RECTAL FOREIGN BODIES BACKGROUND: Patients with rectal foreign bodies frequently present to the ED because of pain or inability to remove the object. Controlled studies on these patients have not been conducted and the literature is largely anecdotal. These patients typically present to the ED in a delayed fashion due to embarrassment or multiple attempts at self-removal. The keys to adequate care for these patients is respect for their privacy, determination of the type and location of the foreign body and use of appropriate techniques for removal. PATHOPHYSIOLOGY Rectal foreign bodies are either inserted (most common) or swallowed. Rectal foreign bodies can be classified as either high-lying or low-lying depending upon their location relative to the rectosigmoid junction. This distinction is important as objects that are past the sacral curve and rectosigmoid junction are difficult to visualize and remove and often unreachable by rigid proctosigmoidoscope. Low-lying rectal foreign bodies are normally palpable by digital exam, and are candidates for ED removal. The frequent delay in presentation leads to mucosal edema and muscular spasms further hindering removal. Rectal lacerations and perforations are less common. FREQUENCY No data on frequency of rectal foreign bodies has been collected. The literature 30 years ago reflected rare occurrences of rectal foreign bodies but evolved to publication of case series and systematic methods of evaluation and extraction. The use of foreign bodies for anal eroticism is apparently increasing, resulting in increased numbers of patients with retained rectal foreign bodies. MORTALITY/MORBIDITY Mortality is rare and results either from bleeding from rectal perforations or lacerations or from infectious complications. Morbidity is somewhat more common and is primarily a result of lacerations or perforations. SEX There is a 28:1 male to female distribution. AGE The age distribution is bimodal, with peaks in the 20’s (anal erotism) and 60’s (felt to be secondary to the use of foreign objects for prostatic massage). The typical patient has been described as 20-30 years old. CLINICAL HISTORY The chief complaint of patients with rectal foreign bodies usually falls into one of three categories: abdominal pain, rectal pain or bleeding or rectal foreign body. In the case of ingested foreign bodies which become lodged in the rectum, the usual etiologic objects are sunflower seeds, toothpicks or bones and the ingestion is typically unknown. These normally present with diffuse abdominal pain, although signs of peritonitis or bowel obstruction may also exist. Patients may also present with complaints of rectal pain, pruritis or bleeding. These patients are typically too embarrassed to mention the foreign body at triage but will normally admit to the physician the actual etiology. A high index of suspicion of rectal foreign body must be maintained in psychiatric patients or prisoners who present with rectal pain or bleeding. The vast majority of patients with rectal foreign bodies will present due to an inability to remove the object. Some patients may claim to have sat or fallen on the object and older patients may state they were engaged in therapeutic prostatic massage or breaking up fecal impactions when the object was lost. Occasionally, objects such as thermometers or enema tips may become lost. Most patients, however, will admit to the history of insertion by self or a partner. Typically there have been multiple attempts at self removal which have failed. It is important to ascertain whether the patient attempted any instrumentation in these attempts as this increases the risk of perforation or laceration. The length of time since insertion, as well as the presence of rectal or abdominal pain, fever or rectal bleeding are important elements of the history. The type of object should be determined as fragile or sharp foreign bodies deserve special consideration. A special circumstance is that of assault. Patients should be asked if the foreign body is the result of assault as more serious injuries are seen in these patients. Legal authorities should be notified. PHYSICALEXAM Vital signs and general appearance will indicate if a resuscitation is required, as fever or hypotension may be indicative of infection or bleeding. An abdominal exam should be performed. Absent bowel sounds, rigidity or peritoneal signs indicate probable perforation. The foreign body, especially if large or in a high-lying position can occasionally be palpated. A rectal examination is indicated in those patients who present with abdominal complaints. In general, it should be deferred in patients with known or suspected rectal foreign bodies, especially in prisoners or psychiatric patients, until after the location and type of foreign body is ascertained radiographically. In some cases, dangerous objects such as guns or sharp objects such as needles or razors are inserted rectally in an