Respectful Insolence

Pulling it out of your posterior

One of the stranger aspects of being a general surgeon or a colorectal surgeon can be summed up by this abdominal X-ray (click on the picture for a bigger image):

i-f8a0d7d843d0b122f64f093051053e40-axr_fb.JPG.jpg

Yep. From time to time, every general surgeon will be called upon to pull something out of someone’s ass. It’s not super common, but common enough that pretty much every general surgeon’s seen a few. In the case above, it would appear that the offending object is an aerosol can. I know what you’re probably thinking first: Why? I also know what you’re thinking next: How? (As in: How on earth did he get that up there?)

Believe me, you don’t want to know. Well, actually, when I encountered these patients I sort of did (and you probably would too), but respect for a patient’s dignity and the need not to embarrass him any more than the already embarrassing situation requires, no matter how much sleep deprivation may have compromised my self-control, prevented me from inquiring too much. (Remember, I trained back in the days of giants, so to speak, before the days of the 80 hour workweek limitations, when it was not at all uncommon for me to be at the hospital well over 110 hours a week. Also remember that these sorts of patients tend to come to the E.R. in the middle of the night, both because not a few of them tend to be drunk and also possibly because they are embarrassed.) After all, part of being a doctor is to try to suppress your curiosity and stick to a “just the facts, Ma’m,” kind of attitude. Such an attitude serves a surgeon well in these situations. Although it’s highly unlikely that this was the case for the aerosol can, sometimes these objects end up getting to the rectum by way of the stomach, when objects are swallowed.

I personally haven’t had to retrieve a rectal foreign body from a patient since my surgical residency (there’s not much call for such skills in surgical oncology or breast surgery), but I fished my share of strange things out of rectums during the five clinical years of my residency. I can’t say that I’ve ever had to deal with an aerosol can, but one case back in Cleveland that I’ll never forget involved a middle aged man who had placed a flaming pink salt shaker from a party center known as Vel’s on the Circle (which, ironically enough, was apparently sold to the Cleveland Clinic a number of years ago). Of course, I didn’t know that that’s what it was until we had retrieved it, but I’ll never forget delivering a large pink, plastic object that we had trouble identifying while we were trying to extract it, but when it suddenly popped free the word “Vel’s” was engraved in my mind in a way that I’m sure the owners of Vel’s on the Circle had certainly never intended.

Of course, this guy was lucky. Although we did have to take him to the operating room in order to get adequate anaesthesia and relaxation of the anal sphincter with to allow extraction of the salt shaker, he escaped harm. What people don’t seem to realize is just how much damage they can do to themselves by sticking objects up their posteriors.

Another rather odd case I recall was a guy who showed up at the E.R. of University Hospitals with the chief complaint that he had shoved several golf balls up there and that he couldn’t get them out. He admitted to having been drunk at the time. He apparently passed out after his attempt to get closer to Tiger Woods, except that this occurred a bit before Tiger Woods had become famous. In any case, after waking up, he remembered what he had done and couldn’t remove them himself–or, for that matter, even find evidence that they were “up there.” We sent him for an X-ray, as you would expect, as that’s frequently one of the easiest ways to figure out what’s up there, assuming the object is something that shows up on X-ray. I even remember that we had a bit of an argument between attendings over whether golf balls were even radioopaque. One settled the argument by referring to a radiology attending who had a bit of a habit of X-raying various objects, who had assured him that golf balls showed up on X-ray.

There were no golf balls seen on the X-ray.

Given the small size of golf balls (come on, what adult hasn’t produced a masterpiece of bathroom creation larger than a golf ball), we ultimately let him go home, unable to find any evidence of a golf ball in the rectum and figuring that he probably either eliminated them himself or never put anything up there in the first place. If he did “dislodge” them himself, I hope he washed them before using them.

If there is no evidence of perforation or obstruction, one of the cardinal rules of dealing with this clinical problem is to decide early whether the foreign body can be extracted in the E.R. or whether the patient needs a visit to the operating room, with the threshold for taking the patient to the O.R. being set quite low. Serious damage can be done to the anal sphincter resulting in permanent incontinence from an ill-advised persistence in trying to use force to muscle out a foreign body that is stuck. Such attempts can also tear the rectum, leading to an abscess. The tools at a surgeon’s disposal include:

The patient was taken to operating room within 12 hours of presentation, with consent for colostomy. Under general anaesthesia in the lithotomy position, dilatation of anal sphincter was performed and per rectum retrieval successful.

