Rectal foreign body (adult)
Adult with a retained anorectal object. Treat with privacy and without judgement.
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Colorectal SurgeryEmergency
Rectal Foreign Body Management (WSES-AAST 2021)
Rectal Foreign Body Management (WSES-AAST 2021): Rectal foreign body (adult) → First: child, assault or drug packets? → History, vital signs and abdomin...
Pathway Overview
23 steps
Algorithm Steps
23 total
01Start 02Warning First: child, assault or drug packets?
These change who treats the patient and what is safe.
- Child: paediatric surgeon and child protection; assault or abuse is the usual cause
- Non-consensual insertion: follow the sexual assault and safeguarding process
- Drug packets: no clamps, forceps or endoscopy; get toxicology advice
03Action History, vital signs and abdominal exam
Do the rectal exam after the X-ray: a sharp object can cut the examiner.
- Object: type, size, shape, number; sharp, glass or fragile?
- Time since insertion; attempts to remove it
- Pain, bleeding, fever, tachycardia, hypotension, peritonism
- Drug packets or drug use? Was insertion consensual?
- No routine blood tests unless perforation is suspected or extraction fails
- Record perianal findings and sphincter tone: needed if assault is alleged
04Decision Haemodynamically unstable?
Shock or hypotension
- If Yes
05Warning Unstable: emergency laparotomy
Resuscitate. Do not delay surgery for imaging. No transanal extraction.
- Damage control surgery approach
- IV broad-spectrum antibiotics
- Perforation with critical illness: Hartmann's procedure
06End After surgery: care under the surgical team
Check for more objects or fragments. Offer psychosocial support.
If No07Action Stable: X-ray chest, abdomen and pelvis
AP and lateral films: object number, shape, size and level; free air.
- A normal X-ray does not exclude a radiolucent object
- Suspected perforation: contrast-enhanced CT abdomen
- CT also for radiolucent objects, obstruction or abscess
- No CT: erect or left lateral decubitus X-ray for free air, or water-soluble contrast enema; consider transfer
- Could be pregnant: pregnancy test; do not withhold needed imaging
- Then rectal exam, with care
- Note if the object is above the rectosigmoid junction
08Decision Perforation or peritonitis?
Free air, peritonitis or sepsis
- If Yes
09Warning Perforation: urgent surgery, no transanal extraction
Resuscitate. IV broad-spectrum antibiotics. FBC, creatinine, CRP, lactate. Laparoscopy or laparotomy.
- Small, recent perforation, healthy tissue: primary repair
- Otherwise, if stable: resection and anastomosis, with or without stoma
- Critically ill or wide contamination: Hartmann's procedure
- Path rejoins step 06Shared downstream outcome
If No10Decision Drug packets suspected?
From the history or the imaging (body packer)
- If Yes
11Action Drug packets: no clamps, forceps or endoscopy
Avoid any manoeuvre that can break a packet. Serum toxicology. Get toxicology advice and a surgical opinion. Admit.
- Signs of drug toxicity, obstruction or leak: resuscitate; urgent surgery
- Opioid toxicity: also give naloxone; surgery is still needed for a leaking packet
- No toxicity or obstruction: conservative care with close monitoring
- CT to find all packets: many are swallowed, not inserted
12End Body packer: admit with close monitoring
Surgery if toxicity, obstruction or packet leak develops.
If No13Decision High, large, sharp or glass object?
High: above the rectosigmoid junction or out of reach. Glass or fragile objects can break. If none of these: bedside extraction.
- If Yes
14Action High, large, sharp, glass or failed bedside: extraction under anaesthesia
Surgical team, in theatre or endoscopy. Spinal or general anaesthesia relaxes the sphincter.
- Above the rectosigmoid junction: endoscopic extraction first
- Sharp object: remove under direct vision with a rigid or flexible scope
- Glass or fragile object: take care not to break it
- Snare, basket, grasper or balloon; fluoroscopy can help
- Preoperative blood tests
15Decision Removed transanally or with the scope?
Yes: check the bowel wall after removal. No: step-up surgery.
- If Yes
16Action After removal: proctoscopy or flexible sigmoidoscopy
Check the bowel wall. Look for more objects or fragments.