attempt to hide the object, or in the case of psychiatric patients, to injure the examiner. The main purpose of the rectal exam is to check for the presence of blood and the position of the foreign body. WORK-UP LAB STUDIES A hematocrit may be useful in the presence of bleeding. A white blood cell count with differential should be obtained in cases where infection is suspected. For patients who are operative candidates due to the presence of peritoneal signs, signs of sepsis or perforation or for rectal foreign bodies that cannot be removed in the ED, routine preoperative lab studies should be obtained. IMAGING STUDIES Flat plate of the abdomen or pelvis is indicated. The foreign object can be identified and localized in most cases. A lateral pelvic film sometimes gives additional information on the orientation of the foreign body, especially if the position of the foreign body (high-lying vs. low-lying) is uncertain. An upright chest radiograph is indicated to evaluate for free air under the diaphragms if perforation is indicated. TREATMENT PREHOSPITAL CARE Transport the patient in a position of comfort. Fluid resuscitation is indicated in cases of hypotension due to sepsis or hemorrhage. EMERGENCY DEPARTMENT CARE After the radiographs have been reviewed and no dangerous or sharp foreign body is present, a rectal exam should be performed. The presence of frank blood is an indication of laceration or perforation, and the patient should be referred to surgery for evaluation. If the foreign body is palpated on rectal exam, the object is considered to be low-lying and a candidate for ED removal. Objects that can be removed in the ED should be smooth, non-breakable and non-friable. The key elements of successful ED removal are visualization and sedation. As the patient will often have developed rectal edema or spasm, adequate sedation and analgesia are required. Under direct visualization with either an anoscope or proctoscope and adequate lighting, the object is grasped with forceps or snares. Retractors have also been used. Difficulties may be encountered in extracting larger objects around which the rectal mucosa has formed a seal. In these cases, placing a Foley catheter beyond the foreign object will break the suction seal and facilitate removal. In general, extraction attempts in the ED should be limited to about 30 minutes. After removal, a repeat exam, preferably direct using the anoscope or proctoscope, is indicated to evaluate for rectal injuries. In high-lying rectal foreign bodies, if the foreign object is palpable on abdominal exam and the patient is cooperative, a manual trans-abdominal attempt to manipulate the foreign body into a low-lying position can be made. If successful, ED extraction can then be attempted. CONSULTATIONS Consult general surgery for the following rectal foreign bodies: Evidence of laceration, perforation or infection High-lying that cannot be converted to low-lying Glass objects, with the possible exception of thick, sturdy objects Breakable or friable objects Sharp or non-smooth objects Dangerous objects Unsuccessful extraction attempt in ED The normal treatment of these patients by surgery will include attempted visualization and removal under general anesthesia using flexible rectosigmoidoscopy. In rare cases, laparotomy will be needed. DISCHARGE FURTHER INPATIENT CARE Arrange for evaluation and treatment for those patients who are not candidates for ED removal. Patients with subsequent non-complicated operating room removal are normally discharged after recovery. FURTHER OUTPATIENT CARE Refer most patients who have had ED extraction to general surgery for follow-up in 24-48 hours. Some patients with simple extractions can be re-evaluated in the ED in 24-48 hours. OUTPATIENT MEDICATIONS Discharge on oral analgesics such as non-steroidals or narcotic medications as indicated. Antibiotics are generally not indicated in patients discharged home from the ED. COMPLICATIONS The most common complications are rectal laceration and rectal perforation, which are determined by direct visualization. Questionable cases should be referred to general surgery. Other complications include infection, including abscesses and sepsis. MISCELLANEOUS MEDICAL/LEGAL PITFALLS Because of the embarrassment involved with the condition, patients will sometimes use false names or identification. After extraction, patients with rectal foreign bodies will sometimes elope from the ED. Ensure privacy and confidentiality for the patient. In some cases, the patient will not want any billing generated and will offer to pay in cash to avoid an insurance paper trail. Attempt to fulfill their requests. Do not perform a rectal examination, especially in prisoners or psychiatric patients, until the number, type and location of the rectal foreign body is ascertained radiographically. This will avoid patient or examiner injury from sharp or dangerous objects such as guns, needles, razors, etc.