These patients typically have a delayed presentation to the emergency department because of embarrassment and after multiple attempts at self removal. Respect for their privacy is a key factor in the patient’s care plan. ED physicians need to decide if removal of foreign body can be performed in the emergency department or surgical team to be notified. Operating room procedures include anal dilatation under GA, transrectal manipulation, bimanual palpation if necessary and withdrawal of foreign body. Laparotomy or laparoscopy are occasionally necessary.

This study gives an idea of the potential complications and points out an important point, namely that the patient may not always tell you that they stuck something up there and that the doctor may have to figure it:

Objective The discovery of foreign bodies (FB) in the rectum is an infrequent clinical problem. Most commonly, FB are introduced through the anal passage or reach the rectum after oral ingestion. We describe our experience in the diagnosis and treatment of FB retained in the rectum.

Method From 1997 to 2004, data were collected prospectively in 30 patients (20 men and 10 women; median age 42.5 years). Extraction method, size and type of object, and postextraction evolution were reviewed.

Results The FB was introduced anally in 16 cases and by oral ingestion in 14. Principal associated factors were: mental disorder in 11, penitentiary confinement in two, and drug and alcohol intake in two. Recent sexual activity had taken place in 14 cases. The size and nature of the FB were varied. The most frequent symptom was constipation with or without pelvic or anal discomfort (n = 23, 77%). Treatment consisted of spontaneous ejection (n = 2), digital extraction with or without enemas (n = 10), digital extraction under local/regional anaesthesia after fragmentation (n = 11) and regional exploratory laparotomy under general anaesthesia (n = 7). Grade I rectal trauma was the most common (n = 23, 77%). Six patients required colostomy. Four patients (13.5%) suffered complications and none died. Only 17 patients were hospitalized, with a mean stay of 6 days. All patients recovered without sequelae.

Conclusion The diagnosis of rectal FB should be suspected when faced with low pelvic or perianal abdominal pain and/or rectal haemorrhage within the context of an unconvincing story in patients without a history of recent instrumental rectal exploration for therapeutic or diagnostic purposes. Because of potential complications, FB in the rectum should be considered a serious condition that must be treated without delay.

In other words, 6/30 patients, or 20%, required colostomy. Albeit uncommon and fairly straightforward to manage if recognized, foreign bodies lodged in the rectum are a serious and potentially even lethal if diagnosis is delayed long enough. All jokes aside, they’re no laughing matter.

Comments

  1. #1 Big Al
    October 3, 2007

    There was a case many years ago in toronto, involving a beer bottle and a vagina, and Xmas.

  2. #2 Ezekiel Buchheit
    October 3, 2007

    This brought to mind the short story Guts by Chuck Palahniuk. All about masturbation gone bad. He also wrote a book called Choke which involves, at one point, a particular type of bead-on-a-string being used in their, ahem, prescribed way and getting “lost.”

    Wow, Chuck writes some freaky stuff.

    I, on a more personal note, got all my stuff-shoved-into-my-rectum needs fullfilled when I was twelve and went through surgery to remove a tumor, and spent the next day bazooka barfing and had to take a suppository. It’s been 15+ years and I still fell a little strange. Like I violated myself.

    I think I’ll go shower now.

  3. #3 the lurking DVM
    October 3, 2007

    Holy CFC-free propellent, Batman! Ouch.

    Years ago, a friend told me of a patient who was seen at his hospital in Chicago when he was a resident (he was a medicine resident and not involved in this patient’s care, but learned of it via that “hey, you gotta see this” network). Same general problem, except it involved Mrs. Butterworth. The radiograph attracted quite a crowd, he said.

    I laughed at the description of attendings arguing over the radioopacity of golf balls. Any veterinarian who has seen a Lab (or other equally dopey breed) with a Titleist fetish will tell you that they are very definitely radioopaque. One of the freebie publications that we all get had a “send us your weirdest foreign body X-ray” contest a couple years ago. One of the runners-up was a Lab that had ingested 14 golf balls. After a gastrotomy, he made an uneventful recovery.

  4. #4 Rev. BigDumbChimp
    October 3, 2007

    I had a friend in highschool whose brother was a resident at Bowman Gray Hospital (Part of Wake Forest U). He used to bring home x-rays of various things they had pulled out of people’s nether regions. I distinctly remember an apple (not sure what kind), various adult “toys”, and a tooth brush.

    I really hope that toothbrush was a one time use.

  5. #5 William the Coroner
    October 3, 2007

    Orac: Vel’s is now a parking lot for the Clinic. It was across the street from the Cuyahoga County Coroner’s Office. I remember getting a table leg in the cutting room with the words “rectal foriegn body” on the req.

