Introduction
Retained Foreign objects are commonly encountered cases in emergency department. Most common location is the upper gastrointestinal system; although rarely, patients may present with foreign body in lower gastrointestinal system or rectum. Rectal foreign bodies are not uncommon in emergency departments worldwide and foreign bodies of various sizes and shapes have been reported in literature. 1 Patient usually presents to emergency department with complain of pain, often after multiple unsuccessful attempts to remove the object on his own. Presentation is delayed owing to shame and embarrassment. Insertion may be accidental, for sexual satisfaction or intentional to inflict harm. Various kinds of foreign bodies have been observed in the rectum, including sharp instruments that may pierce the rectum, colon, or create visceral organ injuries. Till date, no standard guidelines are available to manage such cases owing to diverse presentations. 2 Removal of intrarectal foreign object is technically challenging for surgeons, considering the risk of complications such as rectal perforation and damage to adjacent tissues. 3 Rectal foreign bodies are known for potential complications and present as a challenge to clinical diagnosis and management. Herein we present a case of retained intrarectal foreign body in a middle-aged male that was managed by exploratory laparotomy with no post operative complications.
Case Report
A 48-years-old male presented to the emergency department with complaints of abdominal pain and obstipation for past 2 days. Detailed medical history of the patient revealed that he had placed hot beverage glass with lubricating oil into his rectum following which he couldn’t remove it on his own. There were multiple such episodes of insertion and removal over past 2 years so as to achieve sexual satisfaction. Abdominal examination revealed no abnormality. The abdomen was relaxed. On per rectal examination, a solid object was palpable 5 cm proximal to anal verge. A pelvic radiograph was ordered which revealed radiopaque object in the rectum. [Figure 1]
On the basis of history, clinical examination and radiological evaluation, a diagnosis of retained foreign body in the rectum was made and patient was shifted to operating room for retrieval of same under general anaesthesia, after informed consent. Initially manual extraction was attempted per rectally in lithotomy position, which failed. Patient was then taken up for exploratory laparotomy. Trans-anal extraction was attempted by applying mechanical pressure over rectum and foreign body (beverage glass) was retrieved from anal canal with the help of Cheatle forceps. [Figure 2] Postoperative period was uneventful. Patient was discharged under satisfactory condition. Psychiatric consultation was recommended prior to hospital discharge.
Discussion
Foreign bodies within the rectum are uncommon in Asian continent, and majority of cases are reported from Eastern Europe.4 Males in the age group of 16-80 years are more commonly affected as compared to females.5 Drinking glass, bottle, deodorant container, wooden stick, rubber objects, bulb, tube light, axe handle, vibrators etc. are some of the commonly reported materials in literature with length ranging from 6-15 cm. In majority of the cases, there is history of self insertion, either deliberately or accidentally. Rarely, it may be a result of criminal act. Most of the time, the objects can be removed by the patients themselves. Approximately 20% cases can be managed with endoscopic removal. Only 1% cases require surgical intervention.6 Usually patients present late to the emergency department after multiple unsuccessful attempts to remove the body on his own. This leads to delayed management and increased risks of complications. Radiological imaging in suspected cases is mandatory to confirm the diagnosis and rule out serious complications like intestinal perforation. Prompt management of such cases is important to avoid grave complications. Prior to attempting removal of foreign body, its type and nature should be ascertained as fragile and sharp objects need special consideration.7 Liberal use of lubricant, grasping of foreign body with forceps and gentle withdrawal minimizes damage to the adjacent structures. One can pass a well lubricated Foley's catheter above the foreign body and exert gentle pressure after inflating it to facilitate the removal of foreign body. After removal, rectum should be inspected thoroughly to check for completeness of removal, bleeding points, tear etc. Although rare, mortality can result from bleeding, perforation, laceration and infections complications. One should maintain a high degree of suspicion of rectal foreign body in psychiatric patient or a prisoner who presents with rectal pain or bleeding.8 In the present case, patient had inserted foreign object into his rectum for seeking sexual satisfaction.
Conclusion
Diagnosis can be made on clinical grounds and confirmed by radiological investigations. Management of patients with intrarectal foreign body is challenging for treating surgeons especially in cases of delayed presentation owing to shame and guilt.
Athough various approaches have been described in literature yet no single procedure can be considered as gold standard.
Postretrieval colonoscopy is mandatory to rule out colorectal injury.
