Rectal Foreign Body

Aka: Rectal Foreign Body, Foreign Body in Rectum, Inserted Rectal Foreign Body

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II. Precautions

  1. Patients are typically embarrassed by rectal foreign bodies
    1. Delayed presentations are common (with increased risk of complication)
    2. Maintain patient dignity, privacy in their care

III. Pathophysiology

  1. Typical insertion objects
    1. Sex toys
    2. Household items
      1. Smooth items such as bottles are most common
      2. Atypical objects have been used (e.g. rocks, eggs)

IV. Imaging

  1. Abdominal XRay
    1. Indicated in most cases
      1. Obtain before attempted removal to characterize object (esp. sharp edges that may injure operator)
    2. Often defines the Rectal Foreign Body (and if there are more than one)
      1. Non-radiopaque objects will often be well outlined by surrounding stool
    3. Identifies abdominal free air (although Chest XRay may better define this)
    4. Obtain repeat XRay for Retained Foreign Body or perforation after object extraction
  2. CT Abdomen with IV contrast Indications
    1. No peritoneal signs, but suspicion for small perforation or other bowel injury
    2. Concerning signs include bowel wall thickening, soft tissue stranding, extraluminal gas, suspected abscess
    3. Radiolucent Foreign Body
    4. No oral or rectal contrast needed (unless evaluating for perforation or fistula)
  3. Imaging with water soluble contrast enema (e.g. gastrograffin enema)
    1. Identifies perforation or fistula

V. Management: General Approach

  1. Precautions
    1. Avoid Laxatives as a way to expel foreign body (not effective and increases risk)
      1. May be cautiously used for Constipation
  2. Emergent surgery indications
    1. Generalized peritoneal signs (xray is often sufficient for preoperative evaluation)
    2. Bowel perforation (even small perforations)
  3. Expectant managament
    1. Small round objects (e.g. marbles)
  4. Manual extraction Indications (most cases)
    1. See below
    2. General Surgery for operative removal if Emergency Department manual removal fails

VI. Management: Manual Extraction

  1. Patient Position
    1. Lithotomy position with stirrups (otherwise in decubitus position)
  2. Preparation
    1. Wear full Personal Protection Equipment (mask, gown, footwear, gloves)
    2. Procedural Sedation is helpful
  3. Equipment
    1. Speculum
    2. Sponge sticks (use for manipulating object)
    3. Curved Kocher Forceps with teeth (esp. for plastic bottles)
    4. Foley Catheter (may be inflated behind object and pulled; variable efficacy)
  4. Technique
    1. Place speculum within Rectum
    2. Visualize object
      1. If sharp edges or other impediments to removal (e.g. spray bottle)
        1. Stop and defer to operating room removal
    3. Attempt removal with fingers first
      1. May attempt concurrent bimanual pressure through the abdominal wall
    4. May use instruments but Exercise caution (risk of rectal wall injury)
      1. Start with sponge sticks inserted behind object and pulled out
      2. Avoid excessive pressure or torque (defer to surgery in OR if unable to remove)

VII. Management: Disposition

  1. Observe patient for 4-6 hours after Foreign Body Removal for signs of peritonitis, perforation
  2. Longer observation may be needed for object retained for prolonged period

VIII. Complications

  1. Rectal wall pressure necrosis
    1. Associated with objects retained for a prolonged period
  2. Peritonitis
  3. Colon Perforation
  4. Failed Removal
    1. Objects >10 cm long
    2. Hard or sharp objects
    3. Objects proximal to the Rectum (e.g. sigmoid colon)
    4. Objects retained >2 days

IX. References

  1. Inaba and Swadron in Herbert (2018) EM:Rap 18(11): 5-7

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