Sunday, November 24, 2013

A bottle in the wrong place: unusual foreign object in rectum

Patients presenting with a large foreign body in the rectum are by no means an uncommon occurrence. They commonly present with abdominal and rectal pain, as well as bleeding from the anus. Males are commonly affected. Young men tend to present with objects inserted for autoerotic or sadistic reasons, whereas in men in their sixties or older the reason is usually more prosaic: prostatic massage or breaking fecal impactions. The majority of objects are introduced through the anus, although sometimes a foreign body (e.g. a bone) is swallowed, passes through the gastrointestinal tract and ends up stuck in the rectum.

Medical literature shows that when it comes to things which can be inserted up the butt, human creativity knows no bounds. Examples of removed objects include plastic or glass bottles, cucumbers, carrots, a light bulb, a tube light, an axe handle, a broomstick and, of course, vibrators. The majority (90%) of these cases is treated in a simple fashion - a surgeon sticks his gloved hand, with forceps or without, up the patient's butt and pulls the offending object out. Hard objects can potentially cause injury and tend to migrate upwards, and large objects in particular create a higher risk of complications such as anal perforation.

Akhtar and Arora describe quite a striking case of a rectal foreign body from India. A 44-year-old male came to the hospital bleeding from the rectum, and explained that he had inserted a beverage bottle there for sexual pleasure. Since he could not remove it himself, he sought medical assistance. He also confessed that he had a history of using similar objects for sexual gratification in the past. His abdomen was soft, and the foreign body was not palpable upon feeling it, but an X-ray showed the glass bottle in the pelvis, and during a subsequent rectal examination the surgeon could - just - grasp the base with his fingers.

Removing the bottle proved tricky. It was so coated in mucus that it was impossible to get a good grip on its round and slippery base. Snares repeatedly slipped, and the bottle could not be manipulated upside down in the rectum due to its large size. 

Large bottle in rectum visible on abdomen X-ray. Image from: Akhtar and Arora (2009).

Finally, after exhausting all methods described in the literature, a novel way of removing the bottle was attempted. After reassurance and a dose of intravenous painkiller, the patient was encouraged to bear down as if trying to defecate. As the bottom of the bottle began to protrude from the anus, the surgeon grasped it with an obstetrics forceps and gently pulled it out. Amazingly, a subsequent per rectal examination and sigmoidoscopy did not reveal any colorectal injury except for some minor anal tears. Recovery was uneventful and the patient did not have any problems with incontinence or perianal infection. He was - not surprisingly - referred for psychiatric treatment.

Akhtar MA, Arora PK (2009) Case of Unusual Foreign Body in the Rectum. Saudi J Gastroenterol. 15(2): 131–132. doi: 10.4103/1319-3767.48973

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