Perforative peritonitis caused by long-term retention of a rectal foreign body: A case report

Abstract

BACKGROUND

Rectal foreign bodies (RFBs), mostly due to self-insertion for sexual pleasure, are occasionally encountered in emergency departments. They are more common in young male patients, and because patients often delay seeking medical attention due to embarrassment, complications such as perforation and peritonitis may be present at diagnosis. Emergency physicians must remain mindful of potential RFB insertion and conduct history-taking and physical examinations with sensitivity to patient embarrassment. Reports of penetrating peritonitis caused by long-term RFB retention are rare.

CASE SUMMARY

A 16-year-old male experienced persistent fever of approximately 38 °C for 35 days. Although antipyretics and antibiotics were prescribed at a local clinic, his symptoms did not improve. Later, he disclosed that his condition had worsened after inserting a smartphone stand into his rectum 35 days before for sexual gratification, and he was referred to our hospital. Upon arrival, his vital signs were stable, and mild tenderness was noted in the left lower abdomen. Laboratory tests revealed leukocytosis and elevated C-reactive protein levels (5.21 mg/dL). Abdominal computed tomography revealed a spring-like foreign body and a large amount of fecal material in the rectum. Endoscopic removal was unsuccessful; therefore, laparotomy was performed for object extraction. Intraoperatively, the rectum was found to have perforated into the retroperitoneal cavity. The postoperative course was uneventful, and the patient was discharged 11 days after admission.

CONCLUSION

We report a case of penetrating peritonitis after long-term RFB retention, without an acute abdomen, because the perforation was retroperitoneal.

Key Words: Rectal foreign body; Perforative peritonitis; Long-term retention; Etiology; Management; Case report

Core Tip: Rectal foreign bodies (RFBs) are occasionally encountered, and most cases involve self-insertion for sexual pleasure. They are common in young male patients, and because patients often delay seeking medical attention due to embarrassment, complications such as perforation and peritonitis may already be present at diagnosis. Physicians must remain mindful of the possibility of RFB insertion and conduct history-taking and physical examinations with sensitivity to patient embarrassment. We report the first case of penetrating peritonitis caused by long-term RFB retention, which did not present as an acute abdomen because the perforation was confined to the retroperitoneal space.

INTRODUCTION

Rectal foreign bodies (RFBs) are common and should be recognized as a potentially serious condition that may require urgent proctological surgical intervention[1-5]. Most patients with RFBs present to the emergency room usually after exhausting efforts to remove the object at home[2,6]. Retained RFBs, although common, can pose a unique problem to the acute care surgeon or emergency room physician, due to the variety of objects and difficulty of their extraction[7-10]. There is no limit to the types of objects inserted into the anal canal, and reports have documented various foreign objects. Unusual objects contribute to the growing list of reported occurrences due to their unusual location, presenting clinicians with diagnostic and therapeutic dilemmas that are characterized by severe possible complications and different therapeutic opportunities[4,8,11-13]. Due to their rarity, treating physicians rarely have a standard approach to diagnosis, extraction techniques, and post-extraction care assessment[13].

There is little epidemiologic information on these cases[14]. The incidence of RFB cases has been increasing in recent years, primarily attributable to auto-erotic acts, sexual behaviors, sexual assaults, behavioral disorders, or ingestion, with rare instances of accidental causes. This rising trend is predominantly observed in young patients[1,2,10,14,15]. Anorectal auto-eroticism is a paraphilic involving self-insertion of various objects into the anal canal and rectal cavity to increase or enhance sexual pleasure[4,16,17]. Based on a meta-analysis, the motivation of RFB insertion is mostly sexual stimulation (36%)[7]. Occasionally, a foreign object may be ingested and successfully pass through the entire gastrointestinal tract, being retained in the rectum[16]. Occasionally, the objects are inserted by children themselves[15,18]. In extremely rare cases, foreign bodies in adjacent tissues or organs can penetrate the rectal wall and enter the rectal lumen[16].

Here, we report the first case of penetrating peritonitis caused by long-term RFB retention (35 days). In this case, the patient did not present with an acute abdomen because the perforation was confined to the retroperitoneal space. These findings are novel and are reported in this study.

