An adult male presented to our ED with abdominal pain and constipation for several weeks. Plain abdominal radiography demonstrated a two-inch diameter round object in the distal sigmoid colon and no signs of perforation. He was diagnosed with a rectal foreign body (RFB). Transanal removal with a balloon-tipped urinary catheter was unsuccessful, and the patient required surgical intervention. What do nurses need to know about RFBs?
Sophia Parsh, BSN, RN, Hyun Ah "Esther" Oh, BSN, RN, and Bridget Parsh, EdD, CNS, RN, CPN respond-While the causes for RFBs vary, common circumstances include sexual gratification, anal eroticism, accidental insertion, assault, "body packing" for concealing objects (such as drugs or weapons), and treatments for hemorrhoids and constipation.1 Examples of RFBs include phallic-shaped items, lids, containers, jars, and toothbrushes.2
Due to the embarrassment of the situation, patients often delay seeking medical attention, which can defer treatment by weeks, months, or even years.3 Nurses must exhibit sensitivity and professionalism and know the clinical manifestations, management, and post-removal care related to RFBs to provide optimal and safe patient care.4,5
Clinical manifestations
A thorough patient history can provide details of the RFB-what it is, how it was placed, duration of placement, as well as any actions taken to remove it. Although obtaining an accurate history may be difficult, it is important to determine if the RFB occurred due to assault.2,5
Signs and symptoms of RFBs can include abdominal pain; rectal bleeding; nausea; constipation; lack of flatulence; diarrhea; or signs of perforation of the gastrointestinal (GI) tract, such as pneumoperitoneum, peritonitis, or signs of sepsis.3,6 Tachycardia, hypotension, and fever may indicate peritonitis and sepsis secondary to GI perforation.5
Physical assessment includes a focused abdominal assessment and a rectal exam. A rectal exam can help to determine the size, location, grade of injury (if present), and whether the object can be removed manually.2 If the object is not palpable, endoscopy or surgery may be necessary.7
Diagnostic studies
Imaging studies include an abdominal radiograph or computed tomography scan of the abdomen. Imaging can usually identify and localize the RFB.8 Diagnostic studies for potential rectal trauma include digital rectal exam, proctoscopy, and endoscopy.9 Lab studies are monitored for possible bleeding (hematocrit) and sepsis (leukocyte counts).9
Management
Identification of the RFB is critical to determining the appropriate method of removal.8 No standard of care for treatment currently exists, but choosing the safest and least invasive method of removal is a priority.7 Manual removal of the RFB in the ED is an option in some cases, as long as GI perforation has not occurred.8 I.V. sedation and analgesia can help patients relax, decrease anal spasms, and improve visualization of the RFB.8 Signs and symptoms of peritonitis and sepsis require further evaluation and may require surgery.10
Extraction approaches include the use of a balloon-tipped urinary catheter.6 The catheter is inserted around or into the RFB, then the balloon is inflated and the object is pulled down toward the anus.11 Use of an obstetrical vacuum device to provide suction may remove the foreign body.1 Following removal of the RFB, a sigmoidoscopy is typically performed to assess the anorectal mucosa for injury.1 Postprocedure, an erect chest X-ray should be performed to observe for free air.12 For an erect chest X-ray, the patient should sit up for 10 minutes prior to allow any free air to settle in the subdiaphragmatic space.12
If these steps are unsuccessful or the patient has peritonitis and perforation, laparoscopic or open surgery may be performed.8
Nursing considerations
When caring for a patient with an RFB, consider the sensitive nature of the diagnosis and approach the patient with a nonjudgmental attitude.2 It can be difficult to obtain an accurate history due to embarrassment or fear of stigmatization.4 Many patients are reluctant to reveal details regarding the RFB and implausible situations may be given, such as accidentally sitting on the object. Establish and maintain a rapport with the patient to facilitate honest, open communication. By developing this trust, the patient's symptoms and specific information about the RFB may be obtained. Respect cultural differences and protect patient confidentiality as the patient may not share the diagnosis even with close family members.2
Monitor the patient for potential postoperative complications including hemorrhage and necrosis due to the mucosal trauma secondary to the RFB or its removal. Monitor vital signs, perform focused abdominal assessments, and monitor lab results postextraction. Teach patients the signs and symptoms of possible complications and what to do should they occur. For patients with signs of sepsis or peritonitis, administer antibiotics as prescribed.1 All patients diagnosed with an RFB should be offered the opportunity for psychological support before being discharged.
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