An uncommon problem: Overcoming the challenges of rectal foreign bodies—A case series and literature review

Abstract

Key Clinical Message

Although rectal foreign bodies are rare presentations, this condition should be considered in patients with preanal pain, lower pelvic pain, or rectal bleeding.

Rectal foreign bodies are a rare occurrence and can pose a therapeutic challenge for surgeons. These objects may be inserted through the anus or ingested orally. This study presents a retrospective review of all cases of trapped rectal foreign bodies at a single university hospital. From 2001 to 2020, twelve cases of rectal foreign bodies were diagnosed and treated at Ghaem Hospital in Mashhad. Demographic information, type of foreign body, clinical presentation, and removal method were collected retrospectively. All cases of rectal foreign bodies entered through the anus. Twelve cases involved male patients, with a mean age of 47.5 years (ranging from 24 to 70 years), and two cases involved female patients, with a mean age of 29.5 years (ranging from 29 to 30 years). Patients' main complaint was defecation disorder, accounting for 57% of cases. The types of rectal foreign bodies included two body sprays, two wood pieces, two glass bottles, glasses, eggplants, cucumbers, squash, and anal dilators. One case involved surgical gas. In five cases, rectal foreign bodies were removed under general anesthesia through the rectum by dilatation. Rectal foreign bodies were removed by rectosigmoidoscopy in three cases, forceps in two cases, and abdominal maneuvers in one case. Only one case required laparotomy. Minor complications such as scratches or small mucosal tears were observed in some cases after removal of the foreign body, but no deaths were reported. Although rectal foreign bodies are rare, this condition should be considered in patients with preanal pain, lower pelvic pain, or rectal bleeding when no justification for recent endoscopic examinations is found. Most rectal foreign bodies are removed through the anus under appropriate anesthesia. Rectosigmoidoscopy is a good alternative if needed. Surgical measures are necessary for cases that lead to peritonitis or are likely to cause serious injury.

Rectal foreign body, a rare presentration and its therapeutic challenges.

1. INTRODUCTION

Foreign bodies in the rectum are considered as a rare presentation in medicine and are often associated with anal sexual activity using different objects. ¹ , ² , ³ , ⁴ The presence of foreign bodies in the rectum poses a challenge for physicians caring for these patients, and innovative approaches have been developed to remove them. However, most published studies on this topic are case reports, and there is a lack of complete studies on management strategies and clinical complications. This article reports the authors' experiences in this field and discusses the therapeutic approach to these situations.

2. METHODS AND MATERIALS

This retrospective study was conducted on medical records of patients admitted to Ghaem Hospital of Mashhad University of Medical Sciences between January 2001 and January 2019 with rectal foreign bodies. Patients who had swallowed foreign bodies were excluded. Information, including the year of occurrence, nature, and location of the foreign body, etiology, anesthesia methods, and removal method, was collected. Hospitalization and related complications were also recorded.

3. RESULTS

During the study period of January 2001–January 2019, 14 patients with foreign bodies trapped in the rectum were included in the study (Table 1). Of the 14 patients, 12 were male and 2 were female. The age range of the patients was between 24 and 70 years, with an average of 47 years. The foreign bodies found included various objects and materials such as eggplant, squash, cucumbers, spray, shampoo, cans, and glass bottles. Two cases of wooden cylindrical parts and one case of an anal dilator were also recorded. In one patient, surgical gas was left in the rectum after surgery. The most common cause of foreign body entrapment in the rectum was reported as unusual events such as falling or sitting incorrectly on a foreign object. Two cases of foreign bodies following a quarrel were also reported. The foreign object's location was determined by the surgeon during removal.

TABLE 1.

Information of patients with rectal foreign body.

Number	Age	Sex	Type of foreign body	Position	Anesthesia	Method of removing
1	63	Male	Glass bottle	Lower	Spinal	Sigmoidoscopy
2	43	Male	Glass bottle	Upper	General	Laparotomy and colotomy
3	70	Male	Shampoo can	Lower	General	Sigmoidoscopy
4	32	Male	Deodorant spray	Upper	General	Trans‐anal forceps with abdominal maneuver
5	55	Male	Pumpkin	Lower	Spinal	Trans‐anal forceps
6	24	Male	Cucumber	Lower	General	Trans‐anal forceps with hand
7	29	Female	Surgery gas	Lower	Spinal	Sigmoidoscopy
8	47	Male	Eggplant	Lower	General	Sigmoidoscopy
9	29	Male	Wood part	Lower	General	Trans‐anal forceps
10	69	Male	Wood part	Lower	General	Trans‐anal forceps with hand
11	30	Female	Sexual toy	Lower	General	Trans‐anal forceps with hand
12	43	Male	Deodorant spray	Lower	General	Trans‐anal forceps with hand
13	20	Male	Sexual toy	Lower	Without anesthesia	Spontaneous exit
14	41	Male	Plastic soft drink can	Lower	General	Trans‐anal forceps with hand

