Rectal foreign body

If the foreign body is too big to allow feces from the colon to pass, a mechanical ileus may occur. The distension of the rectum and the disruption of the peristasis reinforce this effect.

The foreign body may cause infections, destroying the intestinal wall. Depending on the location of the perforation, this may lead to a peritonitis due to the feces or an abscess in the retroperitoneal space.

Smaller objects that injure the intestinal wall, but do not perforate it, may be encapsulated by a foreign body granuloma. They may remain in the rectum as a pseudotumor without any further effects.

The most common – but still rare – complication is a perforation of the rectum caused by the foreign object itself or attempts to remove it. Diagnosed perforations are operated immediately by opening the abdomen and removal or suturing of the perforated area. In order to suppress infections, antibiotics are prescribed. Often, a temporary ileostomy is necessary to protect the stitches. After a contrast medium applied by an enema proves the complete healing of the perforated area, the ileostomy is reversed. This usually takes between three and six months.{{cite journal | vauthors = Ruiz del Castillo J, Sellés Dechent R, Millán Scheiding M, Zumárraga Navas P, Asencio Arana F | title = Colorectal trauma caused by foreign bodies introduced during sexual activity: diagnosis and management | journal = Revista Espanola de Enfermedades Digestivas | volume = 93 | issue = 10 | pages = 631–4 | date = October 2001 | pmid = 11767487 }} Average hospitalization is 19 days.

Medical literature describes some deaths due to rectal foreign bodies, but they are very rare and usually classified as autoerotic fatality. A 75-year-old patient died due to a rectal perforation caused by a mentally ill person using a cane.{{cite journal | vauthors = Ikeda N, Hulewicz B, Knight B, Suzuki T | title = Homicide by rectal insertion of a walking stick | journal = Nihon Hoigaku Zasshi = the Japanese Journal of Legal Medicine | volume = 45 | issue = 4 | pages = 341–4 | date = August 1991 | pmid = 1766149 }} Another middle-aged patient died due to a rectal perforation by a vibrator. The perforation was sutured and the patient received intensive medical care, but he contracted acute respiratory distress syndrome and systemic inflammatory response syndrome due to the trauma, resulting in multiple organ dysfunction syndrome and death.{{cite journal | vauthors = Waraich NG, Hudson JS, Iftikhar SY | title = Vibrator-induced fatal rectal perforation | journal = The New Zealand Medical Journal | volume = 120 | issue = 1260 | pages = U2685 | date = August 2007 | pmid = 17726499 }} There is a paper describing a death after a perforation with a shoehorn.{{cite journal | vauthors = Byard RW, Eitzen DA, James R | title = Unusual fatal mechanisms in nonasphyxial autoerotic death | journal = The American Journal of Forensic Medicine and Pathology | volume = 21 | issue = 1 | pages = 65–8 | date = March 2000 | pmid = 10739230 | doi = 10.1097/00000433-200003000-00012 }} The rectum has to be nursed after a surgical procedure until healing is complete. A 54-year-old man, who had been operated on twice in order to remove a foreign body (a cucumber and a parsnip), died due to a peritonitis after he inserted two apples into the rectum before the wound had healed.

Reasons for foreign rectal bodies vary wildly, but in most cases they are of sexual or criminal motivation.{{cite book | vauthors = Messmann H | title = Lehratlas der Koloskopie. | publisher = Georg Thieme Verlag | date = 2004 | isbn = 3-13-136441-6 | pages = 219 }} {{Google books|TCeklf42u0wC||page=219}} The foreign body was inserted voluntarily in the vast majority of cases. This especially includes sexually motivated behaviour, encompassing the majority of cases. Bodypacking, i.e. illegal transport of drugs within a body orifice (here: inside the rectum), is another – potentially – voluntary reason for insertion of foreign rectal bodies.{{cite thesis | vauthors = Laitenberger MC | degree = Ph.D. | url = http://d-nb.info/978949625/34 | title = Klinische und rechtsmedizinische Aspekte des intestinalen Rauschmitteltransportes in Hamburg 1989 bis 2004 | publisher = Universität Hamburg | date = 2005 }} This includes attempts to transport objects like weapons, including knives, or ammunition. According to one study, sexual stimulation was responsible for 80% of clinically relevant foreign rectal bodies. About 10% of the cases were due to sexual assault.{{cite journal | vauthors = Cohen JS, Sackier JM | title = Management of colorectal foreign bodies | journal = Journal of the Royal College of Surgeons of Edinburgh | volume = 41 | issue = 5 | pages = 312–5 | date = October 1996 | pmid = 8908954 }}