  6. #6 George Smiley
    October 3, 2007

    A friend’s spouse, who’s an ER doc, got a patient with a a champagne flute.

  7. #7 NJ
    October 3, 2007

    …a flaming pink salt shaker…

    What? No fusilli Jerry?

  8. #8 madder
    October 3, 2007

    I remember a story from somewhere (not bothering to Google it at the moment) about a lightbulb. The threads were visible, but the attending feared breaking the glass. It was eventually removed when someone got a lamp, screwed it onto the threads, and pulled the whole thing out.

  9. #9 notmercury
    October 3, 2007

    “..we ultimately let him go home, unable to find any evidence of a golf ball in the rectum and figuring that he probably either eliminated them himself or never put anything up there in the first place.”

    Take a Mulligan and call me in the morning.

  10. #10 DrFrank
    October 3, 2007

    Orac, you’re really missing out by not including the table in your post:

    I can’t align the columns properly in text (as it seems to ignore tabs), but I’ve screen-capped it here for anyone without appropriate access.

    The large paintbrush, food tin and apple have to be my favourites ;)

  11. #11 THobbes
    October 3, 2007

    I think this line from the RPOD website sums it all up nicely:

    These patients typically have a delayed presentation to the emergency department because of embarrassment and after multiple attempts at self removal.

  12. #12 John Marley
    October 3, 2007

    Well, that certainly helps me not snack before lunch. I may never eat again.

  13. #13 Donalbain
    October 3, 2007

    I did one year of med school and we saw the following in a lecture

    1) Barbie doll heads. Yes. Heads! I believe there were about a dozen..

    2) Half a (previously) frozen chicken

    3) An aerosol can lid.

  14. #14 Warren
    October 3, 2007

    What people don’t seem to realize is just how much damage they can do to themselves by sticking objects up their posteriors.

    CF. politicians and their crania.

  15. #15 akibare
    October 3, 2007

    There’s always “The Butt Page” a.k.a. “Rectal Foreign Bodies,” (google it, it’s the first hit, a page on the Well).

    The “unconvincing stories” are always amusing. Not being any sort of medical person myself, I’ve wondered if perhaps the best thing dignity-wise is to just reassure the patients, if they don’t already know, that yes in fact there ARE quite a few people out there who put things up the back door for fun and amusement, and yes, occasionally things go wrong, it’s okay, you’re not a uniquely freaky case…

  16. #16 clem
    October 3, 2007

    This topic reminds me of perhaps the most surprising “I Feel Lucky” Google search result I have gotten. Needing an image for reference, I Googled “Hampton Court Maze”. The page I got was a gerbil stuffing howto. IIRC, the phrase Google keyed on was “It’s your intestine, not the Hampton Court Maze”. The only other contender for the strangest irrelevant link title was a page on dressing out , butchering and cooking human beings.

  17. #17 Sid Schwab
    October 3, 2007

    I posted about this a while back, too. I never met a general surgeon who didn’t have a few good stories… In training, in San Francisco, the chief surgery resident’s room had a nice little display case of objet. And for a while, in the ER was a pathology report from a retrieved item that we, in one of those moods, had sent to the lab. It read “Normal cucumber with feces.”

  18. #18 Eileen
    October 3, 2007

    Wow, this was a really interesting post!

    Eileen, living in the Middle East

  19. #19 Calli Arcale
    October 3, 2007

    That is very amusing. ;-) I remember seeing a program on TV that discussed this subject briefly. I can’t even remember what the program was about, but this particular scene really burned itself into my brain. They interviewed a gynecologist who had removed a lot of inappropriate objects from highly embarrassed lady patients. Vegetables were apparently high on the list. With a somewhat exasperated expression, he exhorted viewers to, if they absolutely must put a foreign body in there, at least use a device which is actually made for the purpose. He felt that people’s shyness in seeking out sex toys might be making the FB problem worse, because they are instead using things ill-suited to the task. (He apparently saw a lot of vegetables that had broken off inside.)

  20. #20 Dr B
    October 3, 2007

    The most outre object at my own hospital: a regulation baseball. Eeeeeeeewww. Took the lady to the OR for laparotomy, as removal rectally seemed vain to even attempt. Baseballs, after all, do not have a convenient handle to tote them by, and anyone trying to remove it by gripping it in their fist would never get their hand bak again (and this would constitute a common-law marriage in Massachusetts, I might add).
    The story has a happy, if surprising, ending. Once the patient was under general anesthesia, one of the nurses who also worked on OB started thinking … hmm, when have I seen this problem before? Round object, stuck in narrow passage … hmmm. The baseball was delivered without incident by forceps and tinaculum. Mother and ball discharged home the next morning doing fine.

