanally or through a proctoscope or sigmoidoscope. (See 'Sharp objects' above.)

-In patients who are body packers, we suggest not using sharp medical instruments. (See 'Body packers' above.)

Endoscopic approach – In patients with objects proximal to the rectum, we suggest flexible sigmoidoscopy to attempt to move the object more distally and remove it under direct visualization. (See 'Endoscopy' above.)

Transabdominal approach – In patients in whom transanal approaches are unsuccessful, we suggest assuring that adequate sedation has been achieved (which can often be accomplished in the operating room). Abdominal palpation and adequate sedation may permit the object to be removed transanally. If this is not successful, laparoscopy or laparotomy may be required. The object can be "milked" toward the rectum during surgery, where it can be removed transanally. Colotomy and primary closure are required if this is not successful. (See 'Surgery' above.)

Post-removal management – Regardless of the method used to remove the foreign body, we suggest that after the object is removed patients undergo flexible sigmoidoscopy or rigid proctoscopy to evaluate for mucosal injury and/or additional objects (Grade 2C). Repeat radiography may also be required if perforation is suspected. Before discharge, patients should be offered the opportunity for psychological support, while at the same time avoiding casting judgment or belittling them. (See 'Postremoval management' above.)

Complications – While rectal foreign bodies are common, serious complications related to them or their extraction are infrequent. (See 'Complications' above.)

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