Continuing Education Activity

Rectal foreign bodies can be life-threatening if not promptly evaluated and removed. This activity reviews the role of the interprofessional team in evaluating and managing patients with this condition.

Objectives:

• Identify the common patient and presentation of a patient with a rectal foreign body.
• Explain the management considerations for patients with rectal foreign bodies.
• Recall, analyze, and select appropriate evaluation of the potential complications and clinical significance of retained rectal foreign bodies.
• Identify the importance of improving care coordination amongst the interprofessional team to enhance the delivery of care for patients affected by rectal foreign bodies.

Introduction

Rectal foreign bodies (RFB) are not new to medical literature. One of the earliest examples of rectal foreign bodies (RFBs) ever reported dates back to the 16 century.[1] RFBs cases are no longer a rare presentation in emergency departments, and their incidence is rising, specifically in urban populations.[2] The average age of presentation is 44 years, and there are more commonly seen in men.[2] Although there are various objects inserted in the rectum, the most common among them are glass bottles (42.2%).[3] There are many reasons for rectal foreign body insertion including, sexual gratification, concealment, as may be the case in body packers, sexual assault, and, rarely, accidental causes, but the most common purpose is autoeroticism due to the increasing use of a different object for anal sex.[4][5] The time of presentation varies; some people consult emergency services immediately because of their inability to remove the object. At the same time, other patients might take up to two weeks before the presentation due to embarrassment. Even on arrival, such patients often try to conceal the true nature of their presentation to the emergency department.[6] Different techniques have been developed to remove a foreign body from the rectum. The methodology of removal has evolved with technological advancements, including laparoscopy, endoscopy, and minimally invasive surgical alternatives. A review of these procedures, their indications, and complications, along with their clinical significance, will be discussed in this article.

Anatomy and Physiology

Rectum is the continuation of the sigmoid colon, and it is a tubular structure that begins at the level of S3 and changes into the anal canal at the anorectal hiatus formed by the innermost fibers of puborectalis. It has two major flexure, i.e., sacral and anorectal flexures. It also has three additional lateral flexures. Levator ani muscle provides support to the rectum inferiorly. The fascia of Waldeyer anchors it to the curve of sacrum posteriorly. Laterally, it is supported by the lateral ligaments of the rectum. Denonvillers fascia supports it anteriorly in males and the rectovaginal fascia in the case of females.

Relations:

The rectum is related posteriorly with sacral plexus and sympathetic trucks. Anteriorly, it is related to the urinary bladder, prostate, seminal vesical, and rectovesical pouch in males and uterus, cervix, vagina, and the pouch of Douglas in females. These sacs contain sigmoid colon and coils of the small intestine. The anal canal is supported by fibromuscular structures, including the perineal body in front and the anococcygeal body from behind.

Indications

Any foreign body present in the rectum should be removed promptly[3]. RFBs can be removed by a transanal approach, or sometimes they require an abdominal approach. The transanal approach should be attempted first, and 60% to 75% of the rectal foreign bodies can be removed by this technique.[6][7][8] The indications for the transanal approach is that the foreign body is present within 10 cm from the anal verge, and there are no signs and symptoms of peritonitis. Sometimes the patient may require analgesia if the transanal approach is too painful or if the extraction is too difficult due to edema.

The patients with signs and symptoms of peritonitis or if the foreign body is not papable on digital rectal examination require an abdominal approach. The abdominal approach could be either laparoscopy or laparotomy.

Contraindications

Absolute contraindications of transanal approach are peritonitis secondary to rectal perforation, systemic signs of sepsis, investigations showing free gas under the diaphragm on erect CXR, and free fluid in the abdomen.[3]

Relative contraindications of the transanal approach include an object that is not palpable on digital rectal exam, a foreign body which stuck badly due to edema, fragile or sharp foreign body, or an uncooperative patient.

Equipment

The equipment required for transanal removal are as follows:

• Surgical gloves
• Light source
• Lignocaine gel
• Anal speculum
• Foley catheter
• Vaginal speculum
• Proctoscope
• Grasping forceps
• Rigid or flexible sigmoidoscope if the foreign body is not palpable

Personnel

Management of the patient with a foreign body in the rectum is a team effort.

The team includes a surgeon, psychiatrist (liaison officer), nurses, anesthetist, operation table assistant.

