Intentional   or   unintentional   insertion   of   rectal   foreign   bodies   is   not uncommon and often presents a serious challenge for the clinician. A variety of unusual foreign bodies have been reported introduced into the rectum like a stick, tumbler, pepper pot, screw driver, glass bottle, vibrator, door handles, electric bulb etc. for pleasure  purposes  or  forces  during  the  assault.  These foreign bodies may cause perforations of sigmoid colon and rectum [1,2].  We present the case of a patient with a history of assault and insertion of a long wooden object through his anus. 

A 46 year married male was admitted in surgical OPD with complain of dull pain in anorectal region  after  alleged assault by robbers who forcibly inserted some elongated  foreign  body  through  his  anal  canal.  He did not give history of any perverted sexual behavior. On  per  abdominal  examination,  a  hard  object  was  felt  reaching  above  the umbilical region. A local examination showed slight redness in the perianal region. Per rectal examination showed the presence of irregular, hard wooden foreign body. 

X-ray abdomen AP and lateral views, showed faintly radiopaque rod like a foreign body extending from the pelvic region and reaching up to the epigastric region. Few dilated air filled bowel loops were noted proximal to it. No evidence of free air under the domes or any signs of perforation were noticed [Fig.1a,b]. Abdominal sonographic examination showed a large curvilinear hyperechoic object with dense posterior acoustic shadowing suggestive of some solid foreign body. No free fluid was seen in the peritoneal cavity [Fig.2]. 

Oral and intravenous contrast enhanced CT scan of the abdomen was highly diagnostic for exact site, size, location and nature of the foreign body. On axial and sagittal CT scans [Fig.3a-3d] a large well defined rod like abdominopelvic foreign body was seen in relation to the rectosigmoid colon and reaching up to the epigastric region causing marked stretching and elongation of the sigmoid colon. It measured about 34x4.0 cm in size and showed central heterogeneous linear densities with -243 to 43 HU in its substance. High attenuation area of about 245 HU was seen at the periphery of the blunt upper end. Few dilated large bowel loops were seen proximal to the impacted foreign body. No evidence of any perforation or free peritoneal fluid was seen [Fig.4a,b].

Colotomy was done to deliver the foreign body. A large irregular rod like wooden foreign body was delivered [Fig.5a,b]. Endoscopic removal was avoided as it was quite large, was located high up in rectosigmoid region. Removal of such a large irregularly shaped foreign body could have caused multiple tears or laceration to the mucosal layer of the rectosigmoid colon. The patient recovered well after surgery and was discharged without any complications. 

The incidence of rectal foreign bodies varies according to region, said to be uncommon in Asia and more common in Eastern Europe.  Rectal  foreign  bodies usually  are  inserted  as  a  result  of  erotic  activity.  Still random  cases  of  forcible insertions during assaults or tortures has been reported. Although retained rectal foreign bodies have been reported in patients of all ages, genders, and ethnicities, more than two-thirds of patients with rectal foreign bodies are men in their 30s and 40s [1,2].

   

Almost any object can be seen like candles, glass bottles, electric bulbs, vegetables, containers and odd or unusually large objects beer bottles, rods etc. Other causes  for  insertion  include  diagnostic  or  therapeutic  purposes,  self-treatment  of anorectal disease, criminal assault and accidental [3,4]. Foreign bodies in the rectum in association with Munchausen’s syndrome have been described in the literature [5].

Most patients with rectal foreign bodies present in the emergency department after futile efforts to remove the object at home. The first hand imaging in the evaluation of impacted rectal foreign bodies are x rays and sonography [6]. An abdominal X-ray provides information on the location of the foreign body, whether it is below or above the rectosigmoid junction. Metal and glass objects are well visualized on plain radiograph [Table 1,2]. Sonography helps in localization of the foreign body and complications like free peritoneal fluid. Artifacts however may hinder in diagnosis and exact nature of the object [7]. Computed tomography is an excellent modality  for  localization  of  foreign  bodies  especially  partial  or  non  radiodense objects situated high up in the abdomen and associated with complications [8].

Rectal foreign bodies can be classified as high-lying or low-lying depending on their location relative to the rectosigmoid junction. Objects above the sacral curve and rectosigmoid junction are difficult to visualize and should not be removed by rigid proctosigmoidoscope.  Soft or low-lying objects could be grasped and removed safely in the emergency department. Foreign bodies in the rectum are known for potential complications like rectal bleeding,  mucosal  lacerations,  anorectal  pain, bowel perforations, abscesses and rarely death [9,10].

The majority of retained foreign bodies can be removed on an outpatient basis transanally under local anesthesia [11,12]. Laparotomy is required in high impacted foreign bodies and with associated complications like perforation [13].

The  common  differential  diagnosis  with  associated  abdominal  or  rectal  FB  are Munchausen’s  syndrome and Rapunzel Syndrome. Munchausen’s syndrome is a factitious psychiatric disorder where the affected subject feigns disease in order to draw attention  for  sympathy.  It is also sometimes known as hospital addiction syndrome or hospital hopper syndrome [5]. The Rapunzel syndrome is an unusual form  of  trichobezoar  found  in  patients  with  a  history  of  psychiatric  disorders, trichotillomania (habit of hair pulling) and trichophagia (morbid habit of chewing the hair) consequently developing gastric bezoars [14].

Rectal foreign bodies present a difficult diagnosis and management. Delay in presentation together with multiple attempts at self-removal lead to mucosal edema and muscular spasms, further hindering removal. Most objects can be removed either manually or by using different instruments. Laparotomy is only required when there is a failure of transanal removal as in high or impacted foreign bodies. 

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