Rectum Foreign Body Removal

Anatomy and Physiology

The rectal wall consists of 4 layers: mucosa, submucosa, muscularis propria (comprising inner circular and outer longitudinal muscle layers), and an outer adventitia. A true serosa is absent except on the anterior surface of the upper 3rd. The internal and external anal sphincters—smooth and skeletal muscle, respectively—regulate continence. The internal sphincter is involuntary and formed by the thickened continuation of the circular muscular layer, whereas the external sphincter is under voluntary control via the pudendal nerve.

The rectum is the distal continuation of the sigmoid colon and begins at the level of the 3rd sacral vertebra (S3), transitioning into the anal canal at the anorectal hiatus, which is formed by the innermost fibers of the puborectalis muscle. Measuring approximately 12 to 15 cm in adults, the rectum follows the sacrum's curvature and includes 2 primary flexures, the sacral and anorectal flexures, as well as 3 lateral flexures.

The lateral flexures correspond to the transverse rectal folds, or valves of Houston, which serve as important anatomic landmarks during endoscopy and surgical procedures. The dentate (pectinate) line marks the transition between columnar rectal mucosa and stratified squamous epithelium of the anal canal. This line also demarcates differences in sensory innervation, lymphatic drainage, and vascular supply, and it serves as a key surgical landmark.

The levator ani muscle provides inferior support, while posterior anchoring is achieved through the fascia of Waldeyer, which tethers the rectum to the sacral curvature. The lateral ligaments of the rectum maintain lateral stability. Anteriorly, structural support is provided by Denonvilliers fascia in male individuals and the rectovaginal fascia in female individuals. The anal canal is supported anteriorly by the perineal body and posteriorly by the anococcygeal body, both of which contribute to fibromuscular integrity.

Posterior anatomic relations include the sacral plexus and sympathetic trunks. Anteriorly, the rectum is related to the urinary bladder, prostate, seminal vesicles, and rectovesical pouch in the male body, and to the uterus, cervix, vagina, and pouch of Douglas in the female body. These peritoneal pouches commonly contain loops of the small intestine and portions of the sigmoid colon. The peritoneal reflection varies by segment. The upper 3rd of the rectum is covered anteriorly and laterally, the middle 3rd only anteriorly, and the lower 3rd is entirely extraperitoneal.

Arterial supply to the rectum is derived from the superior rectal artery (branch of the inferior mesenteric artery), middle rectal artery (from the internal iliac artery), and inferior rectal artery (from the internal pudendal artery). Venous drainage mirrors this arrangement, with the superior rectal vein draining to the portal system and the middle and inferior rectal veins emptying into the systemic circulation. This overlap forms the anatomical basis for portosystemic anastomoses. Lymphatic drainage depends on the rectal segment. The upper rectum drains to the inferior mesenteric nodes, while the middle and lower rectum empty into the sacral and internal iliac lymph nodes.

Innervation of the rectum is both autonomic and somatic. Sympathetic fibers arise from the hypogastric plexus, while parasympathetic fibers originate from the pelvic splanchnic nerves (S2-S4). Pudendal nerve fibers provide somatic input to the external sphincter, allowing for conscious regulation of continence.

Physiologically, the rectum serves as a reservoir for stool. Distention triggers rectoanal reflexes, including internal sphincter relaxation and urge sensation.[13]

Obstruction by an RFB disrupts normal rectoanal reflexes, leading to distention, pain, tenesmus, and impaired fecal passage. Prolonged obstruction can result in pressure necrosis, mucosal ulceration, bleeding, or perforation. Direct trauma from pointed RFBs or fractured components, such as glass shards or sharp edges, may cause mucosal laceration, ischemia, or full-thickness injury. These pathologies increase the risk of localized abscess formation, rectal wall necrosis, and generalized peritonitis following a bowel wall breach.

