Approach to the diagnosis and management of retained rectal foreign bodies: clinical update

A case of a stuck mesh in the rectum after pelvic surgery

A 67-year-old woman was referred to our hospital for further evaluation of a positive fecal occult blood test. Colonoscopy revealed an elevated rectal lesion (10 mm in size) with a central depression. A rod-like object was noted in the center of the lesion. Magnifying endoscopy with narrow-band imaging showed obscure surface structures and dilated vessels. Magnifying endoscopy with crystal violet staining showed that the pit pattern had disappeared. These endoscopic findings suggested that the lesion was comprised of granulation tissue. A detailed medical history revealed that she had undergone a total hysterectomy with mesh placement for bladder prolapse. We reasoned that the mesh used during pelvic surgery might have penetrated the rectum. She underwent subsequent surgery to remove the mesh. Although most foreign bodies in the rectum are swallowed or self-inserted, pelvic surgery is another source of foreign bodies in the rectum.

Cough syrup bottle at rectum in elderly male: a rare case report

Foreign body in the anal canal may be inserted for sexual gratification or sexual assault or accidental or drug trafficking. We report a case of a male who accidentally inserted a cough syrup bottle in his rectum. Presentation is usually late due to fear and embarrassment. The manual attempt of removal may be tried under adequate anesthesia. Post-procedure sigmoidoscopy or colonoscopy may be helpful to diagnose laceration or mucosal injury.

Successful Expulsion of a Golf Ball from the Sigmoid Colon Using Volume Laxatives

Background

Rectal foreign bodies form a surprisingly frequent cause of presentation to the emergency department. The materials inserted constitute a wide range of size, shape, and texture with each presenting a unique set of challenges. Despite a seemingly innocuous presentation, if not recognised early and managed accordingly, significant complications can develop including obstruction, perforation, and sphincteric injury. The existing doctrines advocate endoscopic intervention after simple measures fail and advise against the use of laxative therapy due to concerns for complications that may arise. The authors of this study challenge this notion, provided certain conditions are met. Case Presentation. We report the case of a 14-year-old boy who inserted a golf ball into his rectum, which subsequently migrated proximally into the sigmoid colon on plain radiographic films. The patient was asymptomatic on presentation, and there was no clinical evidence of bowel injury or mechanical bowel obstruction. Endoscopic removal of the golf ball was pursued under general anaesthesia. Despite protracted efforts, the golf ball was not able to be retrieved endoscopically. In an attempt to avoid aggressive surgery, volume laxatives were administered with successful passage of the golf ball several hours later.

Conclusions

This case discusses the unique technical challenges, which may be encountered when attempting to retrieve a large, spherical, and non-confirming foreign body entrapped above the rectosigmoid junction and how these factors can complicate endoscopic retrieval. The authors advocate that in the absence of a mechanical bowel obstruction, patients with foreign bodies possessing physical properties that are amenable to spontaneous passage, a trial of strong aperients, should be considered first line. The author's contention is that direct escalation to removal of foreign body in theatre can be resource draining and may expose the patient to additional risk.

Management of unusual rectal foreign body - Case report and literature review

Introduction

Retained rectal objects represent a rare complaint in the emergency room, affecting mainly males between 20 and 40 years, with most objects of a sexual nature, but the examiner must be aware of objects of an unusual nature.

Presentation of case

A 54-year-old male patient arrives at the surgical emergency department, with a report of an accident with the insertion of an object via the rectum, a gym dumbbell. Initially opted for transrectal object removal, but with difficulties due to its position.

Discussion

Retained rectal objects are a rare complaint in the emergency department, but with an increasingly important occurrence in recent years. Physical examination should include an assessment of the abdomen and digital rectal examination. Imaging tests are mandatory for diagnosis, with abdominal and pelvis radiography being the most requested. Although there is no consensus on the most appropriate removal technique, less invasive initial approaches are recommended, with transanal removal with a 60–75% success rate under local anesthesia. The follow-up after the procedure depends on several factors, and in general, the patient should be kept under observation and attention should be paid to significant changes in the evolution and alterations in the imaging tests.

