Chapter 72. Rectal Foreign Body Extraction

Foreign bodies within the rectum are the result of an ingestion from above or are placed into the anus from below.1 Fortunately, the majority of items ingested from above that pass the pylorus and ileocecal valve also pass the anal sphincter. The most frequent types of items found in the anus from above are undigested fish or chicken bones. Foreign bodies that are placed into the rectum from the anus are placed iatrogenically (e.g., enema tips and thermometers), inserted by the patient in an attempt to remove impacted stool, inserted by the patient or their partner as a form of anorectal auto-eroticism, forcibly placed in the anus during a rape, or placed in the rectum to smuggle objects across a border illegally.

The items placed into the rectum from the anus seem to be limitless and represent all the shapes and sizes imaginable.2 This makes their removal more difficult. It is important to attempt to identify the characteristics of the foreign body in order to devise the safest way of removal. As an example, consider the typical electric lightbulb. The glue that attaches the metal base to the glass loosens with moisture and time. Pulling off the metal base exposes a thin, sharp glass edge. The glass globe is very thin and breaks very easily. If the glass breaks, it may take a long time to remove the fragments and cause considerable damage to the surrounding rectal mucosa or the examining finger. The idea is to remove the foreign body without causing further damage to the rectum or the anal sphincter muscle. The more knowledge the Emergency Physician has about the foreign body and how it was inserted, the more likely it is that it will be removed safely.

The significant anatomy of the anal canal is discussed in Chapter 70, describing the anatomy for anoscopy. Important anatomic considerations in removing rectal foreign bodies include the axis of the lumen of the anus. The anus is pointed toward the patient's umbilicus, while the curve of the sacrum forms a posterior arc. If the length of the foreign body is longer than the curve of the sacrum, such as a long vibrator or dildo, the sacral promontory causes the distal end of the foreign body to be directed toward the tip of the sacrum or coccyx. When the object is being removed by bringing the distal end anteriorly, the middle portion may push anteriorly (i.e., into the prostate, uterus, or bladder) and cause considerable discomfort.

The important physiologic considerations include the anal sphincter muscles, edema, and the creation of a vacuum. The anal sphincter is a complex group of muscles. The external anal sphincter muscle is made up of voluntary muscle fibers. The internal anal sphincter muscle is made of smooth muscle fibers. The reflex response to dilatation of the rectum is contraction of the external anal sphincter muscle. The normal tone of the anal sphincter comes from the internal anal sphincter, which can go into spasm with manipulation.

Therefore, it is very important to try to remove foreign bodies with slow and steady traction. Maintain constant pressure and wait for the sphincter muscle to fatigue. The technique is not too dissimilar to the methods used to relocate a shoulder. The slow and constant traction will also help with the edema that forms around rectal foreign bodies that have remained in the rectum for a prolonged period of time.

Finally, it is important to consider the formation of a vacuum, which may result from pulling a large, smooth foreign body such as a bottle or lightbulb. It is sometimes necessary to place one or more soft catheters above the foreign body so that air may get around the object as it is removed. This will prevent the formation of a vacuum and allow the foreign body to be removed. Large Foley catheters with the balloon inflated can be used for air insertion to prevent the vacuum and traction to bring the object further down into the rectum.

The indication to remove a foreign body from the rectum is the identification of a foreign body in the rectum. The majority of patients with this problem have already tried to pass the item with a bowel movement. They may also have already tried oral laxatives. It is impossible to estimate the number of rectal foreign bodies that are removed at home. It is estimated that very few objects inserted through the anus will pass spontaneously. Waiting is detrimental for the vast majority of items. Sharp foreign bodies may already have begun to perforate the rectum. Large foreign bodies will continue to cause irritation and edema, making removal more difficult with the passage of time.

There are a few absolute contraindications to removing a rectal foreign body in the Emergency Department. However, the removal of a rectal foreign body that has not perforated is not an emergency. Time taken to plan the removal and obtain adequate anesthesia and relaxation of the anal sphincter muscles is well spent, especially if the object is difficult to retrieve. The patient's general condition must be taken into account. Patients with peritonitis require operative removal and exploration. The time taken to remove the object is wasted and identification of the perforation is easier in the Operating Room with the item in place. Patients with lower abdominal pain and fever may have a perforation below the peritoneum that can be confirmed with a water-soluble contrast enema. Foreign bodies that are large, irregularly shaped, or have sharp edges should be extracted in the Operating Room. In patients who have been assaulted, a complete assessment of all the patient's injuries is mandatory. It usually is better to leave the object in place to help identify all the possible associated injuries that may have occurred. The foreign body should be removed in the Operating Room if it is not palpable, not visible upon dilating the anus, or removal of the object may cause injury to the patient. Packets containing illicit drugs should be extracted with a rigid rectosigmoidoscope or in the Operating Room. Rupture of the packets can result in significant morbidity and mortality.

