Anorectal Foreign Body Removal

Anorectal foreign body (FB) in a stable, cooperative patient, which is:

Palpable by rectal approach

Absence of a sharp edge

CONTRAINDICATIONS

Obtain surgical consult immediately in following instances:

Signs of perforation, obstruction, or severe abdominal pain

Nonpalpable FB

Broken glass in rectum

Uncooperative or intolerant patient

Lack of equipment necessary for retrieval

General Basic Steps

Determine type of FB

Radiography

Obtain necessary equipment

Patient preparation

Analgesia

FB removal

Assess for structural damage

KEY ELEMENTS OF HISTORY

Ingestion (e.g., bones, toothpicks) versus rectal insertion

Size and composition of FB

Time of ingestion/insertion

Attempts made to remove FB

Assess for red flags—fever, abdominal pain, hematochezia

Assess for sexual/physical assault, sexually transmitted disease (STD) risk

LANDMARKS

Determine the orientation, location, and composition of the anorectal FB and, thereby the appropriate approach to removal by the following:

Detailed history

Consider radiography

Kidney, ureter, and bladder (KUB) x-ray

Chest x-ray for free air detection (if concerned about perforation)

Physical examination, including digital rectal examination (DRE)

Visualization of the anorectum is enhanced with the patient in the lateral decubitus position, lithotomy position, or prone with knees tucked into chest

TECHNIQUE

Equipment

Depends on the composition and locale of the FB but may include:

Anesthesia/analgesia

Light source

Speculum (i.e., vaginal speculum or anoscope) or Parks retractor to improve visualization

Ring and/or tenaculum forceps

Foley catheter and/or endotracheal tube (ETT)

Vacuum extractor

Patient Preparation

Get informed consent detailing risks, benefits, and alternatives

Order KUB x-ray to localize and define FB, and to assess for obstruction or perforation if clinically necessary (FIGURE 83.1)

Parenteral sedation and analgesia to enable relaxation and tolerance of the procedure. Avoid oversedation because the patient must be alert to assist in the delivery of the FB.

Place the patient in the desired position

A perianal block may facilitate further sphincter relaxation. This is achieved by superficial injection of local anesthetic (≤1.5 mg/kg of 0.5% bupivacaine or ≤7 mg/kg of 1% lidocaine with 1:100,000 epinephrine) in a ring around the anus.