Conclusion

The clinical history in these cases can be confusing, due to the patient's fear of reporting the complaints. Radiography is the best initial test, and CT is reserved for cases of suspected complications. Whenever possible, perform the extraction rectally.

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Retained rectal objects are a rare complaint in the emergency department.

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Less invasive initial approaches are recommended.

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The follow-up after the procedure depends on several factors.

Systematic review of rectal foreign bodies in older men: humanistic care and a novel challenge for society

Background

In recent years, rectal foreign bodies have become a common proctological emergency in the male population, especially older Chinese men, often requiring surgical intervention due to associated complications. This review aimed to describe the epidemiology and clinical characteristics of rectal foreign bodies in older men and examine the possible challenges presented by the condition to clinicians and society.

Methods

A comprehensive search was conducted in English-language databases and Chinese databases from January 2000 to December 2020. Studies concerning rectal foreign bodies were considered for this review if they reported the reason for a foreign body being in the rectum and related treatment measures. Contemporaneous rectal foreign bodies case data from General Surgery Department of Tangdu Hospital were also analyzed. According to differences in ethnicity, the older male patients were divided into a Chinese group and a non-Chinese group, and the parameters of the two groups were analyzed using statistical methods.

Results

A total of 159 studies were retrieved in an initial database search using “rectal foreign body” as the search term. These included 86 Chinese studies and 73 English-language studies. Collectively, these studies included 582 older male patients, 276 of whom were Chinese, and 307 who were non-Chinese. According to their source, the rectal foreign bodies were classified into 3 categories. The most common reason for a foreign body in the rectum was insertion for erotic purposes, with everyday articles accounting for most foreign body types. Sexual articles were mainly found to have been used in the pursuit of pleasure. There were no significant differences in foreign body sources, sizes, types, treatment selections, and outcomes between the two groups.

Discussion

Emergency hospital visits by older men with rectal foreign bodies due to erotic and sexual needs and practices are increasing. Although the sources, sizes, and types of foreign bodies were different, and patients recovered well after active and appropriate clinical treatment, the sexual needs of older men are a social issue that requires attention. Acknowledging and dealing with sexual issues is a multidimensional task that requires a collaborative effort to ensure a more humanistic approach to older patients.

Management of Asymptomatic Perforation of a Pediatric Rectal Foreign Body into the Peritoneal Cavity Retrieved with Laparoscopy: A Case Report and Review of the Literature

Rectal foreign body insertion has had an increasing trend throughout the years, whereas it is rarely reported in pediatrics. The management and treatment of these cases can become challenging, since it also can present with atypical or even no symptoms in physical evaluation. A 14-year-old boy was referred to our hospital with a history of insertion of a paintbrush into his anus four weeks before the admission. The paintbrush had perforated the colon and was in the abdominopelvic cavity; however, no symptoms of peritonitis were observed. Rectal examination, sigmoidoscopy, and colonoscopy were unremarkable. Exploratory laparoscopy was performed, and the paintbrush was taken out completely. The patient was discharged in good condition. In cases with rectal foreign body insertion, perforation without causing peritonitis or acute abdomen is possible. In these conditions, imaging examinations play an essential role in managing the patients, and laparoscopy can be a proper procedure for retrieving the foreign body.

Austere Foreign Body Injuries in Children and Adolescents: A Characterization of Penile, Rectal, and Vaginal Injuries Presenting to Emergency Departments in the United States From 2008 to 2017

BACKGROUND

Pediatric foreign body (FB) injuries to the nasal, aural, and/or oral cavities are well documented. Description of austere foreign body (AFB) injuries involving the rectum, vagina, or penis eludes the current pediatric literature. Austere FBs can be difficult to identify and have the potential to cause serious consequences. We aim to characterize AFB injuries by children and adolescents presenting to emergency departments (EDs) in the United States.

