‘What Goes Up, Must Come Down’

Yes, sex toys are probably most common, but it might also be a kitchen tool or even (shudder) broken glass.

We’re talking, of course, about foreign objects that emergency department (ED) physicians may find in patients’ rectums, removal of which is not always straightforward, as was explained at the Society of American Gastrointestinal and Endoscopic Surgeons annual meeting.

In a presentation titled “What Goes Up, Must Come Down,” David Schwartzberg, MD, a colorectal surgeon at Northwell Health in Port Jefferson, New York, told attendees what to look for and how to manage such cases, from the simple to the complex.

Most trauma in the anorectal region stems from more mundane causes — car accidents, gunshot, and stab wounds — and a busy ED might see one case of foreign body insertion a month. Nevertheless, these bring special concerns.

For instance, Schwartzberg said, “Have a chaperone present,” and “consider that the patient may not be entirely forthcoming.”

Other must-do’s include obtaining a thorough history and physical exam and ordering “KUB” (kidneys, ureters, bladder) imaging, as well as CT scans if x-rays aren’t definitive.

One purpose of these initial steps is to confirm where the object really is. He showed an x-ray depicting what looked a dildo, initially thought to be lodged in the rectum, but close inspection of the image indicated that it was actually in the vagina.

The physical exam, with an anoscope or proctoscope, should focus on how much tissue damage was done, and to what tissues, as well as on the degree of contamination that may have been introduced. Answers to those questions will determine whether the patient can be treated in the ED or must go to the operating room, Schwartzberg indicated.

A variety of lab tests should be ordered too, he said, such as blood counts, metabolic parameters, and blood coagulability, which would all be necessary if the patient needs surgery.

Objects confirmed to be relatively smooth, confined to the rectum without mucosal injury, can usually be extracted easily in the ED (A Foley catheter can be a valuable aid, Schwartzberg said). But, “anything more, you’re probably going to the operating room with sedation or general anesthesia,” he warned.

Surgeons will need to perform debridement and whatever repair may be needed, which of course depends on the extent of trauma. With relatively minor injuries to the sphincter or perineum, without intraperitoneal involvement, a quick repair followed by antibiotics and perhaps tetanus prevention can be enough. More severe injuries, of course, will require more extensive treatment. Definitive repair may need to be put off until the situation is fully understood.

When the object can’t be retrieved in the ED — because it’s too far up into the sigmoid colon, for example — surgeons can use an operating proctoscope and endoscopic tools to grab for extraction. Another approach is laparoscopy to manipulate the object into the rectum for easier removal, said Schwartzberg.

Both of those methods are appropriate only when there is no pneumoperitoneum. If air has penetrated or there is clear contamination, and the object can’t be moved into the rectum, then it may have to be extracted surgically, with the resultant need for resection and anastomosis or diversion. The latter is indicated when gross contamination is seen. In such cases, Schwartzberg said distal irrigation through the diversion colostomy should be avoided, even though it may seem logical, as previous studies have shown it increases risk of sepsis.