In rare cases, the patient inserted the object into the rectum without a way to remove it intending to receive attention and pity from doctors and nurses. This behaviour is categorized as Munchausen's syndrome.{{cite journal | vauthors = Khan SA, Davey CA, Khan SA, Trigwell PJ, Chintapatla S | title = Munchausen's syndrome presenting as rectal foreign body insertion: a case report | journal = Cases Journal | volume = 1 | issue = 1 | pages = 243 | date = October 2008 | pmid = 18925957 | pmc = 2572607 | doi = 10.1186/1757-1626-1-243 | doi-access = free }}

Another cause may be attempted self-treatment of diseases. One patient attempted to treat his chronic diarrhea by inserting an ear of maize into his rectum.{{cite journal | vauthors = Stenz V, Thurnheer R, Widmer F, Krause M | title = [Foreign body stories] | journal = Therapeutische Umschau. Revue Therapeutique | volume = 65 | issue = 12 | pages = 699–702 | date = December 2008 | pmid = 19048523 | doi = 10.1024/0040-5930.65.12.699 }} Another patient tried to soothe the itching due to his hemorrhoids (Pruritus ani) with a toothbrush. The toothbrush went out of control and disappeared inside his anus.{{cite journal | vauthors = Kumar M | title = Don't forget your toothbrush! | journal = British Dental Journal | volume = 191 | issue = 1 | pages = 27–8 | date = July 2001 | pmid = 11491473 | doi = 10.1038/sj.bdj.4801082a | url = http://www.nature.com/bdj/journal/v191/n1/full/4801082a.html | url-access = subscription }}

Accidents or torture may cause an involuntary insertion of a foreign body.{{cite report | vauthors = Nuschler F | url = http://inef.uni-due.de/cms/files/report01.pdf | title = Bericht über die internationale Folterfoschung | publisher = Universität Duisburg | date = 1992 | archive-url = https://web.archive.org/web/20110719103018/http://inef.uni-due.de/cms/files/report01.pdf | archive-date = July 19, 2011 }} A mercury medical thermometer inserted into the anus in order to measure the temperature, but broke off while inside, is an example of a foreign rectal body due to an accident.{{cite journal | vauthors = Azman B, Erkuş B, Güvenç BH | title = Balloon extraction of a retained rectal foreign body under fluoroscopy, case report and review | journal = Pediatric Emergency Care | volume = 25 | issue = 5 | pages = 345–7 | date = May 2009 | pmid = 19444034 | doi = 10.1097/PEC.0b013e3181a3494f | s2cid = 13623925 }} Ancient Greece knew the Rhaphanidosis as a punishment for male adulterers. It involved the insertion of a radish into the anus. Many self-inserted rectal bodies are stated as accidentally by the patients due to feelings of shame.

There are several reasons that contribute to the jamming of rectal bodies inside the rectum. Many of the objects used for sexual stimulation have a conical tip in order to facilitate penetration, while the base is flat. Extraction by the user may be impossible if the base of the object passed the anus towards the rectum. In order to receive a stronger stimulation, the object may be inserted deeper than intended. In this case, the sphincter prevents, by mechanical means, the extraction of the foreign body.

The other way for a foreign body to travel through the digestive system (after oral intake and passage through the entire intestines) happens very often, but is only rarely medically relevant. Other constrictions, such as the esophagus, cardia, pylorus or ileocecal valve tend to cause issues with other organs, provided a foreign body is large enough to be an issue. Some foreign bodies may still pass those narrows and may cause medically relevant issues, i.e. toothpicks and bones.{{cite journal | vauthors = Davies DH | title = A chicken bone in the rectum | journal = Archives of Emergency Medicine | volume = 8 | issue = 1 | pages = 62–4 | date = March 1991 | pmid = 1854398 | doi = 10.1136/emj.8.1.62 | pmc = 1285738 }} Bones especially, i.e. from chickens, cause about two thirds of all intestinal perforations.{{cite journal | vauthors = McManous JE | title = Perforation of the intestine by ingested foreign body. | journal = American Journal of Surgery | date = 1941 | volume = 53 | pages = 393–402 | doi = 10.1016/S0002-9610(41)90652-9 }}