CASE PRESENTATION

Chief complaints

A 16-year-old male patient was referred to our hospital due to persistent fever of approximately 38 °C for 35 days and a 5 kg weight loss in 1 month.

History of present illness

Although antipyretics and antibiotics were prescribed at a local clinic, his symptoms did not improve. Later, he disclosed that his condition had worsened after inserting a smartphone stand into his rectum as part of an autoerotic paraphilic activity for sexual gratification 35 days before, and he was referred to our hospital.

History of past illness

The patient had no significant medical history, including mental illness.

Personal and family history

He was a high school student and did not require assistance with daily activities. He had no allergies, underwent annual health checkups, and no abnormalities were noted during his most recent examination 6 months prior. He lived with his parents, twin brother, and sister; there was no family history of hereditary or malignant diseases.

Physical examination

The patient was 170 cm tall and weighed 53 kg, with a body mass index of 18.3 kg/m². At the outpatient department, his vital signs were normal: Blood pressure of 114/60 mmHg, a regular heart rate of 96 beats per minute, body temperature of 36.0 °C, oxygen saturation of 98% on room air, respiratory rate of 18 breaths per minute, and Glasgow Coma Scale score of 15 points (E4V5M6). Physical examination revealed mild tenderness in the left lower abdomen.

Laboratory examinations

Routine serum laboratory examinations performed upon arrival at the outpatient department revealed an increased white blood cell count, neutrophil proportion, C-reactive protein level, and total bilirubin level (Table 1). Urinalysis was not performed because the patient did not complain of lower urinary tract symptoms. Negative test results were returned for a rapid BinaxNOW^™ coronavirus disease 2019/Flu A&B Combo Self Test.

Table 1 Routine serum laboratory tests.

Parameter (unit)	Measured value	Normal value
White blood cells (103/µL)	12.2	3.9-9.7
Neu (%)	82	37-72
Lym (%)	12	25-48
Mon (%)	5	2-12
Eos (%)	1	1-9
Bas (%)	0	0-2
Hemoglobin (g/dL)	13.6	13.4-17.1
Platelets (103/µL)	232	153-346
Aspartate transaminase (IU/L)	19	5-37
Alanine aminotransferase (IU/L)	22	6-43
Lactic acid dehydrogenase (U/L)	143	124-222
Alkaline phosphatase (U/L)	97	38-113
Gamma-glutamyl transpeptidase (IU/L)	33	0-75
Total bilirubin (mg/dL)	1.9	0.4-1.2
Total protein (g/dL)	7	6.5-8.5
Albumin (g/dL)	3.9	3.8-5.2
Creatine kinase (U/L)	102	57-240
Blood urea nitrogen (mg/dL)	13	9-21
Creatinine (mg/dL)	0.81	0.6-1
Amylase (IU/L)	110	43-124
Sodium (mEq/L)	137	135-145
Potassium (mEq/L)	3.9	3.5-5
Chloride (mEq/L)	101	96-107
C-reactive protein (mg/dL)	5.21	0-0.29
Plasma glucose (mg/dL)	84	65-109
Procalcitonin (ng/mL)	0.2	0-0.5
Lactate (mmol/L)	1.1	1-1.5
Hepatitis B virus surface antigen	Negative
Hepatitis C virus antibody	Negative
Rapid plasma reagin qualitative test	Negative
Treponema pallidum hemagglutination test qualitative test	Negative

Imaging examinations

Supine abdominal radiography showed a low-radiolucent spiral-shaped foreign body measuring 17.5 cm long and 6.3 cm wide in the pelvic cavity, along with gas and a large amount of fecal material in the colon (Figure 1A). Plain abdominal computed tomography (CT) revealed the presence of a foreign body in the rectum (blue arrows), with edema of the rectal wall and increased density of the surrounding fat tissue (orange arrows). In addition, marked fecal retention was observed in the proximal bowel (Figure 1B). Electrocardiography revealed sinus tachycardia with a heart rate of 96 beats/minute.

Figure 1 Imaging findings in the outpatient department. A: Supine abdominal radiograph. A low-radiolucent spiral-shaped foreign body measuring 175 cm in length and 6.3 cm in width was identified in the pelvic cavity, and gas and a large amount of fecal material were observed in the colon; B: Plain abdominal computed tomography. A foreign body is present in the rectum, with edema of the rectal wall and increased density of the surrounding fat tissue. Marked fecal retention is observed in the proximal bowel (arrows).

