Rectal foreign body

Background

• Make sure that object is not sharp before exam
• Injuries may consist of hematoma, lacerations (with potential perforation)
• Patients often do not present immediately; this prolonged retention increases the chances of complication

Clinical Features

• Rectal pain and/or fullness
• History of rectal foreign body placement
• Most are in the rectal ampulla and therefore palpable on digital examination
• Rectal bleeding

Differential Diagnosis

Anorectal Disorders

• Anal fissure
• Anal fistula
• Anal malignancy
• Anal tags
• Anorectal abscess
• Coccydynia
• Colorectal malignancy
• Condyloma acuminata
• Constipation
• Crohn's disease
• Cryptitis
• GC/Chlamydia
• Fecal impaction
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Levator ani syndrome
• Pedunculated polyp
• Pilonidal cyst
• Proctalgia fugax
• Proctitis
• Pruritus ani
  • Enterobius (pinworms)
• Rectal foreign body
• Rectal prolapse
• Syphilitic fissure

Non-GI Look-a-Likes

• Prostatitis

Evaluation

Foreign body noted in rectum on lateral abdominal xray

• Abdominal xray
  • Demonstrate position, shapes, and number of foreign bodies
  • Demonstrates possible presence of free air (perforation of rectum or colon)
    • Perforation of rectum below peritoneal reflection shows extraperitoneal air along psoas
    • Perforation above peritoneal reflection reveals intraperitoneal free air under diaphragm
• CT
  • Useful when foreign body is radiolucent and for detection of free air

Management

ED removal

Suitable for non-sharp objects that are in the distal rectum

1. Sedation
   • IV sedation and analgesia usually needed for adequate relaxation for removal of larger FB's
   • Local anesthesia (Perianal Block) will relax the anal sphincter and may be needed.
2. Manual removal
   • Anal lubrication
   • In lithotomy position, suprapubic pressure with DRE and valsalva may deliver object without instrumentation.
   • May also attempt removal in prone knee-to-chest position with the patient bearing down
   • Anoscope utilization and direct lighting will often improve visualization of the object if low lying
   • If obstetric forceps needed, patient should bear down as object is extracted.
   • Large bulbar objects create a vacuum-like effect
     • Break vacuum by passing foley behind object, inject air and pull foley out (balloon up)
     • Can introduce multiple foley catheters from different angles beyond the object, inflate the balloons, and slowly retract the foleys - using the force to help extract the object.

Surgical Consultation Indications

• Removal could injure the sphincter
• ED attempts fail
• Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia)

Consider Gastroenterology Consultation

• Can consider requesting sigmoidoscopy after object removal to rule out mucosal lacerations or small perforations not seen on radiographs
  • This is a concern in prolonged retention, objects with sharp corners, or toxic appearing patients

Disposition

• Consider observation for at least 12hr if concern for rectal perforation

See Also

• Anorectal Disorders
• Foreign bodies