Plant-based food, especially seeds like popcorn,{{cite journal | vauthors = Roberge RJ, Squyres NS, MacMath TL | title = Popcorn primary colonic phytobezoar | journal = Annals of Emergency Medicine | volume = 17 | issue = 1 | pages = 77–9 | date = January 1988 | pmid = 3337421 | doi = 10.1016/s0196-0644(88)80510-9 }} watermelon, sunflower and pumpkin seed, may clump together inside the lower intestines to form bezoars. Those may grow too big for normal anal passage, thus becoming clinically relevant. This kind of rectal foreign body happens chiefly in children, especially in Northern Africa and the Middle East, where those seeds form an elemental part of the diet.{{cite journal | vauthors = Eitan A, Katz IM, Sweed Y, Bickel A | title = Fecal impaction in children: report of 53 cases of rectal seed bezoars | journal = Journal of Pediatric Surgery | volume = 42 | issue = 6 | pages = 1114–7 | date = June 2007 | pmid = 17560231 | doi = 10.1016/j.jpedsurg.2007.01.048 }}{{cite journal | vauthors = Mirza MS, Al-Wahibi K, Baloch S, Al-Qadhi H | title = Rectal bezoars due to pumpkin seeds | journal = Tropical Doctor | volume = 39 | issue = 1 | pages = 54–5 | date = January 2009 | pmid = 19211433 | doi = 10.1258/td.2008.080107 | s2cid = 32157500 }} In very rare cases, seeds inside a bezoar may germinate inside the lower intestines or the rectum, causing a blockade.{{cite journal | vauthors = Mahjoub F, Kalantari M, Tabarzan N, Moradi B | title = Invading plant material appearing as a colonic tumoural mass in a four-year-old girl | journal = Tropical Doctor | volume = 39 | issue = 4 | pages = 253–4 | date = October 2009 | pmid = 19762589 | doi = 10.1258/td.2009.090052 | s2cid = 21877151 }}

Type and size of the foreign rectal bodies are diverse and may exceed the anatomical-physiological imagination.

Objects documented in literature include:

• Razor, screw, screwdriver, small rolled tool bag (15×12 cm, including tools 620 g), hairpin, milk can opener, drill bit
• Short staffs, such as a 27 cm long chair leg, a 19 cm long spade handle and a broken off broom handle, extension parts for a vacuum cleaner
• Containers, sometimes exceeding 0.5 L in volume, e.g. sparkling wine bottles, bottles of Coca-Cola, jam pots, small beer glasses, cups
• Spray can, light bulb, vacuum tube, candle
• WWII artillery shell requiring attention from a bomb squad{{cite web |url=https://news.yahoo.com/bomb-squad-called-er-patient-100800683.html |title=Bomb squad called to ER after a patient turned up with a WWII artillery shell lodged in his rectum, police say |work=Yahoo! News |author=Joshua Zitser |date=December 4, 2021 |access-date=December 4, 2021}}
• Table tennis ball, Boccia ball
• Ammunition, firecracker
• Vibrator, rubber rod, dildo
• a toy car
• spectacles, a suitcase key, a tobacco pouch and a magazine at the same time
• plastic tooth brush case{{cite journal | vauthors = Barone JE, Sohn N, Nealon TF | title = Perforations and foreign bodies of the rectum: report of 28 cases | journal = Annals of Surgery | volume = 184 | issue = 5 | pages = 601–4 | date = November 1976 | pmid = 984928 | doi = 10.1097/00000658-197611000-00011 | pmc = 1345490 }}{{citation |title=Sturz in die Kiste |url=http://www.spiegel.de/spiegel/print/d-13491232.html |work=Der Spiegel |year=1991 |issue=41 |series=7 October 1991 |pages=317–320 }}{{cite journal | vauthors = Akhtar MA, Arora PK | title = Case of unusual foreign body in the rectum | journal = Saudi Journal of Gastroenterology | volume = 15 | issue = 2 | pages = 131–2 | date = April 2009 | pmid = 19568580 | pmc = 2702971 | doi = 10.4103/1319-3767.48973 | doi-access = free }}

