Idiopathic spontaneous perforation of the sigmoid colon or a complication of sexual activity?

John Spiliotis, MD, PhD

Chairman

Department of Surgery

Anastasios C. Datsis, MD, PhD

Staff Surgeon

Department of Surgery

Archodia Vaxevanidou, MD, PhD

Staff Anesthesiologist

Department of

Anesthesiology

Athanasios Georgiou, MD

General Surgery Resident

Department of Surgery

Spiros Kekelos, MD

Vice Chairman

Surgical Clinic

Athanasios Rogdakis, MD, PhD

Staff Surgeon

Department of Surgery

Messologi General

Hospital

Messologi, Greece

Introduction: Inserting foreign bodies into the rectum can cause complications, including lodging, bleeding, or bowel perforation. When the patient extracts theforeign body before presenting to the hospital with a complication such as perforation, the injury may be attributed to other causes or recorded as idiopathic spontaneous perforation.

Results and discussion: The authors report the case of an elderly man who required an urgent laparotomy for a sigmoid colon perforation. This was initially thought to be an idiopathic spontaneous perforation. Nearly 2 years later, the patient presented to the same hospital with a large object lodged in his rectum, which required removal under general anesthesia. The authors suspected a connection between this current incident and the patient's earlier colonic perforation.

Conclusion: Objects lodged in the rectum rarely cause perforation and usually can be removed transanally under conscious sedation or general anesthesia. In some cases, laparotomy may be required to remove the object through a colotomy or allow primary closure of a perforation.

Most reports on the insertion of foreign bodies into the rectum for sexual stimulation involve men between 20 and 30 years of age.¹ For obvious reasons, complications arising from such acts are likely underestimated. The most commonly reported complication is retention of the foreign body by the large intestine. Rarer incidents include bleeding or bowel perforation. Among 149 cases of foreign body extraction reported in the literature, only 20 cases of perforation were described.^2-6

We report the case of an elderly man who underwent an urgent laparotomy due to a sigmoid colon perforation, which was registered as an idiopathic spontaneous perforation. Twenty months later, he presented with a foreign body lodged in his rectum and sigmoid colon. We now suspect that the patient's earlier colonic perforation resulted from insertion of a foreign body into his anal cavity. Patients who engage in such acts are often reluctant to disclose them as the likely origin of their injury, and, consequently, these cases may be misidentified as idiopathic spontaneous perforations.

Case report

An 85-year-old man presented to the emergency department reporting acute abdominal pain, fever, and nausea, which had started 4 hours earlier. All signs of acute peritonitis were present on physical examination. Laboratory studies were normal, except for a mildly elevated white blood cell count. Upright abdominal radiographs revealed free air under the right diaphragm, indicating perforation.

The patient underwent an urgent laparotomy, during which a longitudinal, 3-cm perforation was found on the antimesenteric border of the sigmoidorectal junction. An excisional biopsy from the edge of the perforation was obtained. Because the patient presented within 6 hours of the onset of his symptoms and no anatomical abnormalities or complications were encountered during surgery, primary closure of the perforation was made without a prophylactic colostomy. Had the patient presented more than 6 hours after first showing signs of large bowel perforation, the increased risk of anastomosis failure would have suggested the need for a prophylactic colostomy.

The patient had an uneventful recovery and was discharged from the hospital on postoperative day 10. Because no reason for the perforation was identified during surgery and the pathology report detailed no abnormalities, the case was designated an idiopathic spontaneous perforation.

Twenty months later, the patient returned to the hospital with a foreign body trapped in his rectum. He said the object was a bar of soap that he used to help manage impacted stools. On digital rectal examination, a hard object was palpable. Radiographs revealed a television remote control measuring 20 cm in length (Figure). No signs of bowel trauma, bleeding, or perforation were observed. The patient was taken to the operating room, and the object was extracted through the anus while the patient was under general anesthesia.

Discussion

A variety of foreign bodies have been found lodged in the rectum, including bottles of different shapes and sizes, broom and umbrella handles, teacups, light bulbs, and fruits.^2,3 The rate of complications resulting from foreign body insertion is difficult to estimate because the frequency of this practice is unknown.

Figure—Abdominal radiograph showing a 20-cm long television remote control.

The most common complication of deliberate insertion of a foreign body into the rectum is retention of the object. Several factors make self-extraction of these objects difficult. The shape of the object plays a significant role. Objects used for sexual stimulation tend to be tapered on one side and flat on the other, allowing for deeper insertion and increasing the possibility of retention. Muscle spasms involving the sphincteric mechanism and the valves of Houston in the rectal mucosa may prevent self-extraction. Uncapped bottles inserted rectally may produce a vacuum effect, inhibiting their removal.

More serious complications of foreign body insertion include bleeding and perforation, especially when straight objects that cannot follow the curves of the rectum and sigmoid colon are used. The possibility of seriously injuring the bowel wall, however, seems to correlate more with the force used during insertion than with the object's shape, because most reported perforations are associated with smooth, regular-shaped objects.²

Spontaneous perforation of the rectum or sigmoid colon is a rare phenomenon with an unknown physiopathology. Two categories of this condition have been described: stercoral and idiopathic. Patients with stercoral perforations suffer from chronic constipation and experience hard stools that become lodged and cause ischemic lesions that extend from the mucosa to the muscular layer and perforate the colon.⁷ Patients with idiopathic spontaneous perforations of the large bowel typically have linear lacerations situated on the antimesenteric side of the sigmoid colon, and no identifiable cause of perforation.⁷ During our patient's laparotomy, we found no anatomic abnormalities or hard stools that could have caused ischemic lesions in the intestinal wall. The pathology report revealed no abnormalities, and the case was recorded as idiopathic spontaneous perforation.