METHODS

The National Electronic Injury Surveillance System was queried to include subjects aged 0 to 25 years using a primary search term for diagnosis of foreign body from the period of January 2008 to January 2017. The consumer product and the body part involved (ie, rectal, vaginal, penile) were analyzed. Taylor series linearization generated national estimates. A trend analysis was performed using the Cochrane Armitage test of trend.

RESULTS

There were 27,755 (95% confidence interval, 21,170-34,338) national estimated childhood ED visits for suspected AFB injuries during 2008 to 2017 including an estimated 7756 vaginal FBs, 7138 penile FBs, and 8359 rectal FBs (RFBs). Over the timeline, there was a significant up trend in the frequency of annual RFBs (P < 0.01).

CONCLUSION

Austere FB injuries appear to cluster around age of 7 years. Most AFB injuries are able to be treated and released from the ED. It appears that RFB injury frequencies are rising and tend to require more frequent admission. Providers must be vigilant in the diagnosis and management of these potentially hazardous injury types.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Broken beer bottle as a cause of sigmoid perforation: A summary of causes and predictors in the management of traumatic and non-traumatic colorectal perforation

INTRODUCTION AND IMPORTANCE

The presence of foreign bodies at the colorectal level and associated complications is a problem that has become increasingly common in emergency departments. This condition carries high health costs, in addition to having high morbidity and mortality rates, due to the large number of complications such as perforation.

CASE PRESENTATION

46-year-old male patient, who came to the emergency department of a low-level hospital with a clinical picture of approximately one day of evolution consisting of the violent introduction of a foreign body (bottle) at the anorectal level secondary to aggression in a fight, with subsequent endoluminal rupture.

CLINICAL DISCUSSION

The most recent evidence indicates that the incidence of perforation as a complication of colorectal foreign body introduction is low. However, the presence of profuse bleeding, advanced age, presence of comorbidities and sepsis are predictors of poor prognosis in these cases. In general, perforation secondary to non-traumatic causes is more frequent, being predominantly due to colorectal cancer, ischemia, diverticulitis, inflammatory bowel disease, inadequate use of enema, iatrogenic endoscopy or anorectal manometry or fecal impaction. The presence of unfavorable factors prolongs hospital stay, the risk of reoperation, perianal infection, peritonitis, sepsis and wound infection, generating mortality rates of up to 38%.

CONCLUSION

Colorectal perforation is more frequent in non-traumatic situations and carries health costs and risk of mortality. Its management depends on hospital aspects, clinical context of the patient and training of health personnel. However, most of the outcomes are favorable.

Case Series: Removal of Rectal Foreign Bodies

Introduction: Foreign rectal body is one of the less common presentations in the emergency department and has a variety of etiologies. Our aim is to study the mode of injury, clinical presentation, diagnosis, surgical intervention and outcomes associated with a rectal foreign body.

Methods: This cross-sectional case series was conducted from January 2019 to July 2019 in the surgical unit of a tertiary care teaching hospital in Pakistan. Mode of injury was classified as voluntary - for sexual gratification, involuntary ingestion, assault and fall. We also noted the presenting complaint, diagnosis, surgical intervention and outcome of the case.

Results: Foreign body in the rectum was more common in men (86.3%) than women (13.7%). The mean age of participants was 40 ± 15 years. Various causes include sexual gratification (45.4%), involuntary ingestion (27.2%), assault (22.7%) and history of fall (4.5%). Participants were diagnosed with sub-acute intestinal obstruction (59%), peritonitis (22.7%) and perianal injury (36.3%).

Conclusion: Sexual gratification was the most common reason for the retained rectum body. Timely diagnosis and management are required to prevent perforation and improve prognosis.

Rectal foreign body of a shattered glass bottle; Case report of unexpected late post-operative hemorrhage managed transanally

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Colonoscopy post perforating rectal injury may be employed to evaluate and treat bleeding.