Not all objects are solid. In 1987, a case was documented of a patient who administered a cement enema. After it solidified and impacted, the resulting block had to be surgically extracted.{{cite journal | vauthors = Stephens PJ, Taff ML | title = Rectal impaction following enema with concrete mix | journal = The American Journal of Forensic Medicine and Pathology | volume = 8 | issue = 2 | pages = 179–82 | date = June 1987 | pmid = 3649167 | doi = 10.1097/00000433-198708020-00019 }} Another extreme case occurred in November 1953. A depressed man inserted a 15 cm long cardboard tube into his rectum and tossed a lighted firecracker into the tube's opening, resulting in a large hole in his rectum.{{cite journal | vauthors = Butters AG | title = An unusual rectal injury | journal = British Medical Journal | volume = 2 | issue = 4939 | pages = 602–3 | date = September 1955 | pmid = 13240191 | doi = 10.1136/bmj.2.4939.602 | pmc = 1980742 }}

Many patients feel ashamed during the anamnesis and provide information only reluctantly. This may lead to missing information that may be important during therapy. For the same reason, patients may not visit a doctor until very late. Trusting and sensitive care for the ashamed and uncomfortable patients is paramount for a successful therapy{{cite journal | vauthors = Mackinnon RP | title = Removing rectal foreign bodies: is the ventouse gender specific? | journal = The Medical Journal of Australia | year = 1998 | volume = 169 | issue = 11–12 | pages = 670–1 | doi = 10.5694/j.1326-5377.1998.tb123462.x | pmid = 9887927 | s2cid = 41156541 }} and may be life-saving.{{cite book | vauthors = Stein E | title = Proktologie: Lehrbuch und Atlas. | publisher = Verlag Springer | date = 2002 | isbn = 3-540-43033-4 | pages = 329 }} {{Google books|8yQAecJo5AoC||page=329}}

Usually, several radiological images are recorded in order to pinpoint the precise place and depth of the foreign body. This is usually done by X-ray. Foreign bodies made from low-contrast material (e.g. plastics) may necessitate medical ultrasound or a CT scan. Magnetic resonance imaging is contraindicated, especially if the foreign body is unknown. Foreign rectal bodies may penetrate deep into the colon, in certain circumstances up to the right colic flexure.

An endoscopy, which may also be of use during therapy, facilitates the identification and localisation of the object inside the rectum.{{cite book | vauthors = Axon AT, Classen M | title = Gastroenterologische Endoskopie. | publisher = Georg Thieme Verlag | date = 2004 | isbn = 3-13-132401-5 | pages = 400–401}} {{Google books|6LtyFKwyCv4C||page=400}}

Information about the foreign body obtained in those ways are of high importance during therapy, as a perforation of the rectum or the anus is to be absolutely avoided.

File:Rectal foreign body 02.jpg

The therapeutic measures to remove the foreign body can be as diverse as the objects inside the rectum. In many instances, the foreign bodies consist of fragile materials, such as glass. Most patients wait for several hours or even days until they visit a doctor. Before they do, they often repeatedly try to remove the object themselves or by a layperson. This often worsens the situation for a successful extraction.

In most cases, the foreign body can be removed endoscopically. Vibrators, for example, can be often removed using a large sling usually used to remove polyps during coloscopy.{{cite journal | vauthors = Huang WC, Jiang JK, Wang HS, Yang SH, Chen WS, Lin TC, Lin JK | title = Retained rectal foreign bodies | journal = Journal of the Chinese Medical Association | volume = 66 | issue = 10 | pages = 607–12 | date = October 2003 | pmid = 14703278 }} A flexible endoscope can be of no help with large and jammed objects. It may be preferable to use rigid tools in those cases.

There have been several cases where instruments used in child birth have proven their worth for the removal of those foreign bodies, such as the forceps{{cite journal | vauthors = Peet TN | title = Removal of impacted rectal foreign body with obstetric forceps | journal = British Medical Journal | volume = 1 | issue = 6008 | pages = 500–1 | date = February 1976 | pmid = 1252815 | pmc = 1638849 | doi = 10.1136/bmj.1.6008.500 }} and suction cups.