All patients underwent a comprehensive clinical examination, with abdominal X‐rays performed in all cases. No evidence of intestinal rupture was found during radiological examinations. The objects located in the rectum's ampoule region were classified as being in a lower position, while those adjacent to or above the rectosigmoid junction (approximately 10 cm above the dentition line in an average‐sized adult) were considered to be in an upper position. Among the foreign bodies, 14 were in the lower position, and two were in the upper position. All foreign bodies in the lower position were successfully removed using non‐surgical methods. For foreign bodies in the upper position, most were removed through an abdominal maneuver via the anal route, except for one case that necessitated laparotomy due to the fragile nature of the object.

Rectosigmoidoscopy was performed to assess mucosal damage after foreign body removal. Superficial scratches were observed in the anoderm area in five cases, while mucosal tears were noted in three cases. The duration of hospitalization was 7 days for patients who underwent laparotomy, with an average hospital stay of 1.5 days for patients treated via transanal procedures. No specific side effects were reported.

4. DISCUSSION

Rectal foreign bodies are not a common cause for emergency hospital visits. Although foreign bodies trapped in the rectum have been reported in all ages and races, ¹ , ⁵ , ⁶ about two‐thirds of the cases have been in men, with a ratio of 28 to 1, predominantly in the third and fourth decades of life. ⁴ The most common cause reported in articles for rectal foreign bodies is sexual arousal. ⁵ , ⁶ , ⁷ About 10% to 12% of cases have been due to rape. In a few cases, hard stools and prostate massage have been reported as the causes of foreign body entry. With much less prevalence, sometimes the entry of a foreign object is due to hiding something like drugs or weapons. Remaining gas and surgical tools have also been reported, and rarely, swallowed foreign bodies are trapped in the rectum.

Almost anything has been reported in the list of rectal foreign bodies, including sex toys such as vibrators and dilators, batteries, lamps, plastics, glass bottles, spray cans and detergents, metal objects, wooden parts, fruits, and plants (cucumbers and eggplants). ³ , ⁵ , ⁶ , ⁸ , ⁹

Diagnosing and treating rectal foreign bodies can be very difficult because of the sense of embarrassment that patients feel. ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ Removing foreign bodies is challenging due to their variety. Sometimes patients create unusual stories, such as sitting on or falling onto an object, to justify the trapped rectal foreign body. Patients usually go to the hospital emergency room after several attempts to remove the foreign body themselves, with chief complaints of anal, pelvic, or lower abdominal pain. ² , ³ , ⁴ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² Delay in seeking medical attention and repeated attempts to remove the foreign body can cause mucosal damage, edema, and muscle spasms. These issues can potentially lead to the foreign body moving further upward.

Abdominal and rectal examinations using a finger should be performed and carefully documented. It is essential to evaluate the anal sphincter both before and after removing the foreign body. During the abdominal examination, evidence of peritonitis or upward displacement of the foreign body may be observed. Rectal foreign bodies may be positioned either higher or lower, depending on their location relative to the rectosigmoid junction. In most cases, diagnosis can be made through examination and a simple abdominal X‐ray.

The basic principles of therapeutic intervention include removing the foreign body through the anus under appropriate anesthesia and logically selecting patients for surgical procedures. After foreign body removal, performing rectosigmoidoscopy to assess possible damage and monitoring the patient for potential complications is also essential.

Foreign body removal should only be attempted after ensuring adequate relaxation of the anal sphincter, a condition achievable in the operating room with the assistance of an anesthesiologist. Consequently, all cases, except those where the foreign body spontaneously exits during defecation, were transferred to the operating room for removal.

Efforts to remove the foreign body through the anus in an emergency room have proven unsuccessful in approximately 90% of cases and may even result in the foreign object being displaced to a higher position. As such, it is not recommended to attempt foreign body removal in an emergency room. Instead, it is strongly advised that the patient be promptly transferred to the operating room, where they can be adequately relaxed and where there is sufficient lighting and appropriate tools.