FINAL DIAGNOSIS

The suspected diagnosis was an RFB caused by a smartphone stand, resulting in perforative peritonitis.

TREATMENT

Endoscopic removal was unsuccessful; therefore, a laparotomy was performed to extract the object. It was approximately 70 cm in length. Intraoperatively, the rectum was perforated into the retroperitoneal cavity (Figure 2A). Images of the removed foreign body are presented in Figure 2B.

Figure 2 Surgical findings. A: Laparotomy was performed, and a foreign body approximately 70 cm long was removed. Intraoperative findings revealed perforation of the rectum into the retroperitoneal space (blue arrows); B: Foreign body removal. The length was approximately 70 cm.

OUTCOME AND FOLLOW-UP

The postoperative course was uneventful. Antibiotic therapy was discontinued on postoperative day 5, and oral intake of a liquid diet was initiated on the same day. His recovery remained favorable; the intra-abdominal drain was removed on postoperative day 6, and he was discharged on postoperative day 11.

DISCUSSION

We report the first known case of penetrating peritonitis caused by long-term RFB retention (35 days), which did not present as an acute abdomen because the perforation was confined to the retroperitoneal space. This is new knowledge, and consequently, there is value in reporting this case. In addition, the diagnosis was delayed because of an atypical course, including young age, mild abdominal findings, and prolonged fever. This case offers an important clinical insight.

In an epidemiological study between 2012 and 2021 in the United States, patients were typically young (the average age was 43 years) and predominantly male, with a male-to-female ratio of 6:1 from 20 years to 90 years of age, and a bimodal age distribution[7,8,14]. Males exhibited a bimodal age distribution, with peaks in the fifth decade, whereas females showed a right-skewed distribution that peaked in the second decade. The types of RFBs are classified into the following categories: Everyday items, food, and sexual articles[19]. Sexual devices (55%) and glass objects (18%) were the most commonly self-inserted RFBs, and remedies for constipation were present in 0.4% of patients[7,14]. In this case, the patient was male and had inserted a foreign body through his anus to obtain sexual gratification, which was consistent with previous reports[4,16]. In contrast, the patient was 16 years old, which was younger than those described in previous cases[14].

The timing of presentation varies widely. Some individuals seek immediate emergency care due to significant discomfort or inability to retrieve the object, while others delay for several days to weeks[7,20]. Patient management includes a detailed history and examination, followed by necessary tests, as careful assessment is essential for accurate diagnosis of RFBs[8,21]. Early diagnosis and timely intervention are important to prevent complications in RFBs[22]. Proper imaging to assess the object’s shape, size, nature, and location is essential[22]. However, diagnosis is often delayed due to patient embarrassment and reluctance to seek medical help, which may increase the likelihood of complications[3,23]. Therefore, patient histories should be taken with the appropriate sensitivity after diagnostic evaluation and identification of the object[7]. Additionally, clinicians should be aware of this condition, as it could indicate underlying psychiatric issues, drug trafficking, or sexual assault[3]. Reports of penetrating peritonitis caused by prolonged foreign body retention are rare. However, its occurrence is a well-established fact. In this case, gradual weight loss in one of the twins raised concerns about his health among family members, leading to medical consultation and ultimately to the diagnosis of an RFB. The severity of rectal injury was determined using the Rectal Organ Injury Scale (ROIS) as follows: Grade I - contusion or hematoma without devascularization or partial thickness laceration; Grade II - laceration involving 50% of the rectal wall circumference; Grade III - laceration involving > 50% of the rectal wall circumference; Grade IV - full-thickness laceration extending into the perineum; and Grade V - devascularized segment[4].