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DRE should be cautioned when suspecting hazardous material in the colorectal tract.

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Mobilization of foreign bodies must be determined in a case by case basis.

Introduction

Retained rectal foreign bodies are commonly implicated in patients engaging in erotic behavior. The foreign bodies vary widely, however, penetrating rectal wounds are uncommon and often complicate the retrieval of the object. The rich vascular bed of the rectal mucosa provides additional bleeding complications.

Presentation of case

A 55-year-old male presented with active bleeding after intentional insertion of a glass bottle into the rectum which shattered. Partial retrieval via proctoscopy was followed by an exploratory laparotomy with a diverting colostomy, mucous fistula, and presacral drainage. Postoperative course was complicated by severe hematochezia. Colonoscopy was performed in the operating room found actively bleeding ulcers at sites of previously lacerated mucosa; one pulsating, protruding, vessel was visible. Clips were placed over the vessel with cessation of bleeding. Barium enema at three months follow revealed no leaks allowing for reversal of the colostomy.

Discussion

This case of operative retrieval of a rectal foreign body is unique because it displays deviation from commonly used algorithms are periodically needed to optimize patient recover.

Conclusion

The utilization of minimally-invasive colonoscopy prior to additional surgical intervention in post-operative rectal bleeding following a rectal foreign body retrieval may improvie patient recovery time, functionality, and long-term outcomes.

The Management of Retained Rectal Foreign Body

Purpose

Because insertion of a foreign body (FB) into the anus is considered a taboo practice, patients with a retained rectal FB may hesitate to obtain medical care, and attending surgeons may lack experience with removing these FBs. We performed this study to evaluate the clinical characteristics of Korean patients with a retained rectal FB and propose management guideline for such cases based on our experience.

Methods

We retrospectively investigated 14 patients between January 2006 and December 2018. We assessed demographic features, mechanism of FB insertion, clinical course between diagnosis and management, and outcomes.

Results

All patients were male (mean age, 43 years) and presented with low abdominal pain (n = 2), anal bleeding (n = 2), or concern about a retained rectal FB without symptoms (n = 10). FB insertion was most commonly associated with sexual gratification or anal eroticism (n = 11, 78.6%). All patients underwent general anesthesia for anal sphincter relaxation with the exception of 2 who underwent FB removal in the emergency department. FBs were retrieved transanally using a clamp (n = 2), myoma screw (n = 1), clamp application following abdominal wall compression (n = 2), or laparotomy followed by rectosigmoid colon milking (n = 2). Colotomy and primary repair were performed in four patients, and Hartmann operation was performed in one patient with fecal peritonitis. No morbidity or mortality was reported. All patients refused postextraction anorectal functional and anatomical evaluation and psychological counseling.

Conclusion

Retained rectal FB is rare; however, colorectal surgeons should be aware of the various methods that can be used for FB retrieval and the therapeutic algorithm applicable in such cases.

Repeat presentation of large rectal foreign body requiring surgical intervention

Irretrievable rectal foreign bodies can cause significant distress and generally require emergency medical attention. While smaller objects can often be removed trans-anally, larger objects typically require more invasive intervention. Here, we report the case of a 57-year-old man who had previously presented to the emergency department with a baseball lodged in the rectosigmoid that required a laparotomy. One year later, he represented with a significantly larger object also affixed in the rectosigmoid. Exploratory laparotomy revealed an edematous, inflamed bowel with extensive adhesions from the pervious surgery. Given the degree of tissue damage and large size of the object, the decision was made to perform a Hartmann’s procedure. The object, an 11 × 10 cm rubber chew toy, was successfully removed and the patient was referred to the appropriate mental health professionals during follow-up.

A Particular Use of Endobag®: Extraction of Rectal Foreign Bodies

Introduction

The incidence of foreign bodies (FBs) in the rectum has recently increased. FB removal by the transanal way or by colonoscopy is generally feasible and only in few cases surgery is strictly necessary. Due to FB dimensions or rectum and colon anatomy, sometimes it may represent a challenge.

