Unusual Finding of Deodorant Bottle in the Rectum

An Interesting Case Report

Abstract

Rectal foreign body is not an uncommon encounter these days in the current medical practice. It usually occurs due to sexual eroticism, sexual abuse, assault, or rarely accidental involuntary insertion. This condition possesses a significant challenge among general surgeons on handling these cases. Diagnosis is usually made by history taking, physical and radiological examination. Here, we present a case of a 22-year-old young male college student with retained rectal foreign body of 3 h duration who presented with impacted foreign body per rectum, nonspecific abdominal pain, abdominal mass, and nonpassage of stool and flatus. Successful removal of rectal foreign body was done manually under local anesthesia in lithotomy position in the operation theater.

INTRODUCTION

Foreign body inside the rectum is now common these days, especially in young males, although due to less common experience, they tend to be a difficult case for many new surgeons.[¹] Most of these patients may present with symptoms of intestinal obstruction and some may have no symptoms at all. Most case reports associate the rectal foreign body with anorectal eroticism.[²] Rectal foreign body brings a great challenge in clinical management, as they may cause serious complications and may also cause severe permanent damage if not well-managed.[³]

CASE REPORT

A 22-year-old young male college student came to the emergency trauma center in our hospital (JNMCH, Aligarh, UP, India) with retained rectal foreign body of 3-h duration. It was associated with nonpassage of stool and flatus. There were multiple failed attempts of the passage of the foreign body by himself. He also claimed to have mild colicky abdominal pain while attempting to pass foreign body vigorously. Socially, he was a single young man staying in the family with separate rooms for him. There were no prior significant medical or surgical problems earlier. On further probing, he admitted to had frequent involvement of homosexuality and other malpractices for about the past 3 years.

He is a well-build young man with the following vitals – pulse rate – 84/minute; blood pressure – 114/74 mm of Hg; respiratory rate – 18/minute; temperature – 98.2°F; oxygen saturation – 100% on room air; and general and systemic examination were within the normal limits.

On per abdominal examination, we noticed a hard mass in his lower abdomen, just above the pubic symphysis extending just below the umbilicus. It was mobile laterally, but not vertically. We could get above the mass but not below it. The mass was hard with well-defined borders and appeared cylindrical. No other mass was noted. His abdomen was nontender on palpation.

Perrectal examination revealed lax anal tone with wide anal cavity and cylindrical object palpable in it. In view of the presentation, proctoscopy was done, and to our surprise, we noted a pinkish metallic cylindrical object in the rectum. Abdominal X-ray revealed a bottle in a standing up position from mid-abdomen until the pelvic bone [Figure 1]. No intraperitoneal gas or fluid was present [Figure 2]. His blood investigation was within the normal limits.

Figure 1: Abdominal X-ray image of foreign body in the rectum

Figure 2: Chest X-ray image of the patient

The patient was shifted to the operation theater, attempt of bottle removal under local anesthesia keeping in lithotomy position was planned and keeping the option for exploratory laparotomy in mind with instrument trolley ready and the anesthesia team informed. The bottle was manually retrieved successfully in the lithotomy position [Figures 3 and 4].

Figure 3: Bottle retrieval in lithotomy position

Figure 4: Retrieved bottle

DISCUSSION

The retained rectal foreign body appears an easily manageable procedure, to many, yet it is a difficult emergency. The exact incidence is unknown; though based on the current case reports worldwide, it is most common in young men with a male-to-female ratio of 2:1[⁴] with most cases were reported in the Western society than in the Asian population.[⁵] The most common etiology is due to eroticism, but some reported cases were due to sexual abuse, assault, or accidental foreign body impalement. The involuntary nonsexual foreign body generally occurs among the elderly, children, mentally ill, and mentally challenged cases.[¹] Items reported in the rectum as foreign body vary from large smooth objects such as bottles and small objects in children.[¹] Most patients present with acute intestinal obstruction symptoms, but for some, they present with nonobstructive vague abdominal pain, rectal bleed or infection, or no symptoms at all.[⁶]

On examination, complicated rectal foreign body may have signs and symptoms of peritonitis, while noncomplicated rectal foreign body may not have any symptoms. Perrectal examination may have a lax anal tone with wide anal cavity, especially in recurrent anorectal stimulation with foreign body. The easiest available investigation to confirm this condition is abdominal radiography, including the pelvic area (X-ray). The image of foreign body is usually visible, and other pathological conditions such as intestinal perforation can also be identified.

Rectal foreign body that lies below rectosigmoid junction usually can be retrieved perrectally. However, if it lies above the rectosigmoid junction, exploratory laparotomy might be the best choice of treatment. Besides this, other factors such as the size and shape of the objects, presence of signs and symptoms of peritonitis, and evidence of perforation will also affect the choice of treatment. The failure of retrieving the items perrectally or through laparotomy may need help from orthopedic colleague to open up the pelvic symphysis as the object can be stuck around the pelvis region due to its massive size. Our patient did not require exploratory laparotomy. Postretrieval, his overall condition improved quickly and hence was discharged on the postoperative day 2. For the benefit of the readers, we proposed the below algorithm for the management of the rectal foreign body [Figure 5].

Figure 5: Suggested pathway for the management of patient with rectal foreign body

CONCLUSION

Foreign body inserted perrectally can present as an acute or delayed event. It can be a straightforward case or clinically challenging. Hence, the proper assessment of clinical features and prompt investigations should be carried out to ascertain the diagnosis. Once the diagnosis is confirmed, the method of retrieval should be of concern to minimize complications with a proper plan.

Consent

Well-informed and written consent had been taken from the patient in his own language.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Ethical clearance

Ethical clearance is taken from the institutional ethical committee.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.