The maneuvers and interventions, such as pudendal nerve block, spinal anesthesia, venous sedation, reverse Trendelenburg position, and suprapubic pressure, can increase the success rate of removing the foreign body by reducing anal sphincter spasm and relaxing the patient.

The anoscope and rectosigmoidoscope are used to remove the foreign body when direct observation is possible. Many techniques for removing foreign bodies in this method are described in the article, including the use of polypectomy snares, forceps, inflated Foley catheters, midwifery forceps, vacuums, and balloon dilators. ¹³ , ¹⁴ , ¹⁵ If these methods are not successful in removing a foreign body through the anus, using flexible sigmoidoscopy and minimally invasive surgery through the anus (TAMIS) may be considered before laparotomy. ⁵ , ⁸ , ¹⁶ Laparoscopy can also be considered for cases where the foreign body is in the upper position and cannot be accessed through the anus. ⁹ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ In this technique, pressing and milking the foreign body on the distal part of the intestine can facilitate its removal through the anus.

Performing rectosigmoidoscopy after the removal of the foreign body is necessary to rule out intestinal damage and ensure the absence of the remaining foreign body. ⁵ , ⁶ , ²⁰ Minor traumas such as scratches, superficial mucosal tears, and localized edema are relatively common. Patients with such injuries are hospitalized and closely monitored to enable early diagnosis of any potential delayed complications.

The predictors of failure in removing the rectal foreign body through the anus are as follows: objects more than 10 cm long, sharp‐edged objects, objects that have moved into the sigmoid, and those that more than 2 days have passed from trapping. ²¹

Laparotomy should be used as the last resort after all attempts to remove the foreign body through the anus have failed. Laparotomy is also required in cases of perforation or peritonitis. ⁹ , ¹³ , ²² If there are no signs of perforation, it is appropriate to press the foreign body on the rectum and remove it through the anus. ¹⁶ If there is perforation, the foreign body can be removed from the perforated area or through colotomy. Initial repair with or without a protective colostomy and Hartmann colostomy is one of the options that can be performed based on the patient's condition. ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³

In our study, 14 foreign bodies were removed through the anus with and without the help of sigmoidoscopy. Laparotomy was performed in one case where the foreign body was a glass bottle in the upper position, and attempts to remove it through the anus failed. A colotomy was performed, the foreign body was removed, and initial repair was done with a protective colostomy. Figures 1, 2, 3 show some abdominal X‐rays.

FIGURE 1.

Abdominal X‐ray (AP).

FIGURE 2.

Abdominal X‐ray (Supine).

FIGURE 3.

Abdominal X‐ray (Supine).

Furthermore, our experience indicates excellent outcomes for patients with rectal foreign bodies, even in cases of rupture or perforation, provided that appropriate and timely treatment is administered. Most complications arise from damage to the anal sphincter, resulting in varying degrees of incontinence. Infection and pelvic sepsis may occasionally occur due to perforation. Psychological counseling is essential for patients with a history of psychological issues or those who have experienced sexual assault.

A practical algorithm is presented for the therapeutic approach to rectal foreign bodies, relying on the removal of the foreign body in the operating room (Figure 4).

FIGURE 4.

Approach to the Rectal Foreign body.

5. CONCLUSION

In conclusion, while rectal foreign bodies may be unusual and uncommon, surgeons can effectively treat these patients with a timely and appropriate approach.

AUTHOR CONTRIBUTIONS

Ghodratollah Maddah: Resources; supervision. Abbas Abdollahi: Project administration; writing – original draft; writing – review and editing. Alireza Tavassoli: Project administration; resources. Mohammad Taghi Rajabi Mashhadi: Project administration; resources. Ali Mehri: Project administration; writing – original draft; writing – review and editing. Mohammad Etezadpour: Project administration; supervision.

CONFLICT OF INTEREST STATEMENT

All authors declare no conflicts of interest.

ETHICS STATEMENT

Surgery and all other procedures were done with the agreement of the 1975 Helsinki Declaration, and informed consent was obtained from patients.

CONSENT

Written informed consent was obtained from the patients to publish this report in accordance with the journal's patient consent policy.

Maddah G, Abdollahi A, Tavassoli A, Mashhadi MTR, Mehri A, Etezadpour M. An uncommon problem: Overcoming the challenges of rectal foreign bodies—A case series and literature review. Clin Case Rep. 2023;11:e8313. doi: 10.1002/ccr3.8313

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

No one of the authors listed on the manuscript are employed by a government agency that has a primary function other than research and education. No one of the authors are submitting this manuscript as an official representative or on behalf of the government.