Rectal foreign bodies are not uncommon in emergency departments around the world and potentially cause management difficulties.

Epidemiology

The incidence varies according to the region, said to be uncommon in Asia and most common in Eastern Europe 1. Typically patients are male with a wide range of age.

The vast majority of such objects are inserted via the anus and are the result of sexual misadventure. This is usually voluntary although occasionally happens as part of sexual assault/rape. In older men, the objects may be introduced to aid in manual disimpaction for constipation or to massage the prostate. Occasionally a foreign body may be ingested (e.g. fish bone 2, chicken bone or wood splinters 3), and successfully navigates the entire gastrointestinal tract only to become impacted at the rectum.

Very rarely a foreign body enters the rectum from an adjacent organ, such as cases of IUCDs passing from the vagina/uterus and migrating into the rectum 6.

Clinical presentation

Patients usually know that there is something in their rectum although are often at a loss as to how the object got there, although quite clearly embarrassment may prevent them from being completely frank in their account.

The list of retrieved objects is legion, and due to the chronic nature of the habit are often surprisingly large. Objects reported in the literature include:

bottles

sex toys

vegetables

broomstick

ax handle

curtain rod

light bulb/fluorescent tube

frozen pig's tail

toothbrush

drug packets

cigar cover

Complications

Due to the physiological distensibility of the rectum, and sigmoid colon, significant colorectal injury/perforation is mercifully rare

Radiographic features

In almost all cases plain radiography suffices, and poses little diagnostic difficulty. Occasionally body packers (drug smuggling) or some softer silicone objects may be less radiopaque.

An erect chest x-ray is often useful if there is any suggestion of peritonism to assess for free subdiaphragmatic gas.

Treatment and prognosis

Removal of such objects can be challenging depending on the shape, material and orientation within the rectum. If possible, they should be removed via the anus, although in some cases a laparotomy may be required. Techniques described include:

manual extraction/obstetric forceps/snares etc.

abdominal pressure/manipulation may help

passing a Foley catheter distal to the object and inflating the balloon

Following successful transanal retrieval, colonoscopy/sigmoidoscopy is prudent to exclude colonic injury.