- Mucosal tear or full-thickness injury?
- Suspected perforation: contrast-enhanced CT (X-ray can miss free air)
17Decision Full-thickness injury or perforation?
Yes: admit under surgeons. No: observe, then discharge.
- If Yes
18Action Full-thickness injury: admit under surgeons
IV broad-spectrum antibiotics. Serial abdominal exams.
- Intraperitoneal perforation: surgery (repair, resection or Hartmann's)
- Small extraperitoneal injury: nil by mouth, IV antibiotics, observe
- Larger extraperitoneal injury or soiling: consider a diverting stoma
- Anal sphincter injury: colorectal surgeon review
19Outcome Outcome
Transanal extraction succeeds in 60 to 75% of cases. Perforation occurs in about 15%.
If No20Action No full-thickness injury: observe, then discharge
Discharge when well and eating.
- No routine antibiotics
- Analgesia; return if pain, fever or bleeding
- Offer mental health or social work review if needed
- Path rejoins step 19Shared downstream outcome
If No21Action Failed transanal extraction: step-up surgery
Milk the object down for transanal removal. Colotomy only if that fails.
- Laparoscopy first if skills and equipment are available
- Otherwise midline mini-laparotomy
- Inspect the bowel for perforation and contamination
- Proctoscopy or sigmoidoscopy after removal to check the bowel wall
- Path rejoins step 06Shared downstream outcome
If No22Action Low, small, blunt object: bedside extraction
Stable, no perforation, no drug packets, not sharp or glass. Relaxation is the key to success.
- Perianal or pudendal block, with or without IV procedural sedation
- Lithotomy or left lateral position; gentle anal dilation
- Grasp with fingers or clamps; firm pressure on the lower abdomen
- Suction seal: pass a Foley catheter past the object, inflate the balloon
- If it fails, do not persist: go to theatre
23Decision Object removed intact?
Yes: check the bowel wall after removal. No: extraction under anaesthesia.
- If Yes
- Path rejoins step 16Shared downstream outcome
If No- Path rejoins step 14Shared downstream outcome
Guideline Source
Tarasconi A et al. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021;16:48 (section 6: retained anorectal foreign bodies)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Evidence is low quality (WSES-AAST 2021: mostly weak recommendations, grade 2C to 2D). No ASCRS guideline covers rectal foreign bodies.
- Adults only. A child needs a paediatric surgeon and child protection; body packers need toxicology and surgical care.
- No extraction technique is proven better than another; choice depends on the object and local skills.
- Extraperitoneal rectal injury management is summarised only; follow the surgical team and trauma guidance.
Contraindicated Populations
Children (paediatric surgery and child protection)Body packers with drug packets (toxicology and surgical care)
Applicable Regions
USEUAU
AU: Toxicology advice: Poisons Information Centre 13 11 26 (24 h). Sexual assault support: 1800RESPECT 1800 737 732 and the state sexual assault service. Report child abuse concerns to the state child protection service.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Rectal Foreign Body Management (WSES-AAST 2021)?
The Rectal Foreign Body Management (WSES-AAST 2021) is a emergency clinical algorithm for Colorectal Surgery. It provides a structured decision tree to guide clinical decision-making, based on Tarasconi A et al. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021;16:48 (section 6: retained anorectal foreign bodies).
What guideline is the Rectal Foreign Body Management (WSES-AAST 2021) based on?
This algorithm is based on Tarasconi A et al. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021;16:48 (section 6: retained anorectal foreign bodies) (DOI: 10.1186/s13017-021-00384-x).
What are the limitations of the Rectal Foreign Body Management (WSES-AAST 2021)?
Known limitations include: Evidence is low quality (WSES-AAST 2021: mostly weak recommendations, grade 2C to 2D). No ASCRS guideline covers rectal foreign bodies.; Adults only. A child needs a paediatric surgeon and child protection; body packers need toxicology and surgical care.; No extraction technique is proven better than another; choice depends on the object and local skills.; Extraperitoneal rectal injury management is summarised only; follow the surgical team and trauma guidance.. Individual patient factors may require deviation from these recommendations.
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