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.
Examination
External examination: Assess for signs of trauma
DRE
Gauge location and orientation of FB
Assess for discharge or bleeding
Small, blunt FBs may be removed during DRE
Anoscopy
Assess for mucosal injury
Visualize FB
Removal of FB
Attempt delivery of the FB by applying suprapubic pressure in synchrony with the patient bearing down