Two hypotheses have been proposed to explain idiopathic spontaneous perforations. The first is the vascular theory, which suggests that a combination of hypoperfusion of colonic tissue and some form of parietal suffering results in a constitutional weakness of the bowel wall, leading to perforation. Another hypothesized cause is intraluminal hypertension, which can result from intestinal hernias, rectal prolapse, or abnormal depth of a Douglas pouch.⁷ After our experience with this patient, we now think that some "idiopathic spontaneous perforations" may result from foreign bodies that are inserted into the rectum, possibly for sexual stimulation, and removed before the patient presents to the hospital. These patients are likely embarrassed and unwilling to disclose the origin of their injury, leading some of these cases to be classified incorrectly as idiopathic perforations.

Presentation

Most patients who seek medical assistance for foreign bodies lodged in the rectum or experience resultant bowel perforation are men, and the male to female ratio is 28:1.¹ There are two peaks in the age distribution of these patients. The most common distribution is among men between 20 and 30 years of age, followed by men who are 60 years of age or older.¹ Most patients with foreign bodies retained in the rectum arrive at the hospital after self-extraction attempts have proven unsuccessful. These patients usually report anal and rectal pain, bleeding, or, less frequently, lower abdominal pain. The insertion of a foreign body with a potentially traumatic shape may cause a bowel perforation without lodging. We speculate that such a scenario may have resulted in our patient's first admission. Patients with intraperitoneal perforations generally present with abdominal pain, fever, paralytic ileus, leucocytosis, and, in some cases, tachycardia.

Diagnosis

The diagnostic workup of patients with lodged foreign bodies must include digital rectal examination and plain radiographs. Radiography will show the shape, size, nature, and exact location of the object. It will also detect free intraperitoneal air, which indicates perforation. If the foreign body is not visible on radiography, diagnosis may be facilitated using endoscopy or computed tomography scanning.

Treatment and literature review

In most cases, the lodged foreign body can be removed through the anal canal while the patient is under conscious sedation or general anesthesia. In other cases, exploratory laparotomy will be necessary. Barone and colleagues reported on 23 patients with lodged foreign bodies.² Of these patients, 15 were successfully treated in the emergency department and 8 required hospitalization. Of those requiring hospitalization, 4 had the foreign body removed in the endoscopy suite and 4 required extraction in the operating room under general anesthesia. None of the 8 patients needed a laparotomy or colostomy, and none had any serious complications after the object was removed. Sigmoidoscopy was performed in 17 patients after extraction, and abrasions and small mucosal lacerations were noted in all cases. Clarke and associates reported on 13 patients with retained colorectal foreign bodies.³ In 7 cases, the object was removed transanally without surgery (3 in the emergency department using conscious sedation and 4 under general anesthesia). The remaining 5 patients were operated on; 2 had diffuse peritonitis, resulting from a large bowel perforation into the peritoneal cavity, and the remaining 3 required extraction through colostomy. In a series of 87 patients, bedside extraction was successful for 64 patients (74%).⁴ Of the 23 who required surgery, 15 had the object removed transanally under general anesthesia and 8 underwent an exploratory laparotomy. During laparotomy, there was one successful delivery of the object into the rectum followed by transanal extraction of the object. The remaining laparotomy patients required surgical repair of perforations or colostomy for extraction. In Clarke and associates' report, 55% of patients with a foreign body lodged in the sigmoid colon required surgical intervention, compared with only 24% who had objects retained in the rectum.³ In Ruiz del Castillo and colleagues' series, transanal extraction of the foreign body was possible in 10 patients, whereas 7 required surgery (prophylactic colostomy was performed in 5 patients, and 2 underwent simple closure of the rectal lacerations).⁵ Several devices were used to extract the lodged foreign bodies from the anal canal, including gynecological forceps, Foley catheters, and vacuum extractors.

In cases of bowel perforation, the type of surgical intervention needed depends on several factors. High-risk patients—those who present late or with shock, bleeding, extended stool contamination, and perforations larger than 40% to 50% of the bowel diameter—usually require prophylactic colostomy. In high-risk cases, primary repair has a high rate of failure. In lower-risk situations, such as in our case, primary suture of the laceration without prophylactic colostomy can be performed.

Conclusion

In is unclear how many people insert foreign bodies into the rectum for sexual stimulation or other reasons, because reported complications associated with this practice are rare. The most commonly observed complication is retention of the object. Other complications include bleeding and bowel perforation. Our case report suggests that some patients who undergo surgery for bowel perforations deemed "spontaneous" may have removed the foreign body before presenting to the hospital and are too embarrassed to reveal the facts surrounding their injury. In most cases, lodged foreign bodies can be removed transanally without surgery. If a laparotomy is necessary, a primary closure can be performed and, for high-risk patients, a prophylactic colostomy may be warranted.

References

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3. Clarke DL, Buccimazza I, Anderson FA, et al. Colorectal foreign bodies. Colorectal Dis. 2005;7(1):98-103.
4. Lake JP, Essani R, Petrone P, et al. Management of retained colorectal foreign bodies: predictors of operative intervention. Dis Colon Rectum. 2004;47(10):1694-1698.
5. Ruiz del Castillo J, Selles Dechent R, Millan Scheiding M, et al. Colorectal trauma caused by foreign bodies introduced during sexual activity: diagnosis and management. Rev Esp Enferm Dig. 2001;93(10):631-634.
6. Yaman M, Deitel M, Burul CJ, et al. Foreign bodies in the rectum. Can J Surg. 1993;36(2):173-177.
7. Basile M, Montini F, Cipollone G, et al. Spontaneous perforations of the large intestine [in Italian]. Ann Ital Chir. 1992;63(5): 625-629.