• Local anesthetic solution with epinephrine (1% lidocaine or 0.5% bupivacaine)
• 25 gauge needle, 2 in. long
• 10 mL syringe
• Povidone iodine or chlorhexidine solution
• Anoscope
• Ring forceps
• Tenaculum
• Park retractor
• Hill-Ferguson retractor
• Large spoons
• Foley catheters
• Endotracheal tubes
• Endoscopic snare
• Rigid rectosigmoidoscope
• Vacuum extractor (optional)

The patient must undergo a complete history and physical examination. It is important to ascertain the overall health of the patient in case it is necessary to go to the Operating Room to extract the foreign body. Attempt to identify patients with rectal perforations as they need to go to the Operating Room quickly. Biplane plain radiographs with an upright are useful to determine the number, shape, and location of the foreign bodies as well as the presence of free air under the diaphragm. It is necessary to look at both the anteroposterior view as well as the lateral view to completely appreciate the object in three dimensions.1 It is important to inform the patient in advance that while 90% of the objects can be removed from below, some may require general anesthesia or even an operation and a temporary colostomy. Explain the local anesthesia and the extraction procedures to the patient and/or their representative. Obtain an informed consent for the extraction of the foreign body.

Ascertain the type and number of objects in the rectum. It is possible to remove one foreign body and miss others that the Emergency Physician was not aware were present. Unfortunately, it is common to find that the patient is unsure of this part of the history; this is why plain radiographs can be so helpful. It is also important to identify the technique of insertion. Patients with objects that were inserted forcefully should undergo a trauma-oriented workup, and sexual abuse must be considered. Determine the length of time since insertion. Edema formation will be significant if the object has been present more than 24 hours. This will make it more likely that an anesthetic will be needed or that it will be necessary to use catheters to break the vacuum that forms during extraction.

The parts of the physical examination that are most helpful are the abdominal and rectal examinations. The abdominal examination should focus on the presence or absence of tenderness, peritonitis, and the palpation of a mass. Many objects are long enough to be palpated in the left lower quadrant. It may be useful to apply pressure on the lower portion of the abdomen to help remove the object. The rectal examination should include a careful external examination looking for evidence of trauma. The digital portion of the examination should roughly quantify the sphincter tone and squeeze pressure.

The remainder of the examination should consist of careful palpation of the foreign body to determine its location, texture, and mobility and to identify possible areas to grasp. Examples would include the open end of a bottle or the narrow end of a lightbulb. Determining if the object is hard, soft rubber, or plastic will help determine which tool would be best suited to grasp the object. One exception to performing the digital rectal examination would be determining, on radiographs or by history, whether the object is sharp (such as a knife blade) or consists of broken glass. It is recommended to postpone the digital rectal examination, especially in prisoners and psychiatric patients, until a radiograph rules out a sharp foreign body. If the examiner is not able to palpate the foreign body, a rigid rectosigmoidoscope should be used to identify and remove the object. The technique of rigid rectosigmoidoscopy is described in Chapter 71.

Anesthesia

The second general consideration is to have a relaxed anal sphincter. The use of intravenous or procedural sedation will relax the patient and relieve any discomfort associated with the procedure. It may be necessary to inject the anus with local anesthetic solution if the patient experiences pain or if slow steady traction will not overcome the tone of the anal sphincter.3,4 Anesthesia of the sphincter muscles will provide for patient comfort and allow dilation of the sphincter muscles. Place the patient in the lithotomy position (Figure 72-1A). Wipe away any dirt, debris, and fecal material from the perianal skin and surrounding area. Apply povidone iodine or chlorhexidine solution and allow it to dry. Inject local anesthetic solution subcutaneously and circumferentially around the anus (Figure 72-1A). Inject 1 to 1.5 mL of local anesthetic solution into the anal sphincter muscles at the 12, 3, 6, and 9 o'clock positions (Figure 72-1B).

An alternative is a pudendal nerve block. Determine if the ischial spines are palpable through the rectum. Insert the needle through the skin and toward the ischial spine. Use the finger inside the rectum to palpate and guide the needle to the ischial spine. Inject 3 to 5 mL of local anesthetic solution just medial to the ischial spine. Repeat this procedure on the other side. The main disadvantage of the pudendal nerve block is that it is a blind procedure and has the potential for a needle stick. If these are not successful, it will be necessary to take the patient to the Operating Room for regional or general anesthesia.

The patient may remain in the lithotomy position for the extraction of the foreign body (Figure 72-2A). Other positions include the modified Lloyd Davies position (Figure 72-2B) and the Sims position (Figure 72-2C). The choice of positions is physician dependent and limited by patient comfort.

