Rectal Foreign Bodies

Epidemiology

Rectal foreign bodies are a challenging, unique, and commonly seen problem. The true incidence of rectal foreign bodies varies throughout the literature because of patient underreporting. Most patients with rectal foreign bodies are male and range from 30 to 90 years of age. Rectal foreign bodies are most often retained from transanal insertion for the purpose of anal eroticism, but they can also be the result of penetrating or blunt trauma, assault, and concealment of drugs, and they can be iatrogenic. Objects rarely pass though the gastrointestinal tract and become lodged in the rectum. A wide variety of foreign objects have been reported in the rectum, including vibrators, glasses, bottles, toothbrushes, light bulbs, flashlights, aerosol canisters, cell phones, fruits, and vegetables. In this chapter the evaluation, management, and postextraction care for patients with rectal foreign bodies will be reviewed.

Evaluation

Initially, patients with a rectal foreign body should be treated similarly to patients who have sustained rectal trauma by confirming a patent airway and hemodynamic stability. The patient is examined for evidence of peritonitis such as hypotension, tachycardia, fevers, and severe abdominal pain. Abdominal radiographs with the patient in the flat and upright positions may be obtained to assess for pneumoperitoneum and to locate the object. If imaging shows that the patient has peritonitis or free air, a laparotomy should be performed without delay. When perforation is suspected in an otherwise stable patient, a helical computed tomographic (CT) scan may be performed. Findings on a CT scan suggesting a rectal full-thickness injury include rectal wall thickening, mesorectal air, pelvic fluid collections, and mesorectal fat stranding.

Patients with rectal foreign bodies are often reluctant to visit the emergency department because of embarrassment and fear of humiliation. In many circumstances, they may not provide a history of foreign body insertion or trauma, but rather present to the emergency department with reports of anal pain and bleeding. However, once the diagnosis is made, it is important to obtain information about the object inserted in the rectum, including its size and shape, the length of time it has been retained, and any attempt at removing it.

Physical examination should include abdominal and digital rectal examination to assess the location of the rectal foreign body. Foreign bodies proximal to the rectosigmoid junction usually are not palpable on digital examination. An assessment of internal and external sphincter integrity and tone may detect internal and external sphincter damage as a result of foreign body insertion or attempted removal. Alternatively, the sphincter may be increased in tone as a result of splits in the anoderm or sphincter spasm. When the foreign body is not palpable, a rigid or flexible proctosigmoidoscopy and/or abdominal imaging should be performed. For most rectal trauma, a CT scan is substituted for abdominal plain films, especially when rectal perforation is suspected.

An algorithm for evaluation of patients with a rectal foreign body is provided in Figure 25-1 .

Classification

Rectal foreign bodies are classified in a variety of ways.

American Association for the Surgery of Trauma Rectal Organ Injury Scale

Most of the information about rectal foreign bodies is an extension of information gained from the trauma literature on rectal injuries, and the American Association for the Surgery of Trauma (AAST) Rectal Organ Injury Scale for blunt and penetrating trauma can be used to describe trauma from rectal foreign bodies ( Table 25-1 ). The degree of injury as detailed in the AAST scale dictates the treatment necessary for rectal injuries. Full-thickness lacerations, extension into the peritoneum, and the presence of devascularized tissue will require more extensive surgical debridement and repair and often will require diversion, distal washout, and presacral drainage.

TABLE 25-1

American Association for the Surgery of Trauma Rectum Injury Scale

Grade	Description of Injury
I	Contusion or hematoma without devascularization or partial-thickness laceration of wall
II	Full-thickness laceration, <50% of circumference
III	Full-thickness laceration, >50% of circumference
IV	Full-thickness laceration, extends into perineum
V	Devascularized portion of rectum