Indications

RFBs may be removed using various techniques, including transanal, transabdominal, and endoscopic approaches.[14] The transanal method is generally the 1st-line option and is effective in approximately 60% to 75% of cases. However, caution is necessary when dealing with fragile objects such as glass or items creating a suction effect, as attempted extraction may result in breakage, bowel perforation, bleeding, or injury to the anal sphincter.[15] The transanal approach is most appropriate when the foreign body is located within 10 cm of the anal verge, and the patient shows no signs of hemodynamic instability, perforation, or peritonitis. Adequate sedation and analgesia, ranging from procedural sedation to general anesthesia, must also be ensured to facilitate safe removal.[16]

Contraindications

Absolute contraindications to the transanal approach include peritonitis secondary to rectal or bowel perforation, clinical signs of sepsis or hemodynamic instability, and radiologic evidence of perforation, such as intraabdominal free air on plain radiographs or computed tomography (CT), or the presence of free fluid.[17] Relative contraindications include failure to localize the RFB on digital rectal examination, extensive edema resulting in impaction, increased risk of mucosal injury due to object fragility or sharpness, and patient noncooperation or contraindications to sedation.[18]

Equipment

Equipment selection depends on the object's characteristics, location, and whether sedation is required. The following equipment should be prepared in advance to facilitate safe and effective transanal removal of an RFB:

• Personal protective equipment, including a gown, gloves, and an eye or face shield
• Monitoring equipment, including a noninvasive blood pressure cuff and pulse oximeter. Continuous capnography must be used if procedural sedation is planned.
• Airway and rescue equipment for sedation, including a bag-valve mask, oropharyngeal airway, suction, laryngoscope, and appropriately sized endotracheal tubes
• Intravenous access and medications for anxiolysis or sedation
• Illumination using a high-intensity headlamp or overhead lighting
• Lidocaine gel
• Water-based lubricant
• Anal speculum
• Proctoscope
• Vaginal speculum, which may be used for removal of large cylindrical objects
• Foley catheter, which may aid in dislodging certain objects
• Ring forceps
• Rigid or flexible sigmoidoscope if the RFB is not palpable

Transanal extraction may be performed without operative intervention if adequate tools and monitoring are available. Proper preparation is essential to minimize risk and optimize outcomes.

Personnel

Management of an RFB involves coordinated care from an interprofessional team. Team members may include specialists in emergency medicine, surgery, anesthesia, and, when indicated, psychiatry. Allied health personnel, such as nursing staff and procedural technicians, also play key roles in ensuring patient safety, preparation, and postprocedural care.

Preparation

The patient should be moved to a private room, if available. Evaluation begins with a focused history to determine the type, number, size, and shape of the object, duration since insertion, any self-removal attempts, and associated symptoms such as pain, bleeding, or systemic signs. History should also assess for the possibility of multiple RFBs and identify factors that may contraindicate nonoperative removal techniques, such as suspected perforation or fragile materials. Although the patient's account may suggest the approximate location, confirmation requires physical examination and imaging. Vital signs must be obtained, followed by an abdominal examination to assess for rebound tenderness, guarding, or rigidity, and a rectal examination to evaluate the presence, position, and characteristics of the RFB.[19]

Immediate removal may be considered if the RFB is readily visible and can be grasped safely. Otherwise, imaging should be obtained before attempting extraction. The initial study of choice is plain radiography of the abdomen and pelvis in anteroposterior and lateral views. Although these views may provide sufficient information for management, plain films have limited sensitivity and may yield false-negative results in cases involving small or radiolucent objects.

When the object is not radiopaque, or when complications such as perforation, abscess, or obstruction are suspected, a noncontrast-enhanced CT scan of the abdomen and pelvis is preferred. This modality is also indicated when anatomy is unclear or the object is positioned beyond the rectum. Point-of-care ultrasound may assist in detecting radiolucent objects within 2 cm of the anal verge.[20] Plain chest radiography has limited value in detecting pneumoperitoneum and should not be used to rule out perforation.