It is important to understand that since the types of foreign bodies found in the rectum are so variable, it is impossible to give exact instructions on how to remove them. There are some general considerations to remember. The first is to visualize the foreign body. Gentle suprapubic pressure will often push the foreign body into the distal rectum. The distal end of the foreign body may get caught along the curve of the sacrum. Place a finger in the rectum to redirect the orientation of the foreign body. The second consideration is to grasp the object. Sometimes an object is low-lying and may be grasped with gloved fingers. The object can then be removed by gentle continuous traction. Low-lying objects may be soft enough to be grasped with an instrument. It is necessary to do this under direct vision so that the rectum will not be damaged in the attempt to grasp the foreign body. Hard, low-lying objects made of metal or plastic may be grasped with a tenaculum.

Insert two well-lubricated fingers into the anesthetized anus and gently dilate the anal sphincter muscles. The anus can be maintained in the open position by the insertion of a Park retractor (Figure 72-3A) or a Hill-Ferguson retractor (Figure 72-3B). An anoscope or vaginal speculum may be used if these retractors are not readily available in the Emergency Department. View the distal end of the foreign body. Never insert instruments unless the foreign body is visualized. Blind insertion of instruments may push the foreign body more proximally or perforate the rectum. Never grasp a foreign body blindly. This can cause injury to the rectum upon removal of the instrument if the rectal mucosa is entrapped between the instrument and the foreign body.

Digital Extraction Technique

Foreign bodies within reach may be grasped with the fingers and extracted. This often proves very difficult as the foreign body will be coated with lubricant, mucus, and/or stool. Instruct the patient to bear down as if having a bowel movement. The intraabdominal pressure generated in this way may expel the foreign body. The foreign body may become entrapped against the sacrum. Insert a finger into the rectum to dislodge the foreign body from against the sacrum as the patient continues to bear down. Attempt one of the techniques described below if digital extraction is ineffective.

Foley Catheter Technique

A Foley catheter has been successfully used to aid in the extraction of rectal foreign bodies.5–7 This is especially helpful if the foreign body is made of glass, an inverted bottle or can, large, or present for more than 12 to 24 hours. Pulling these types of foreign bodies can result in the formation of a vacuum proximally and inhibit their extraction.

Liberally lubricate a Foley catheter. Insert the Foley catheter between the foreign body and the rectal mucosa. Advance the catheter until the balloon is proximal to the foreign body (Figure 72-4A). Fluoroscopy, if available, can be used to confirm the location of the balloon and guide the removal of the foreign body.13 Inflate the balloon with 30 mL of saline or water. Inject air with a syringe through the Foley catheter to break the vacuum proximal to the foreign body. Remove the syringe so that air can move freely through the Foley catheter and prevent a vacuum from becoming reestablished. Apply constant, gentle, and steady traction to the Foley catheter. This will prevent the foreign body from migrating proximally. It may also move the foreign body distally so that it can be grasped and extracted with fingers or an instrument. The use of two to four circumferentially placed Foley catheters may apply evenly distributed traction to extract the foreign body more easily.

Endotracheal Tube Technique

An endotracheal tube has been used in place of a Foley catheter by some physicians (Figure 72-4B). The advantage of using an endotracheal tube is that it is relatively stiff and can apply more traction than a Foley catheter to help remove the foreign body. Unfortunately, there are also disadvantages. The endotracheal tube is larger and less flexible than a Foley catheter. This may result in difficulty advancing it past the foreign body. The larger and stiffer endotracheal tube can more easily lacerate the rectal mucosa and perforate the rectum. For these reasons, the use of an endotracheal tube cannot be recommended.

Spoon Technique

The removal of smooth, round, fragile, or glass foreign bodies can be problematic. This can include lightbulbs, balls, fruits, and vegetables. These foreign bodies can be extracted with a pair of large spoons. Liberally lubricate the posterior surface of a pair of spoons. Insert a Foley catheter to eliminate the vacuum proximal to the foreign body. Insert the spoons until they are cupping the foreign body (Figure 72-4C). Grasp and gently squeeze the handles of the spoons so that they hold the foreign body. Withdraw the spoons and the foreign body.

A more readily available alternative to large spoons are obstetric forceps. These have also been successfully used to extract a rectal foreign body. The use of obstetric forceps cannot be recommended due to their large size, unfamiliarity to most Emergency Physicians, and the potential to perforate the rectum.

Ring Forceps or Tenaculum Technique

Rectal foreign bodies that are not fragile may be grasped with a ring forceps or tenaculum and then extracted. Insert a Foley catheter to eliminate the vacuum proximal to the foreign body. Firmly grasp the foreign body with a ring forceps or a tenaculum (Figure 72-4D). A tenaculum has teeth on its distal tips. These may be advantageous as the teeth can grip and firmly hold the foreign body, making the extraction easier. This must be performed under direct visualization to ensure that the rectal mucosa is not entrapped between the instrument and the foreign body. Apply gentle, firm traction to extract the foreign body.

