An unusual case of rectal foreign body
In a rare and strange case, a 54-year-old Brazillian man presented to a hospital in Manaus with complaints of abdominal pain, nausea and an inability to defecate. While initially, the man was reluctant to tell the doctors what was causing his suffering – it was later revealed that his symptoms were caused by a rectal foreign body.
The patient initially waited 2 days before he presented to the hospital. The cause of his symptoms was unclear because the patient was ‘uncooperative’ during physical examination. The doctors advised an X-ray for further examination. X-ray findings showed a 2kg dumbbell, measuring 20 cm lodged in the patient’s colon where it meets the rectum. According to the International Journal of Surgery Case Reports, the surgeon had to use his forearm to manually remove the 2kg dumbbell from the man’s anus. The case was ‘fraught with difficulties, therefore, there was no other option for the surgeon to remove the dumbbell but with his forearm. Fortunately, it was a success in the end. The patient was discharged 3 days after admission.
Sexual gratification is a common motivation in male patients
Doctors report that most of the patients presenting with items stuck in their anus are men. Studies show that even though this is a problem reported in both genders, the ratio of men to females is 28:1. In addition, it is more specifically seen in white men between the ages of 20 and 40 years. The study further states that sexual gratification is one of the most common motivations. While in this case, the patient did not suffer any long term consequences or severe injuries, internal injuries and faecal incontinence are common consequences in several cases. Although the number of cases reported with retained rectal objects has become common in recent years. According to a Caribbean study, 0.15 cases per 100,000 population/year are reported every 5 years.
Patients have reported several retained rectal objects in the past, even including glass bottles. Most of the objects are of sexual nature. However, glass bottles increase the risk of injury, especially if broken. In this case, the patient used a metallic dumbbell, measuring 20 cm and 2kgs in weight. Similarly, most patients don’t seek immediate medical help because of embarrassment. However, after several unsuccessful attempts to remove the object alone, they have no other option but to visit a doctor. According to studies, on average, patients delay seeking medical help for 1.4 days.
Signs and symptoms
Patients generally present with complaints of lower abdominal pain, bleeding, anorectal pain, and constipation. Therefore, it is up to the doctor whether they want to examine the patient for a suspicion of a retained object. A careful approach needs to be followed to reach the correct diagnosis. A good history includes evaluating the nature of the object and how it was inserted. Furthermore, the material, size and location of the object are also important to decide on an approach to removal. In addition, to rule out signs of peritonitis, a physical examination should include inspection, abdominal auscultation and palpation. Whereas digital rectal examination is essential for diagnosis since it provides the presence, size and location of the object.
Diagnosis
The presence of glass and sharp objects in the rectum can be ruled out with an abdominal radiograph. Moreover, also avoids secondary injuries to the patient and examiner. The study further states that imaging tests are essential to confirm the diagnosis with radiographs of the abdomen and pelvis. The radiographs help with locating the rectal objects and confirming the presence and number. X-rays also check for the presence of free air and should be considered when evaluating pneumoperitoneum. Other imaging tests include non-contrast tomography, which is important for the evaluation of non-opaque rectal objects. And for diagnosis in case of suspicion of perforation. Laboratory tests are not essential for initial evaluation unless there is a need to rule out peritonitis or preoperative preparation is needed.
In this case, radiographic examination showed “findings of distention of the descending, transverse, and ascending colon loops, with the presence of a radiopaque dumbbell-shaped foreign body in the rectosigmoid transition, but without signs of pneumoperitoneum or perforation”.
Management
Although there is no standard technique, it is recommended that the initial approach for removal of a rectal foreign body should always be less invasive. If the patient is stable, techniques to remove the object include bimanual extraction, similarly, “if the patient is calm, collaborative, and tolerates the procedure without the need for sedation, there is an advantage in asking to be performing the Valsalva manoeuvre actively at the correct time, other techniques include the use of forceps and finally endoscopic assistance”.
The emergency approach includes laparotomy or exploratory laparoscopy which is reserved for patients presenting with instability, signs of peritoneal irritation, severe pain and fever. All these signs are an indication of perforation. Despite the high location of the object, in this case, doctors considered manual extraction. The surgeon removed the object using his forearm without any post-operative complications. The patient was kept under observation at the hospital for 3 days and showed no signs of complications. He was discharged on the 4th postoperative day.
Source: ScienceDirect