Immediate surgical intervention is warranted in the presence of peritoneal signs or clinical evidence of sepsis. Two large-bore intravenous lines should be established, and crystalloid resuscitation initiated at 30 mL/kg ideal body weight. Stat laboratory tests should include a complete blood count, electrolyte panel, coagulation profile, type and screen, and serum lactate. Broad-spectrum antibiotics should be administered, such as ceftriaxone 2 g with metronidazole 500 mg or piperacillin-tazobactam 4.5 g. Surgical consultation must be obtained without delay, as the presence of peritoneal or sepsis signs precludes safe nonoperative management.[21]

Analgesia and procedural sedation should be prepared. Common regimens include an intravenous opioid combined with midazolam or propofol. Full monitoring must follow the recommendations of the American Society of Anesthesiologists, including electrocardiography, pulse oximetry, capnography, and airway support equipment. Deep sedation increases the likelihood of successful bedside removal and reduces the risk of sphincter trauma.[22]

Prior to removal, clinicians must discuss the risks, benefits, and alternatives with the patient. Options include endoscopy, transanal minimally invasive surgery (TAMIS), laparoscopy, and laparotomy. Tetanus immunization should be updated if more than 10 years have elapsed. Informed consent must be obtained before any attempt at extraction.

Technique or Treatment

RFB retention is a medical emergency, and management should follow a deliberate approach that minimizes the risk of iatrogenic injury. Most objects may be retrieved transanally if no signs of perforation or peritonitis are evident.

When the object is visible and can be grasped, the initial attempt should involve a carefully lubricated manual extraction performed under adequate analgesia and, whenever possible, moderate-to-deep procedural sedation. Recent meta-analyses confirm bedside transanal removal success rates of 60% to 75%, especially with adequate sedation and muscle relaxation. Moderate-to-deep sedation remains critical for success.[23] (Source: Tian et al, 2024)

Asking the patient to initiate a controlled Valsalva maneuver may assist in driving the object caudally, although this measure is not appropriate for sedated individuals. Emphasis on multimodal analgesia and anxiolysis to optimize patient comfort and cooperation has increased, with regional anesthesia (eg, pudendal nerve block) reported as an adjunct.[24] Manual removal must be deferred if the object is sharp or fragile, or if peritoneal signs are present, as these cases require operative management. Early imaging with CT is advocated to clarify risks before attempting extraction.

Patients identified as “body packers” should be taken directly to the operating room under general anesthesia. Minimal manipulation is advised because rupture of a drug packet can lead to rapid systemic toxicity. Newer protocols recommend interprofessional involvement, including toxicology and surgery teams.[25]

Several bedside adjuncts have been described. Passing a Foley catheter beyond a smooth object and inflating the balloon may disrupt a vacuum seal and allow controlled traction. Recent reports describe reliable success with this technique.[26] Suction devices from obstetrics, such as a Ventouse or Kiwi extractor, may be effective for retrieving large cylindrical or glass objects. Increasing case reports confirm utility but require operator experience.[27] Magnets may assist in the removal of small metallic bodies, while long clamps may be used to fragment soft organic matter when appropriate.[28][29]

Transfer to the operating suite is recommended if bedside attempts are unsuccessful, or if the RFB is located proximal to the sigmoid colon—a scenario that still results in operative intervention in approximately half of patients. In some cases, deeper anesthesia alone may permit successful transanal removal. Endoscopic retrieval using flexible sigmoidoscopy or colonoscopy with snares, baskets, or retrieval nets has a reported success rate of 70% to 90% in otherwise inaccessible cases and also allows immediate evaluation of the rectal mucosa.[30]

A TAMIS platform provides a viable alternative when endoscopic retrieval is unsuccessful or the RFB is located high and firmly impacted. Single-port access with carbon dioxide insufflation and laparoscopic graspers has been reported to achieve retrieval rates of 85% to 96% while avoiding the need for laparotomy.[31] Laparoscopy is indicated when TAMIS is not feasible or when perforation is suspected. This approach often involves gentle milking of the object toward the rectum. Open laparotomy is reserved for cases where the patient is hemodynamically unstable or laparoscopy fails. Regardless of the approach, postremoval care must include completion flexible sigmoidoscopy to assess for occult mucosal injury, administration of appropriate antibiotics if the bowel wall has been breached, tetanus prophylaxis, and psychosocial follow-up.

