A total of 159 literatures were preliminarily retrieved in initial literature search with rectal foreign body as the search term, including 86 Chinese literatures and 73 English literatures. A total of 737 patients were retrieved, among whom 582 were male, accounting for 79%. There were 276 Chinese patients, all of whom were male, and 461 non-Chinese patients, among whom 307 were male. The sources of foreign bodies can be divided into three categories: the ones that are inserted from the anus, the ones that are swallowed and thereafter become stuck in the rectum, the other that are caused by improper medical practices. Among them, the first categories are the group of objects that are inserted via the anus and accounted for the majority, while the second are the group of objects that become stuck in the rectum after swallowing and was more common in children under 10 years old and elderly female patients.one case was found to be iatrogenic.
The types of foreign bodies can be classified as daily necessities, food and sexual articles, among which daily articles account for the majority, mainly for pleasure seekers and partly for unexplained reasons. Sexual articles are mainly found in pleasure seekers. The largest foreign body size was a 77cm long steel rod, and the smallest denture and vegetable residue (granuloma formation) could be seen.
The most common purpose for a foreign body in the rectum was insertion for erotic purposes, and occasionally there may be involuntary insertions. It should be noted that a small number of drug dealers are included. The characteristic of transoral foreign body is mostly edible prickly food;
The process for the identification and selection of the relevant literatures, according to the inclusion and exclusion criteria, is depicted in Fig. 1. After screening the titles or abstracts, and retrieving for full texts ,the twenty studies that fulfilled the inclusion criteria were published between 2000 and 2020, and 35 male patients were analyzed in this systematic review, included 20 Chinese patients with age range (70.70 ± 6.76) and 15 non-Chinese patients with age range(70.83 ± 7.14). All of the included literatures were available as fully published papers. The characteristics of the literatures included are shown in Table 1.
Among the elderly Chinese patients, 3 cases rectal foreign bodies were swallowed, passed through the gastrointestinal track and held up in the rectum, including jujube stone, duck bone and fish bone, and 17 cases rectal foreign bodies were inserted through the anus. In the elderly Chinese patients, most of the foreign bodies were daily articles and sexual articles, but no iatrogenic rectal foreign bodies were found. Among the elderly non-Chinese patients, 1 case rectal foreign bodies were swallowed and 14 cases inserted rectal, most of which came from household articles, including screwdrivers and various bottles. There was no significant difference in foreign body source between the two groups (P༞0.05) (Fig. 2a). Further analysis was made from the source of the foreign body. We found that the swallowed foreign bodies of both groups of elderly patients were mainly derived from sharp food, such as fish bones, while the inserted foreign bodies were mainly derived from daily necessities and the patients who use sexual objects are mainly elderly non-Chinese patients or those with a high degree of education.
We showed that in 60% of the elderly Chinese cases and in 66.7% of the elderly non-Chinese cases, the foreign bodies were inserted into the rectum for erotic stimulation and gratification (Fig. 2b). By analyzing the shape and texture of rectal foreign bodies in the two groups, blunt foreign bodies and non-fragile foreign bodies accounted for a higher proportion than counterparts (Fig. 2c/2d).
The method of retrieval and complications of various anorectal foreign bodies were further analyzed. In elderly Chinese patients, transanal removal under local anesthesia was the main method. Compared with elderly non-Chinese patients, most retained anorectal foreign bodies in elderly Chinese patients can be successfully removed transanally under appropriate local anesthesia and only a small proportion will require general anesthesia and abdominal operation, the difference is statistically significant(p = 0.036/0.028) (Fig. 2e/2f). While one elderly non-Chinese patient died because of the necrosis of intestinal mucosal tissue and systemic infection caused by a long time of treatment, there were no significant differences in the incidence of complications (P = 0.383) (Fig. 2g).
The data of a total of 8 patients, who received our hospital with complete data over 10 years, were prospectively recorded in Table 2. All patients had a median age of 58 years and included 2 female and 6 male patients. The purpose of inserting rectal foreign body was to stimulate erotic feeling in 5 male patients. 2 had vibrators (Fig. 3a/3b/3c),1 had a can of portable toothbrush (Fig. 3d/3e),1 had a ceramic drinking cup,1 had a 30cm long bamboo (Fig. 3f/3g). All of these foreign bodies were cylindrically shaped objects. Other objects that were encountered included a piece of date pit that was stuck on the rectum wall in one 53 years female case (Fig. 3h), an intrauterine contraceptive device (IUCD) that migrated to the rectouterine space in one 57 years female case (Fig. 3i), Stapler residual nail that was remained in a 34-year-old male individual who had undergone hemorrhoids.
The etiology of the foreign body in the rectum was erotic purposes in 5 elderly male patients, migration of an intrauterine device in one elderly female patient and accidents swallow in one female case. All patients in the erotic group were male and most of them live alone or are divorced.
The diagnosis was verified by ask the medical history, rectal examination and plain X-ray imaging in 5 patients who had foreign bodies in their rectum for erotic purposes. The patients who had a piece of date pit in their rectum presented with pelvic and perianal pain, which became exacerbated with defecation and diagnosed by anal fingering examination. The diagnosis was confirmed by anamnesis and plain X-ray imaging in one patient who had an intrauterine contraception device that had migrated to the rectum. The patient who had a stapler residual nail that presented pain in the stools was diagnosed during an anoscope examination.
In the process of clinical treatment, we successfully removed the foreign body of a patient whose rectum was inserted into a bamboo node about 30cm long for sexual needs directly through surgical forceps and the patient's action of increasing abdominal pressure. The one erotic object could not be extracted even with laparotomy and bimanual maneuvers, and a colostomy was the selected method in this case, which was returned to colostomy 3 months after the operation without any complications. The other erotic object was extracted from 3 of the patients by rectoscopy or surgical forceps under spinal or general anesthesia performed in our general endoscope room. Extraction attempts to remove the foreign body with colonoscopy were successful in 3 of the patients. All patients recovered without any complications after aggressive clinical treatment.