  21. #21 Dan
    October 3, 2007

    Included in one of the radiology lectures at my wife’s medical school was a collection of images of such foreign bodies. The professor called it his “Rectal Horror Picture Show.”

  22. #22 Dr Grumble
    October 3, 2007

    Never ever climb a stepladder and use a broom handle.

  23. #23 Jennifer Ouellette
    October 3, 2007

    The wife of my high school biology teacher was an ER doc. She once encountered a man in a long raincoat, who opened it in the examining room to reveal… a glass soda bottle, into which he had inserted his “member” and subsequently become stuck.

    People do funny things…

  24. #24 HCN
    October 3, 2007

    Dr. B said “The baseball was delivered without incident by forceps and tinaculum.”

    plus other folks have mentioned apples…

    I had a horrific birth story for child #1. It included being ripped from stem to stern, which required lots of repairing stitching (including some anal muscles), so I had to be in the hospital longer than normal.

    Unfortunately, my baby experienced seizures on his second day, so he was transported to another hospital (a Children’s Hospital) while I was left in the original hosptital.

    So after a very trying evening, where I was introduced to a breast pump, and being in pain both physically and emotionally I attempted to go to sleep. As it turns out I was the only patient in the very small maternity ward (of a very small community hospital). So while I was lying in the bed attempting to brush away the thoughts of the day, and get some sleep… I heard a conversation outside my door at the nurse’s station.

    Someone had come up from the Emergency Department requesting forceps. Apparently there was a fellow who had come in with an apple up his bum. The guy talking said it was too slippery to get a hold of, and any kind of tool they would use would cut through the apple.

    The reactions from both the fellow with the request and the two nurses were incredulous giggling.

    I confess, I also cracked a smile.

  25. #25 funstuff
    October 3, 2007

    I’m wondering what billing code you use for an aerosol can up the rectum. Would insurers even pay for that?

  26. #26 A. N. Onymous
    October 3, 2007

    A long time ago, we had a guy who drove more than two hours to have a vibrator removed from his rectum. He was well-known in his home town, and he didn’t want to go through the embarassment.

    Another guy, in his late 50s/early 60s, had a sweet potato removed from his rectum. His wife was most displeased, as she hadn’t been the one to place it!

  27. #27 Tlazolteotl
    October 3, 2007

    Hmm. Like that clip from the Ali G Show where he interviews the ER doctor….. (it’s up on YouTube)

  28. #28 Chris Noble
    October 3, 2007

    I take it an X-ray is normally requested in these cases and not an MRI.

  29. #29 JJ
    October 3, 2007

    In med school we were shown an x-ray of a guy with a ninepin in his rectum – kind of a half-size bowling pin. His excuse was that he slipped and fell on it. Later, our school bowling club had shirts made with “Just knock the pins down, don’t sit on them” written on the back.

  30. #30 pseudonym
    October 3, 2007

    OK, I am NOT going to post this under my usual handle.

    As it happens I sometimes hang around, more than one should probably admit in public, with people who are quite serious about their anal play. One of the cardinal safety rules is that anything that gets stuck into the butt, regardless of size, should have a flange at the base so that it can’t enter all the way and get lost. This is right up there with ‘you can never use too much lube’ and ‘if it hurts at all, you’re going way too fast.’

    I think this should probably be taught in school. (I’ll duck under furniture now… but given the frequency of the kind of story Orac tells here, I’m only partially kidding).

  31. #31 Graculus
    October 3, 2007

    In the immortal words of somebody or other: “That’s an exit, not an entry”

  32. #32 Uncle Dave
    October 3, 2007

    One can only hope that the spray can was completely empty prior to insertion?

  33. #33 Orac
    October 3, 2007

    I posted about this a while back, too.

    Actually, in retrospect, I remember your post. If I had remembered it when I wrote this, I would have included a link.

  34. #34 (suppressed for this post)
    October 4, 2007

    I have seen, or come across indirectly in my medical travels:

    Two diloes in the anus “unable to remove” (one in a sixteen year old boy).

    One cucumber up the rectum (he nearly haemorrhaged to death).

    One… I don’t know what it was exactly, but it was described as sort of a “Japanese ceremonial chopstick”, from what I remember, which perforated the rectum and required a colostomy.

    Sticking loose objects up your arse is dangerous. The best apocryphal internet story I heard is of the man who used to anally masturbate with a WW2-vintage 40mm Bofors cannon shell. One day it slipped in, as these things do, and as the junior registrar was feeling around inside (gently), he asked the patient “This thing’s defused, isn’t it?”