Complications

As mentioned, prolonged gut obstruction by a retained RFB may lead to pressure necrosis and mucosal ischemia, while direct trauma from pointed or fractured objects can result in full-thickness injury and predispose to necrosis or peritonitis. The curvature of the rectum and its proximity to adjacent organs make it particularly susceptible to perforation by RFBs. The most serious complication is perforation with resulting peritonitis when not contained.[32] Abscess formation may occur even when perforation is localized. Sharp objects may also injure adjacent structures, including the urinary bladder or vagina, potentially resulting in vesicorectal or rectovaginal fistulas. Delayed removal can lead to additional complications such as bleeding, ulceration, bowel obstruction, or sepsis.

The transanal approach, although successful in many cases, also carries risks. Incomplete extraction, mucosal tears, sphincter injury, or fragmentation of fragile foreign bodies may complicate otherwise straightforward removals. Inadequate sedation and poor visualization further increase the risk of iatrogenic harm.[33]

Endoscopic and surgical techniques are associated with their own set of risks. Endoscopy may cause perforation or bleeding, particularly when the mucosa is friable or the object is embedded. Laparoscopy or laparotomy may lead to anesthetic complications, surgical site infection, or injury to surrounding viscera. Postremoval care must remain vigilant for these complications through appropriate imaging, endoscopic evaluation, and clinical monitoring.

Clinical Significance

Prompt removal of a persistent RFB is essential. Delays can lead to colonic edema and perforation, both of which increase the risk of serious complications. While case volume continues to rise, RFBs remain underrepresented in formal emergency medicine curricula. As a result, many clinicians are unfamiliar with optimal bedside techniques, escalation thresholds, and complication management. The absence of standardized algorithms or national guidelines contributes to inconsistent practices, which may delay definitive care or expose patients to unnecessary surgical intervention.[34]

Beyond procedural concerns, RFBs carry unique psychosocial and medicolegal implications. Many patients present with vague or misleading complaints due to embarrassment, stigma, or previous failed self-extraction, which can obscure diagnosis and delay appropriate treatment. Inadequate sedation, poor visualization, or improper instrumentation can result in iatrogenic injury during removal, underscoring the need for meticulous technique and preparation. Emergency physicians must be equipped not only with the technical skills for transanal extraction but also with clinical judgment to anticipate complications, recognize when escalation is required, and ensure safe follow-up after removal.

Enhancing Healthcare Team Outcomes

Patients may be apprehensive about seeking medical attention for RFBs due to embarrassment, fear of judgment, or underlying psychosocial stressors. This hesitation often contributes to delayed presentation, increased risk of complications, and incomplete or misleading histories. Preserving patient dignity and ensuring privacy during the evaluation are critical to establishing trust. Emergency medicine personnel, nursing staff, and consulting teams must adopt a nonjudgmental and professional demeanor to encourage open communication and facilitate appropriate care.

In certain cases, early involvement of psychiatry or behavioral health specialists may be warranted. Patients who present with repeated insertions, exhibit signs of underlying psychiatric illness, or engage in self-injurious behavior may benefit from formal psychiatric evaluation. Psychosocial support is also valuable for individuals experiencing emotional distress, sexual trauma, or interpersonal violence. Incorporating psychiatric consultation into the acute management plan, particularly when concerns for compulsive behaviors or comorbid mental health conditions exist, can help prevent recurrence and support long-term well-being.

Nursing, Allied Health, and Interprofessional Team Monitoring

Vital signs should be monitored every 15 minutes during procedural sedation, with continuous pulse oximetry and capnography if available. Hourly monitoring of vital signs and serial abdominal examinations should be performed following transanal extraction. Nursing staff must remain vigilant during nonoperative removal, as small mucosal tears or leaks may present in a delayed fashion. Close observation is essential to detect emerging complications.