Vacuum Extraction Technique

A vacuum dart or obstetrical vacuum extractor may be used to extract a rectal foreign body.6,8 Emergency Physicians are usually not trained in the proper use of a vacuum extraction device. It may be beneficial to have an Obstetrician, Gynecologist, Family Practitioner with obstetric experience, or a Nurse Midwife to assist with this technique.

Insert a Foley catheter to eliminate the vacuum proximal to the foreign body. Place the vacuum cup of the device onto the foreign body. Ensure that none of the rectal mucosa is entrapped between the rim of the suction cup and the foreign body. Apply the suction to seal the cup against the foreign body. Recheck to ensure that none of the rectal mucosa has become entrapped. Apply steady traction to extract the foreign body.

Miscellaneous Techniques

Numerous other techniques have been devised to remove a rectal foreign body.9–12 These include the use of proctoscopes and snares, de Pezzer catheters, cyanoacrylate glue, clamps covered with rubber tubing, a tonsil snare, Sengstaken–Blakemore tubes, and plaster of Paris. Cyanoacrylate glue can be used to attach a handle to the foreign body. The foreign body can be extracted by withdrawing the handle after the glue has dried. A Sengstaken–Blakemore tube can be inserted into a foreign body with a small opening (e.g., glass bottle, soda can, etc.). Inflate the balloons and apply traction to extract the foreign body. Plaster of Paris can be used to fill a hollow object and allowed to harden around a tongue blade (Figure 72-4E). This is analogous to making a popsicle on a stick. The major disadvantage of using plaster of Paris is that it generates heat as it hardens. This heat may damage the rectal mucosa or shatter a glass bottle. The technique used and the choice of devices are limited only by one's imagination.

Examine the rectum with a rigid rectosigmoidoscope to assess the mucosa for tears or perforations after the foreign body is extracted. Some physicians believe that this examination is not necessary if the patient is asymptomatic, the foreign body is smooth, it was extracted atraumatically, and no complications arose from the extraction procedure. These patients may be discharged with follow-up as an outpatient for rectosigmoidoscopy. If obvious damage to the mucosa exists, the patients should remain in the hospital for observation. The patient should remain NPO and be prepared for possible surgery. Other indications for admissions include abdominal pain, significant bleeding, or the suspicion of a rectal perforation. Broad-spectrum intravenous antibiotics should be administered if a rectal perforation is suspected.

Perform a digital rectal examination to document the presence and quality of anal sphincter tone after the procedure. This should be delayed until the effects of any general, local, or regional anesthesia have dissipated. Rectal tone that is decreased or diminished from the initial (i.e., preprocedural) digital rectal examination requires the consultation of a General or Colorectal Surgeon.

Patients may be discharged home after the extraction procedure if they are asymptomatic, have normal rectal tone, and have no complications demonstrated on rigid rectosigmoidoscopy. They should be instructed to return to the Emergency Department immediately if they develop abdominal pain, pelvic pain, bright red blood per rectum, or a fever.

The major complications include rectal bleeding, rectal perforation, and damage to the anal sphincter. Since the patient may very well have presented with these complications, it is important to document them or their absence on the initial (i.e., preprocedural) examination. Rectal bleeding is common after a difficult extraction. It is important to rule out a perforation. This can be performed with the rigid rectosigmoidoscope after the extraction. Most perforations occur at the rectosigmoid junction, approximately 15 to 16 cm from the anus. Perforation above the peritoneal reflection will result in peritonitis and free air noted under the diaphragm on upright plain radiographs. Perforation below the peritoneal reflection may take several days to manifest pelvic pain, signs of a pelvic abscess, or sepsis. If there is no evidence of perforation or significant mucosal damage, the patient may still be discharged. However, large amounts of bleeding or significant mucosal damage require observation at the least. A Gastrografin enema without the use of the balloon may be used to identify a perforation if there is significant concern that it exists. Patients with perforation of an unprepared rectum require surgical intervention and broad-spectrum intravenous antibiotics. Any evidence of acute sphincter damage requires a surgical evaluation for possible debridement. The majority of these lesions are observed, allowed to heal secondarily, and then repaired surgically.

The majority of rectal foreign bodies can undergo transanal extraction. Removal of rectal foreign bodies should include an appropriate history and physical; biplane abdominal radiographs; relaxation of the anal sphincter; firm attachment to the foreign body and slow, firm traction extraction; and postextraction rectosigmoidoscopy. Inpatient observation is indicated if the rectal mucosa is traumatized. The patient should be taken to the Operating Room if the foreign body cannot be removed in the Emergency Department, for pain control, if a perforation is suspected, or if removal may result in secondary injury.