    “Oh no, sonny; it’s still got enough kick to knock down a Messerschmitt!” (single seat fighter plane)

    They took him to theatre to get it out of him, and everyone in the room wore body armour.

  35. #35 jm
    October 4, 2007

    “I sat on it.”

    Right, sir, of course you did.

  36. #36 David Harmon
    October 4, 2007

    I’ve heard various such stories before; supposedly the single trickiest object the prior raconteur had encountered, was lightbulbs inserted threads-first. (fragile, round, and smooth)

  37. #37 Rev. BigDumbChimp
    October 4, 2007

    Later, our school bowling club had shirts made with “Just knock the pins down, don’t sit on them” written on the back.

    Very nice

  38. #38 Tegumai Bopsulai, FCD
    October 4, 2007

    The guy talking said it was too slippery to get a hold of, and any kind of tool they would use would cut through the apple.

    Why would the latter be a problem? A little D&C just might be helpful.

  39. #39 Amy Alkon
    October 4, 2007

    As I wrote on my blog when I linked to this, “One man’s Aqua Net is another man’s suppository.” And, “It’s the surgical version of ‘What’s in your wallet?'”

  40. #40 Amy Alkon
    October 4, 2007

    As I wrote on my blog when I linked to this, “One man’s Aqua Net is another man’s suppository.” And, “It’s the surgical version of ‘What’s in your wallet?'”

  41. #41 Wicked Lad
    October 4, 2007

    That’s a scary x-ray, but at least it wasn’tordinance!

  42. #42 trrll
    October 4, 2007

    While walking around a shopping mall with an ER doc friend, he made a point of visiting the Disney store. Turns out that he was looking for an object that had been retrieved one night while he was working the ER–a glass baby bottle with pictures of Mickey and Donald.

  43. #43 Cam
    October 4, 2007

    My personal experience is limited to a nine-inch vibrator.

    Er, my experience as a physician, not a patient.

    I was very proud when I was the only one in the ER able to identify the little squiggle ahead of the motor assembly as a lightbulb filament. And, to my credit, I didn’t crack a smile until this exchange:

    Me: So, was this… on… at the time?
    Him: Yes, yes it was.
    Me: So, uh, when’d it turn off?
    Him: (sigh) After many, many, many hours.

  44. #44 James
    October 5, 2007

    This may say more about me than anything else, but I thought “How?” first, and “Why?” second.

  45. #45 JJ
    October 5, 2007

    I’ve heard various such stories before; supposedly the single trickiest object the prior raconteur had encountered, was lightbulbs inserted threads-first. (fragile, round, and smooth)

    Somebody must have told him he couldn’t find his a$$ with a flashlight and he tried to prove them wrong.

  46. #46 Julie Stahlhut
    October 5, 2007

    Ouch, ouch, ouch. Having once had minor surgical repairs done to that sensitive portion of my own anatomy (and, no, foreign objects were emphatically NOT involved), I don’t even want to think about how these folks felt the next morning.

    A surgeon friend of ours had a standard question he asked after treating the results of stupid sex tricks: “How do you feel about the person who suggested you do this?” Surprisingly, most such patients hadn’t changed their opinions of the person in question one bit. That is, presuming that the person who wound up in the ER wasn’t the one who had the idea in the first place.

    And more ouch.

  47. #47 Rick Pikul
    October 6, 2007

    Only “why?” I have is “why would you use _that_? there are far better things that are just as big.”

    No real how, given that I know of a couple people who have claimed to use Zeta Creations’ “Thor” toy in anal play. (Thor is a dildo modeled on a Clydesdale, 1:1 scale.)

  48. #48 Paul Crowley
    October 28, 2007

    You must all now listen to “P. S. A.” by The Wet Spots.

    “Honey if like us you linger
    Around your rear end with a finger and
    Stimulate your prostate, just for fun
    It’s natural to fantasize
    About a toy of larger size, and
    By all means, friend, go out and purchase one!

    But if your prudishness pre-empts it
    You may find you’re sorely tempted
    To improvise with what you have on hand…
    And though it seems a perfect fit,
    We advise you – wait a bit!
    Listen to this song, and you will understand…”

  49. #49 Leni
    October 28, 2007

    I know this is no laughing matter… but I still keep laughing!

    The Rectal Foreign Bodies page is hilarious. I came across it years ago, and the “You should really chew your food better” joke still makes me laugh. And the old “I slipped in the shower and fell on it” line has now become a staple for me.

The site is currently under maintenance and will be back shortly. New comments have been disabled during this time, please check back soon.