Preparation

The patient should be seen in a private area to allow for digital manipulation. An abdominal exam is to be performed to look for a rebound, guarding, or a rigid abdomen. If there are peritoneal signs present, patients will require large-bore intravenous access for fluid resuscitation and laboratory studies, including blood count, electrolytes, coagulation panel, and type and screen. The clinician may consider sending a lactic acid if the patient appears septic. In this case, wide-spectrum antibiotics should be administered, which include 3rd generation cephalosporins and metronidazole. An upright chest x-ray may ascertain the presence of free air, which could indicate that perforation has occurred. An abdominal x-ray can be obtained to identify and confirm the presence of a RFB if the object is radio-opaque. Adequate analgesia and possible sedation medications should be available to facilitate manual removal if needed. A conversation about the risks and benefits of the procedures to be performed should occur with the patient to obtain informed patient consent.

Technique or Treatment

Rectal foreign bodies constitute a proctological emergency. Numerous approaches have been described in the literature that can be used to extract RFBs with their number as large as the variety of foreign bodies reported.

One should move from the least invasive to complex, more invasive approaches. The majority of foreign bodies can be removed by the transanal approach. The standard technique for the transanal approach involves the combined use of analgesia, sedation, anesthesia, and an attempt at manual removal of the foreign body[2]. Manual extraction should be attempted first, and if unsuccessful, may be removed in the operating room. Manual removal success depends on the size of the clinician's hand and the adequacy of anal sphincter relaxation. Patients may also be asked to perform a Valsalva maneuver to help propel the RFB caudally. Manual removal should not be performed in the case where there are signs of perforation or peritonitis as they need surgical evaluation. It should also be avoided if the RBF is a sharp object, which has increased the risk of trauma to the mucosa and to the provider.

Body packers are another subset of patients where RFB removal ought to take place in the operating room given the fragility of the packaging holding drugs, and the risk of systemic toxicity should cause the contents to spill during removal.

Using a Foley catheter may aid bedside RBF removal. Passing a foley catheter past the object can allow air to pass the object to break the vacuum seal that may occur in these cases.[9][10][11] Inflation of the balloon of the foley may help provide traction with the removal of the RFB.[10] The use of atraumatic surgical instruments such as uterine clamps or suction devices used in obstetrics has also been reported, though it may be difficult when the RFB is smooth.

Other techniques:

• Magnets to removal metal objects.[12]
• Using clamps to break up organic material, such as fruit or vegetables, into smaller, easier to removal pieces.[9]
• Inflating a Sengstaken-Blakemore tube inside objects, like a bottle or a jar, to provide traction.[13]
• Obstetrical vacuum device.[14]

Some patients may need more advanced approaches if bedside manual removal is unsuccessful. At times manual extraction may be successful in the operation suite due to deeper sedation levels and relaxation of the sphincter.  55% of patients that have RFB proximal to sigmoid required operational intervention[6]. Objects in the distal sigmoid colon may be removed with a flexible sigmoidoscope where the polypectomy snares can be wrapped around the object and air can be insufflated to break the seal[2]. Another advantage of sigmoidoscopy is that the mucosa can be easily evaluated for injury after removal.

Another approach for RFB removal is a transanal minimally invasive surgical technique (TAMIS). A laparoscopic trocar is placed through the anus and hubbed to create a seal. The rectum can then by insufflated and laparoscopic graspers are used to grab the object[15].

A more invasive approach includes laparoscopy and laparotomy, where the object is milked towards the rectum for manual removal[16]. If there is suspected perforation, a colostomy may be performed for transabdominal removal, and a Hartmann procedure with colostomy may be used for diversion depending on the severity of the patient's condition.[3][17]

Complications

The curvature of the rectum and its proximity to various structures makes it vulnerable to perforation from foreign bodies. The most dreadful complication with a foreign body in the rectum is perforation leading to peritonitis if perforation is not contained[18]. If the perforation is contained, then it can result in local abscess formation. A sharp object can also injury to nearby organs like urinary bladder or vagina, which could result in vesicorectal and rectovaginal fistulas. Delayed removal of a foreign body can also cause bleeding, ulceration, obstruction, and sepsis.

Clinical Significance

Removal of a foreign body should be performed promptly. Delay in the removal of a foreign body can result in edema and perforation of the colon, which requires a complicated intraabdominal procedure for the removal of the foreign body.

Enhancing Healthcare Team Outcomes

Most of the patients are reluctant to seek medical help in the case of the rectal foreign body; therefore, their privacy should be maintained, and some patients need counseling from psychiatrists and counselors.

Nursing, Allied Health, and Interprofessional Team Monitoring

Hourly monitoring of patient vitals and abdomen should be done in case of transanal extraction. The nurse should remain vigilant in case of nonoperative removal of the foreign body because sometimes small tears and leaks may present after some time; therefore, thorough monitoring is required.