Wooden objects have been retrieved with corkscrews and drinking glasses after filling them with plaster.{{cite book | vauthors = Bailey H, Love J | title = A short textbook of surgery. | veditors = Rains AJ, Ritchie HD | edition = 16th | publisher = Verlag Lewis | date = 1975 | pages = 1013 }} A spoon can be used as an "anchor" by leaving it inside the glass during the plaster filling, removing it together with the glass. Light bulbs are encased in a gauze shroud, shattered inside the rectum and extracted.

There have been successful cases using argon-plasma coagulation. The object in question was a green apple wrapped in cellophane inside the rectum of a 44-year-old patient. The argon-beam coagulation shrunk the apple by more than 50%, enabling its removal. Previous extraction attempts using endoscopic tools failed due to the flat surface of the object.{{cite journal | vauthors = Glaser J, Hack T, Rübsam M | title = Unusual rectal foreign body: treatment using argon-beam coagulation | journal = Endoscopy | volume = 29 | issue = 3 | pages = 230–1 | date = March 1997 | pmid = 9201486 | doi = 10.1055/s-2007-1004178 | doi-access = free }}

If the object is too far up, in the area of the colon sigmoideum, and cannot be removed using one of the above methods, bed rest and sedation can cause the object to descend back into the rectum, where retrieval and extraction are easier.

In difficult cases, a laparotomy may be necessary. Statistically, this is the case in about 10 percent of patients. The large intestine can be manipulated inside the abdominal cavity, making it possible for it to wander in the direction of the anus and be grabbed there. A surgical opening of the large intestines can be indication in very difficult cases, especially if the manipulation of the object may pose a serious health risk. This may be the case with a jammed drug condom.

Mild cases may need a sedation at most. Local and spinal anaesthesia find common use. Difficult interventions may need general anaesthesia; surgical opening of the abdominal cavity or the colon require it. General anaesthesia can be beneficial for the relaxation of the sphincter.

After the surgery, a sigmoidoscopy – a colonoscopy focused on the first 60 cm of the colon – is good practice in order to rule out possible perforation and injury of the rectum and the colon sigmoideum.{{cite journal | vauthors = Koornstra JJ, Weersma RK | title = Management of rectal foreign bodies: description of a new technique and clinical practice guidelines | journal = World Journal of Gastroenterology | volume = 14 | issue = 27 | pages = 4403–6 | date = July 2008 | pmid = 18666334 | doi = 10.3748/wjg.14.4403 | pmc = 2731197 | doi-access = free }} Stationary aftercare may be indicated.

: APC = Argon beam-coagulation

: N.A. = Not available

(Source:)

There is no reliable data about the incidence of clinically meaningful foreign rectal bodies. It may have increased in the long term{{cite web | vauthors = Munter DW | url = http://emedicine.medscape.com/article/776795-overview | title = Foreign Bodies, Rectum. | date = September 2009 }} as it is observed more often in recent times.{{cite journal | vauthors = Manimaran N, Shorafa M, Eccersley J | title = Blow as well as pull: an innovative technique for dealing with a rectal foreign body | journal = Colorectal Disease| volume = 11 | issue = 3 | pages = 325–6 | date = March 2009 | pmid = 18662236 | doi = 10.1111/j.1463-1318.2008.01653.x | s2cid = 29092891 }}

The incident rate is significantly higher for men than for women. The gender ratio is in the area of 28:1.{{cite journal | vauthors = Clarke DL, Buccimazza I, Anderson FA, Thomson SR | title = Colorectal foreign bodies | journal = Colorectal Disease | volume = 7 | issue = 1 | pages = 98–103 | date = January 2005 | pmid = 15606596 | doi = 10.1111/j.1463-1318.2004.00699.x | s2cid = 25964610 }}{{cite journal | vauthors = Stack LB, Munter DW | title = Foreign bodies in the gastrointestinal tract | journal = Emergency Medicine Clinics of North America | volume = 14 | issue = 3 | pages = 493–521 | date = August 1996 | pmid = 8681881 | doi = 10.1016/s0733-8627(05)70264-9 }} A metastudy in the year 2010 found a ratio of 37:1. Median age of the patients was 44.1 years, with a standard deviation of 16.6 years.{{cite journal | vauthors = Kurer MA, Davey C, Khan S, Chintapatla S | title = Colorectal foreign bodies: a systematic review | journal = Colorectal Disease | volume = 12 | issue = 9 | pages = 851–61 | date = September 2010 | pmid = 19895597 | doi = 10.1111/j.1463-1318.2009.02109.x | s2cid = 8776335 }} Rectal foreign bodies are not an unusual occurrence in hospital emergency rooms.

