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Clinical Procedures > Gastrointestinal Procedures
Foreign Body Removal, Rectum
Article Last Updated: Jun 29, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Victoria L Hogan, MD, Assistant Professor, Department of Emergency Medicine, University of Alabama at Birmingham
Victoria L Hogan is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Coauthor(s):
Andrew Edwards, MD, Associate Residency Director, UAB Department of Emergency Medicine
Editors: Andrew K Chang, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Attending Physician, Windham Memorial Community Hospital; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
rectal foreign body, object in rectum, gastrointestinal tract, GI tract, foreign body, anus, anal foreign body, rectum, digital rectal examination, DRE, foreign body removal
Anorectal foreign bodies are usually inserted transanally for sexual or medicinal purposes. Rectal foreign bodies may also be observed with body packing or stuffing or after prior oral ingestion of the object. Anorectal foreign bodies are more common in men than in women. Rectal foreign bodies may include such objects as bottles, vibrators, fruit, vegetables, and balls. Cylindrical objects are common. In addition, thermometers may accidentally break while a rectal temperature is being obtained. Be aware that patients have usually made multiple attempts to remove the object prior to presentation in the emergency department. Patients may create unusual stories to explain how the object became lodged in the rectum.
Indications for bedside rectal foreign body removal in the emergency department include the following: - Object palpable on digital rectal examination
- Object less than 10 cm proximal to the anal verge
Relative contraindications to bedside rectal foreign body removal in the emergency department include the following:
- Severe abdominal pain
- Object not palpable on digital rectal examination
- Object more than 10 cm proximal to the anal verge
- Broken glass present in the anus or rectum
- Fragile object (eg, light bulb) present
- Extended time since insertion
- Inexperienced physician
- Uncooperative patient
Absolute contraindications to bedside rectal foreign body removal in the emergency department include the following:
- Intravenous relaxation medications and analgesia are required.
- The extent of sedation required depends on the anticipated difficulty of the procedure and the patient’s tolerance.
- Intravenous benzodiazepines allow for patient sedation and muscle relaxation.
- Intravenous narcotics should be used for pain control.
- Perianal block with lidocaine or longer-acting bupivacaine may be considered, although this is not commonly used.
Equipment used may vary based on availability in the emergency department or hospital. - Light source
- Retractor-type instrument for visualization
- Anal or rectal speculum
Rectal speculum (closed).
Rectal speculum (open).
Rectal speculum (closed).
Rectal speculum (open). - Vaginal speculum
Vaginal speculum (closed).
Vaginal speculum (open). - Hill-Ferguson retractor
Hill-Ferguson retractor. - Anoscope, proctoscope, or rigid sigmoidoscope
- Grasper-type instrument for removal (These should be used only under direct visualization of the foreign body because of the increased risk of perforation.)
- Ring forceps
Ring forceps. - Tenaculum forceps
Tenaculum forceps.
- Foley catheter
- Placement in the lithotomy position allows for palpation of the object in the lower abdomen to assist in retrieval.
- Another option for placement is the left lateral decubitus position, with the right lower extremity partially flexed at the hip and knee.
- Patients may be positioned prone, such as in the knee-to-chest position.
- Evaluation of the patient with a rectal foreign body begins with a thorough history.
- Most patients mention the presence of a rectal foreign body as part of the chief complaint. Vague reports of abdominal pain or rectal pain are uncommon.
- The history obtained should focus not only on signs and symptoms of perforation or complications but also on possible indications that removal in the emergency department may be difficult. Items to include in the history include the following:
- Fever
- Severe abdominal pain
- Rectal bleeding
- Systemic illness
- Time elapsed since insertion
- Type and size of object
- Methods attempted to remove foreign body prior to arrival
- The physical examination should include the following:
- Abdominal examination to evaluate for peritonitis
- External anal and perineal examination to evaluate for trauma
- Digital rectal examination (DRE) to determine if the foreign body is palpable (DRE should not be attempted if the object is sharp.)
- Radiographic evaluation includes an abdominal series to attempt visualization of the object and to evaluate for signs of complications.
Rectal foreign body that is difficult to observe on radiography.
Rectal foreign body readily visible on radiography.