Treating RFBs presents a complex challenge for surgeons because of various factors, including the type of object, the patient's anatomy, how long it has been inserted, possible associated injuries, and the level of local contamination[5,10,24]. To date, there is no standardized management protocol for RFBs that aids in the avoidance of serious complications[5,12]. However, there are currently studies that precisely indicate strategies for the diagnosis and treatment of rectal injuries caused by foreign bodies[25]. While most cases are effectively managed with conservative treatment, surgical intervention might sometimes be needed[10]. When extracting a foreign object, the primary consideration is choosing the least invasive and safest method for the patient. Usually, removal under anesthesia is a safe approach, though laparotomy carries the standard surgical risks[6,18,21]. Extraction, when possible, allows the avoidance of surgery that might be necessary in the case of failure or complications[11]. Most of the time, these can be removed trans-anally at the bedside using anesthesia, along with manipulation techniques involving specialized devices or endoscopy for challenging objects, with only a small proportion of patients requiring hospitalization for > 24 hours[1,8]. 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 intra-abdominal free air on plain radiographs or CT, or the presence of free fluid[4,26]. Surgical interventions have been reported to be necessary in the following cases: Cases with acute abdomens due to intestinal perforations, pelvic abscesses, obstruction, and bleeding; when the object is fragile and poses a high-risk during removal; and when the object is too large to be removed manually, has migrated proximally, or when the object is deeply impacted at the rectal valves[7,21]. Specifically, if the patient does not have peritonitis or perforation, a laparotomy can be performed, and the RFB can be milked toward the anal canal for extraction. If the milking method fails, primary repair is possible after a colotomy and removal of the object. In cases of perforation or peritonitis, resection of the perforated rectum or colon segment and colostomy should be performed. The use of minimally invasive methods such as laparoscopy instead of laparotomy has increased in recent years[27]. Thus, in this case, there was incomplete damage to the rectal wall (probably a bedsore) ROIS Grade I. Therefore, it is probably not very accurate to talk about the development of peritonitis in this patient. Nevertheless, we quite correctly attempted to remove the foreign body nonoperatively, and it was justified to perform a laparotomy after the failure of transanal removal.

RFBs inserted into the anus constitute one of the most important problems needing emergency surgery due to their potential complications[21]. While most RFBs typically do not cause major injury, inserting certain objects into the rectum can lead to unpredictable and potentially deadly consequences[17]. According to a meta-analysis, the total complication rate of RFBs was described to be 30%, and rectal perforation or peritonitis caused by foreign bodies has been reported[7,12,28]. Rectal injury was more severe in patients with self-inserted RFBs, such as rectal laceration, rectal mucosal ulcers, and bleeding[13]. Occurrence of retained RFBs with bowel perforation resulting from auto-eroticism is rare among males[23].

We discuss the pathophysiology of rectal perforations with retroperitoneal penetration, as observed in this case. Typical rectal perforation can have a fatal course. In the present case, the sharp, pointed shape of the object and prolonged retention due to delayed diagnosis contributed to rectal penetration[13]. In cases of rectal perforation, either peritonitis or retroperitoneal phlegmon will develop in any case. In the presented case, there are no clinical or CT signs of complete damage to the rectal wall. Rectal wall thickening on CT indicates some degree of inflammatory changes but not perforation. Minor deviations from the norm in laboratory tests confirm this. In addition, perforation of the rectum with penetration limited to the retroperitoneum caused leakage of intraluminal fecal contents into the retroperitoneal space, more accurately, in this case, the perirectal tissue, leading to chronic inflammation with neutrophilic infiltration and persistent fever. Conversely, because the inflammation was initially confined to the retroperitoneum, it is presumed that several days elapsed before the development of peritonitis. The suspected pathophysiology of rectal perforation and retroperitoneal penetration is shown in Figure 3.

Figure 3 Pathophysiology of rectal perforation and retroperitoneal contamination.

This case report is limited since it only reports a single case. Therefore, the actual condition and characteristics of the disease may deviate from the findings of the literature review due to reporting bias. Further studies are necessary to better assess the effects of clinical presentation, laboratory and imaging tests, treatment approaches, and outcomes.

CONCLUSION

Herein, we report the first known case of penetrating peritonitis caused by long-term RFB retention (35 days). A high index of suspicion, a systematic approach, and a low threshold for imaging studies are essential for the successful management and positive outcomes of patients with RFBs. Emergency physicians should conduct history-taking and physical examinations with sensitivity to the patient’s embarrassment while always considering the possibility of foreign body insertion. In addition, in cases of RFBs, objects with certain shapes are more likely to cause intestinal perforation and may require surgical intervention for removal; therefore, careful management is essential.