The first documented case dates from the 16th century.{{cite journal | vauthors = Haft JS, Benjamin HB | title = Foreign bodies in the rectum: some psychosexual aspects. | journal = Medical Aspects of Human Sexuality. | date = August 1973 | volume = 7 | issue = 8 | pages = 74–95 }}

Foreign rectal bodies are rare in veterinary medicine. A passage through the entire intestines, followed by a stay inside the rectum is – as with humans – rare.{{cite journal | vauthors = Webb CB, McCord KW, Twedt DC | title = Rectal strictures in 19 dogs: 1997-2005 | journal = Journal of the American Animal Hospital Association | year = 2007 | volume = 43 | issue = 6 | pages = 332–6 | pmid = 17975215 | doi = 10.5326/0430332 }} Animals may have bezoars out of different materials, which may migrate to the rectum and cause problems.{{cite journal | vauthors = Sargison ND, Scott PR, Dun KA | title = Intestinal obstruction in a blue-faced Leicester ram associated with a phytobezoar lodged at the pelvic inlet | journal = The Veterinary Record | volume = 137 | issue = 9 | pages = 222 | date = August 1995 | pmid = 7502475 | doi = 10.1136/vr.137.9.222 | doi-broken-date = November 1, 2024 | s2cid = 27561735 }}

The Ig Nobel Prize was awarded in 1995 to David B. Busch and James R. Starling from Madison, Wisconsin, for their 1986 article Rectal foreign bodies: Case Reports and a Comprehensive Review of the World's Literature{{cite journal | vauthors = Busch DB, Starling JR | title = Rectal foreign bodies: case reports and a comprehensive review of the world's literature | journal = Surgery | volume = 100 | issue = 3 | pages = 512–9 | date = September 1986 | pmid = 3738771 }} (see List of Ig Nobel Prize winners).Improbable Research: [http://improbable.com/ig/winners/ Winners of the Ig® Nobel Prize.]

• Đorđe Martinović incident
• Foreign body in alimentary tract
• Urethral foreign body insertion
• Butt plug

{{Reflist}}

{{Medical resources

| DiseasesDB =

| ICD10 = {{ICD10|T18.5}}

| ICD9 = {{ICD9|937}}

| ICDO =

| OMIM =

| MedlinePlus =

| MeSH =

| GeneReviewsNBK =

| GeneReviewsName =

}}

{{Commons category|Rectal foreign bodies}}

• [http://www.emedicine.com/emerg/topic933.htm eMedicine gastrointestinal emergency medicine]
• [http://www.mja.com.au/public/issues/xmas98/mkinnon/mkinnon.html Medical Journal of Australia] {{Webarchive|url=https://web.archive.org/web/20120218211904/http://www.mja.com.au/public/issues/xmas98/mkinnon/mkinnon.html |date=February 18, 2012 }}
• British Dental Journal case report: [http://www.nature.com/cgi-taf/DynaPage.taf?file=/bdj/journal/v191/n1/full/4801082a.html Don't forget your toothbrush!] (subscribers only - with useful bibliography)
• [http://chilearning.charite.de/index.php?id=92 X-rays of rectal bodies] {{Webarchive|url=https://web.archive.org/web/20160304062951/http://chilearning.charite.de/index.php?id=92 |date=March 4, 2016 }} at the Berlin Charité
• [http://www.spiegel.de/spiegel/print/d-13491232.html Sturz in die Kiste.] In: Der Spiegel Ausgabe 41, 1991, S. 317–320.
• [http://einestages.spiegel.de/static/entry/lachsalven_aus_dem_labor/35617/alles_im_a.html?o=position-ASCENDING&s=4&r=1&a=5125&c=1 Alles im A…] In: einestages vom 7. Juni 2007

Category:Anal eroticism

Category:Medical emergencies

Category:Rectum

Category:Foreign body