- Consider a lateral view for further delineation of the object's orientation and location.
- If the foreign body is not radiopaque, an abnormal gas or stool pattern may be visualized around the external surface of the object. Air may be observed inside a hollow object.
- Specifically note the presence or absence of free intraperitoneal air.
- Look for an obstructive bowel gas pattern.
- Intravenous pain control and benzodiazepines should be administered.
- Performing the Valsalva maneuver may keep the patient alert enough to assist with the procedure.
- A perianal block may be considered.
- Formal procedural sedation may also be considered.
- Continuous electrocardiographic and vital sign monitoring should be performed.
- Instruct the patient to assume a preferred position (see Positioning).
- The object can often be removed with digital manipulation.
- If the object cannot be successfully removed with digital manipulation, insert a retractor or speculum device.
- If the object is visible, grasp the edge of the object under direct visualization.
- Never attempt to grasp an unseen object because of the risk of pinching the rectal mucosa, which can cause further injury.
- If the object cannot be visualized with a retractor instrument in place, consultation with a surgeon is indicated.
- If a glass object is being grasped, pad the ends of the forceps to avoid breakage.
- Apply steady, gentle traction on the forceps to withdraw the object.
- Suprapubic pressure may assist with object removal.
- The object may need redirection around the sacral curve.
- Have the patient bear down, which may aid in removal.
- The foreign body and the speculum may need to be removed as a single unit if the object is too large to be withdrawn through the speculum.
- If suction created by the rectal mucosa is hindering withdrawal, a Foley catheter may be advanced proximal to the object and the balloon inflated to break the suction. The Foley catheter can then be used as an additional traction device to aid in removal.
- If the foreign body cannot be removed safely, obtain a consultation with a surgeon. The patient may require an examination under general anesthesia or a laparotomy.
- Once the object is removed, consider sigmoidoscopy if mucosal injury or perforation is suspected.
- If no injury is found, the patient may be discharged home after observation in the emergency department.
- If injury is discovered, a surgeon should be consulted for likely admission.
- If only superficial mucosal injury is found, consider discharging the patient in conjunction with a surgical consultation.
- Discharge instructions should include warning signs for perforation, infection, and bleeding. The patient should understand that he or she needs to return to the emergency department if these signs or symptoms develop.
- Consider assault as an etiology for an anorectal foreign body.
- Delayed removal of rectal foreign bodies can lead to severe complications, including the following:
- Perforation
- Peritonitis
- Infection or sepsis
- Mucosal ulcerations, lacerations, or edema
- Obstruction
- Bleeding
- Enemas, laxatives, and cathartics should not be used to aid in removal of a foreign body.
- Objects within the sigmoid colon frequently require operative intervention for removal.
- Orally ingested foreign bodies that traverse the GI tract without difficulty do not commonly become lodged in the colorectum. Small pointed objects, especially toothpicks or fish bones, may become impacted in the anal crypts.
- A few unusual methods have been used to successfully remove rectal foreign bodies, including a vacuum-extractor device, plaster of Paris, and obstetric forceps.
- Inability to remove the object or retained foreign body
- Perforation
- Mucosal injury
- Bleeding
National Center for Emergency Medicine Informatics: Rectal Foreign Body
| Media file 10:
Rectal foreign body that is difficult to observe on radiography. |
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Media type: X-RAY
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| Media file 11:
Rectal foreign body readily visible on radiography. |
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Media type: X-RAY
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- Management of rectal foreign bodies. In: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th. Philadelphia, PA: WB Saunders Company; 2004:875-7.
- Hellinger MD. Anal trauma and foreign bodies. Surg Clin North Am. Dec 2002;82(6):1253-60. [Medline].
- Lake JP, Essani R, Petrone P, et al. Management of retained colorectal foreign bodies: predictors of operative intervention. Dis Colon Rectum. Oct 2004;47(10):1694-8. [Medline].
- Management of specific anorectal problems. In: Marx JA, Hockberger RS, Walls RM. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th. St Louis, MO: Mosby; 2002:1356-1358.
Foreign Body Removal, Rectum excerpt Article Last Updated: Jun 29, 2007
Topic originally published: Jun 29, 2007
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