Materials and Methods

Two cases of FB inserted in the rectum were treated in our institute. They underwent surgery using Endobag, a laparoscopic surgical device. The device was inserted through the anus in order to catch and remove the FB.

Results

Both the procedures were easily performed, without any complication.

Conclusions

The use of Endobag seems to be a good and effective way to remove FB from rectum.

Successful Retrieval of a Retained Rectal Foreign Body in the Emergency Department

Rectal foreign bodies are a common presenting complaint in the emergency department. Anal eroticism is the major reason for the majority of cases of rectal foreign bodies. A high index of suspicion is required to accurately diagnose a rectal foreign body as patients are often embarrassed about their condition and may not present in a timely fashion to be evaluated or volunteer their history. Extraction techniques include transanal, endoscopic, and laparotomy with repair of complications. Here, we present the case of successful transanal manual removal of a retained dumbbell in the rectum of a middle-aged man.

Increasing trend in retained rectal foreign bodies

AIM

To highlight the rising trend in hospital presentation of foreign bodies retained in the rectum over a 5-year period.

METHODS

Retrospective review of the cases of retained rectal foreign bodies between 2008 and 2012 was performed. Patients’ clinical data and yearly case presentation with data relating to hospital episodes were collected. Data analysis was by SPSS Inc. Chicago, IL, United States.

RESULTS

Twenty-five patients presented over a 5-year period with a mean age of 39 (17-62) years and M: F ratio of 2:1. A progressive rise in cases was noted from 2008 to 2012 with 3, 4, 4, 6, 8 recorded patients per year respectively. The majority of the impacted rectal objects were used for self-/partner-eroticism. The commonest retained foreign bodies were sex vibrators and dildos. Ninty-six percent of the patients required extraction while one passed spontaneously. Two and three patients had retrieval in the Emergency Department and on the ward respectively while 19 patients needed examination under anaesthesia for extraction. The mean hospital stay was 19 (2-38) h. Associated psychosocial issues included depression, deliberate self-harm, illicit drug abuse, anxiety and alcoholism. There were no psychosocial problems identified in 15 patients.

CONCLUSION

There is a progressive rise in hospital presentation of impacted rectal foreign bodies with increasing use of different objects for sexual arousal.

[Treatment of rectal foreign bodies]

AIM

to present the results of treatment of rectal foreign bodies.

MATERIAL AND METHODS

15-year outcomes of 112 patients with rectal foreign bodies were analyzed.

RESULTS

Outpatient and hospital care were applied in 52 (46%) and 60 (54%) of cases respectively. Transanal removal was made in 97 (87%) patients including 28 (25%) cases of general anaesthesia. 14 (13%) patients underwent surgery. Colostomy was performed in 7 (6%) cases. We presented cases of foreign bodies removal through laparotomy, colotomy and SILS-assisted transanal approach.

DISCUSSION

From clinical point of view foreign bodies should be first of all classified by their dimensions. Anamnesis and physical examination are very important. Abdominal X-ray survey is obligatory. Transanal removal under general anaesthesia is advisable if perforation is absent. If such procedure is impossible laparotomy is indicated.

CONCLUSION

Algorithm of survey and treatment is presented.

Anorectal emergencies

Anorectal emergencies refer to anorectal disorders presenting with some alarming symptoms such as acute anal pain and bleeding which might require an immediate management. This article deals with the diagnosis and management of common anorectal emergencies such as acutely thrombosed external hemorrhoid, thrombosed or strangulated internal hemorrhoid, bleeding hemorrhoid, bleeding anorectal varices, anal fissure, irreducible or strangulated rectal prolapse, anorectal abscess, perineal necrotizing fasciitis (Fournier gangrene), retained anorectal foreign bodies and obstructing rectal cancer. Sexually transmitted diseases as anorectal non-surgical emergencies and some anorectal emergencies in neonates are also discussed. The last part of this review dedicates to the management of early complications following common anorectal procedures that may present as an emergency including acute urinary retention, bleeding, fecal impaction and anorectal sepsis. Although many of anorectal disorders presenting in an emergency setting are not life-threatening and may be successfully treated in an outpatient clinic, an accurate diagnosis and proper management remains a challenging problem for clinicians. A detailed history taking and a careful physical examination, including digital rectal examination and anoscopy, is essential for correct diagnosis and plan of treatment. In some cases, some imaging examinations, such as endoanal ultrasonography and computerized tomography scan of whole abdomen, are required. If in doubt, the attending physicians should not hesitate to consult an expert e.g., colorectal surgeon about the diagnosis, proper management and appropriate follow-up.

