Patients afflicted with a retained foreign body commonly have a delayed clinical presentation. Social stigmas or embarrassment hinders patients from seeking immediate attention for care. The afflicted remain hopeful that normal, antegrade peristalsis may lead to a prompt resolution without medical intervention, a hope that results in hours to days of delay before seeking medical attention. The angulations of the pelvis often will not cooperate with large objects that have traversed the levator plate. Common presenting symptoms include abdominal pain, constipation, rectal bleeding, and mucus leakage. In some cases, patients will present with symptoms of rectal trauma well after the foreign object itself was removed. While often challenging, obtaining an appropriate history is extremely important. Special attention should be paid to the timing of the event, associated symptoms, the history of trauma, and any details on removal attempts. The provider must use a nonconfrontational approach that concentrates on the issue of the retained body, rather than trying to analyze the circumstances that lead to the event. Each patient differs in his or her willingness to provide highly personal information. Patients need to remain in charge of the information they provide including any information released to even immediate family. Physicians treating patients with anorectal trauma or rectal foreign bodies must be aware of the potential psychosocial and legal implications of the clinical setting. Rape evaluations must not be excluded and, if suspected, the
proper authorities brought forward to assist in patient care when appropriate.

In addition to a hesitation by patients to explain the circumstances of the event, patients will often withhold previous or current history of sexually transmitted disease, illicit drug use, and previous episodes of trauma; all aspects of the history are potentially important to providers carrying for the patient. Because of the social stigma and embarrassment, providers should be prepared to hear outlandish fables associated with the event without passing judgment or confronting the patient.

Once a history is obtained, the physical examination should start with an evaluation for potentially life-threatening conditions. The initial inspection and examination must exclude acute peritonitis. If signs of peritonitis are noted during the initial evaluation and resuscitation, plain radiographs of chest and abdomen should be obtained to evaluate for perforation and localization of the foreign body; if free air is noted, the patient should be transitioned to the operating room for further examination and intervention.

If patients are minimally symptomatic, they often resist medical intervention and seek reassurance that the device will be spontaneously evacuated. Physical examination at this point should concentrate on trying to identify the location of the foreign body as well as any associated peroneal trauma or injury. This often requires conscious sedation, local anesthetic, and possibly anesthesia, so a determination on the proper place for examination should be made early. A physical examination should always include an abdominal examination. The peroneal portion of the examination is best performed in lithotomy position, at which time the peroneum should be carefully examined for any signs of mechanical or chemical trauma. A gentle digital rectal examination should be performed to assess the location of the foreign body as well as sphincter tone and any evidence of bleeding. As the anal sphincter may already be injured (often associated with bleeding, hematoma, and edema), and can also be further damaged during the extraction, careful documentation of the initial sphincter examination is very important. Asking patients to Valsalva will often assist in the assessment of the foreign object’s location and probability of transanal removal. Endoscopy, whether rigid or flexible, can be extremely useful in the initial assessment of the patient. The endoscopic examination should concentrate on signs of laceration, proctitis, hematoma, and ulceration. If a prolonged retention and trauma is suspected, the evaluation should include laboratory examination to look for signs of infection, inflammation, and hypovolemia, evidence of which often necessitates hospitalization and further workup. If the object is removed, but the patient continues to present with symptoms, rectal trauma should be suspected. In this situation, in addition to an obligatory endoscopic examination (rigid rectosigmoidoscopy is enough for most of the patients) a water-soluble enema should be considered to evaluate for any signs of trauma and perforation. The absence of hematochezia is notoriously nonreliable in ruling out rectal trauma and has up to 30% false-negative rate.

Once the location of the foreign body has been determined and patient is deemed to be stable, an extraction approach is chosen. In general, foreign bodies in lower and midrectum can be successfully removed transanally, but once the object is slipped above the anorectal angle into the upper rectum and rectosigmoid junction, a laparotomy may be needed. When rectal foreign bodies migrate proximally, the objects change their axial position, induce edema in the bowel, or become trapped in the natural concavity of the sacrum. Such changes make it more difficult to extract the foreign body from a transanal approach alone.