Retrospective Audit of the Management of Anal Insertion of Foreign Bodies: A Holistic Approach

Most patients with voluntary anal insertion of a foreign body (IFB) present to the emergency department and are then managed by the surgical team. This report reviews the medical literature on IFB and includes results of a chart review of operative logged interventions and clinically coded procedures for anal IFBs at a single acute hospital in the United Kingdom between May 2009 and September 2013. The objective was to establish the current practice in the management of anal IFB and update a framework for the initial workup, surgical procedure, and appropriate mental health intervention.

Removal of Rectal Foreign Bodies Using Tenaculum Forceps Under Endoscopic Assistance

The incidence of rectal foreign bodies is increasing by the day, though not as common as that of upper gastrointestinal foreign bodies. Various methods for removal of foreign bodies have been reported. Removal during endoscopy using endoscopic devices is simple and safe, but if the foreign body is too large to be removed by this method, other methods are required. We report two cases of rectal foreign body removal by a relatively simple and inexpensive technique. A 42-year-old man with a vibrator in the rectum was admitted due to inability to remove it by himself and various endoscopic methods failed. Finally, the vibrator was removed successfully by using tenaculum forceps under endoscopic assistance. Similarly, a 59-year-old man with a carrot in the rectum was admitted. The carrot was removed easily by using the same method as that in the previous case. The use of tenaculum forceps under endoscopic guidance may be a useful method for removal of rectal foreign bodies.

Removal of a sex toy under general anaesthesia using a bimanual-technique and Magill's forceps: A case report

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A case of a 68-year-old male with large bowel obstruction due to the presence of a phallic object in the rectum is presented.

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Removal of the phallic object was achieved using a pair of Magill’s forceps and bi-manual manipulation under general anaesthesia.

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This case demonstrates the use of Magill’s forceps to aid removal of a foreign body in the rectum.

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Laparotomy and open removal may, therefore, be rarely necessary.

Introduction

Phallic objects may cause large bowel obstruction if not promptly removed. A bi-manual technique with the aid of a Magill’s forceps is presented here.

Presentation of case

A 68-year-old man presented to the emergency department with severe lower abdominal discomfort, distension and inability to pass urine, flatus or bowel motions. He had inserted a phallic object in the rectum 10 hours prior to presentation and had been unable to remove same. Abdominal examination was remarkable for distension with tenderness also elicited suprapubically and in the left iliac fossa. The foreign body was barely palpable per rectum. Plain radiographs showed prominent left-sided colonic segments. Following the trial of a manual attempt at removal in the emergency department, a decision was made to remove this under anaesthesia due to worsening symptoms. The phallic object was successfully removed under general anaesthesia using bi-manual manipulation assisted by a pair of Magill’s forceps.

Discussion

The method of removal of phallic objects varies from one individual case to another. In the presence of obstruction, a quick decision must be made for removal under general anaesthesia and the patient will also need to be consented for laparotomy. Previous literature described a “cork-in-bottle” technique using myomectomy screws as well as use of single-incision laparoscopic surgery (SILS) ports for removal of phallic objects.

Conclusion

Extraction of phallic objects requires ingenuity. We describe another minimally invasive technique of removal that adds to the literature, thereby limiting the need for laparotomy and open removal of foreign bodies.