Although literature is sparse on the subject, anecdotal evidence and the author’s experience suggests that injuries to the colon, rectum and anus are an increasing cause of mortality and morbidity.
VOL: 100, ISSUE: 38, PAGE NO: 30
Bruce Turner, BN, RN, is staff nurse, A&E department, Chelsea and Westminster Hospital, London
These are often caused by the insertion of foreign bodies into the rectum or other rectal sexual injury. Although the subject remains taboo and often provokes humorous reactions from staff in A&E, it can be serious or even life-threatening. This article aims to increase nurses’ knowledge about this problem, so that a situation sometimes seen as a joke can be recognised as a potentially serious condition, and patients can be treated appropriately in meeting both their physical and psychological needs. It discusses the incidence and treatment of retained foreign bodies and rectal sexual trauma, and the nurse’s role in caring for these patients and ensuring that their privacy and dignity are protected.
Different civilisations throughout history have dealt with anal sex in different ways ranging from accepting it as a normal practice to condemning it as an abomination to be punished. For example, the Mochica Indians of Peru had laws that demanded anal intercourse between husband and wife from the beginning of postnatal lactation until the third year of the infant’s life as a form of birth control. Although condemned in biblical times and punishable by death by burning in the Middle Ages, homosexual sex was commonplace in Roman and ancient Greek societies (Irizarry and Gottesmann, 1996). Over the past 20 years many western societies have become more tolerant towards homosexuality, and this may have contributed to increased sexual permissiveness among the homosexual community. In turn this may have led to an apparent increase in cases of rectal sexual injury, which means that health care professionals are increasingly likely to come in contact with such cases, particularly in A&E.
Colorectal foreign bodies
Numerous substitutes, mainly phallic, have been used for anorectal eroticism, sometimes with serious consequences including death (Cohen and Sackier, 1996). According to Crass et al (1981), the only limitation to the variety of objects used is the capacity of the rectum to accommodate them, and a vast number of different items are reported to have been recovered from the rectum (Box 1). One of the most intriguing reports, cited by Irizarry and Gottesman (1996), describes how the contents of an entire toolbox were found at autopsy in a prisoner who died of bowel obstruction. Although the main reason for insertion appears to be autoeroticism the literature also contains information pertaining to insertion by sexual partners; during assaults; as a remedy for constipation (Fig 1) and other ailments; drug smuggling; ingested objects and falling on objects. Although the incidence of rectal foreign bodies being retained is not known, their use for anal eroticism appears to be increasing (Shah et al, 2002; Irizarry and Gottesman, 1996).
The predominant group presenting to hospital is male (ratio 28:1), as foreign body insertion in females is often vaginal. This has fewer associated risks as the vagina has advantages in terms of control, comfort, distensibility, sensation, strength, and lubrication (Bush and Starling, 1986). Incidence among females may also be lower because women have no prostate gland, from which sexual pleasure is sometimes found on palpation. Documented cases among males show a broad age range from a 14-year-old boy with a glass TV vacuum tube (Cohen and Sackier, 1996) to a 63-year-old man with a 12-inch long and 8-inch circumference salami (Shah et al, 2002). No generalisations can be made regarding sexuality as that information is not available - while one study suggests the ‘typical patient’ is a homosexual male (Crass et al, 1981), this was undertaken in an urban hospital with a large gay community.
The literature shows that second to autoeroticism objects were inserted during consensual sexual acts, but incidents of assault are reported, including a cucumber forcibly inserted into a 31-year-old married man by three men (Panasci and Zutrauen, 1956), insertion of a broken stick by two attackers (Hartwig, 1921), insertion of a whisky bottle into a 59-year-old man by two hitchhikers (ReBell, 1948), insertion of an unknown object in a homosexual rape (Crass et al, 1981), and a case of a 15-year-old boy who died of phosphorous poisoning after a woman inserted phosphorous match heads into his rectum (Gould and Pyle, 1901).
In other cases that were initially reported as assault, patients later admitted they were acts of autoeroticism that they were originally too embarrassed to disclose to hospital staff. Busch and Starling (1986) state that when sexual assault is suspected examination for perianal bruising as well as for other injuries should be undertaken. The police and rape counsellors should also be consulted and careful documentation and preservation of evidence is paramount. Other reported reasons for the insertion of foreign bodies include treating a medical condition. For example, one patient self-inserted a lemon and a jar of cream to soothe haemorrhoids, another two patients inserted drinking glasses to soothe itching, while an eight-year-old child had a bar of soap inserted into her rectum by a midwife to treat constipation (Cohen and Sackier, 1996; Busch and Starling, 1986).
Rectal sexual injury
Fist fornication or ‘fisting’ is the insertion of a partner’s fist into the rectum, which for some increases sexual arousal. This activity has the potential to cause severe rectal trauma and even death (Crass et al, 1981). Busch and Starling (1986) describe how a 30-year-old man may have died from this type of injury, while Crass et al (1981) say it may disrupt the anal sphincters and cause faecal incontinence. Miles et al (1993) found increased prevalence of incontinence to either flatus, liquid or solid stool or urgency requiring immediate defecation in sexually anoreceptive people compared with those who were not anoreceptive. Circumstantial evidence of ‘fisting’ has shown its incidence to be increasing, with more patients being admitted to hospital for treatment of rectal trauma.
The use of enemas for sexual gratification (klismaphilia) has been associated with acute colitis (Baker, 1945) and allergic reaction (Egdell and Johnson, 1973). Toxicity to drugs and alcohol via enema administration has also been reported, as has water intoxication and electrolyte depletion following high-volume enemas and burn injuries following the use of hot enema fluids (Irizarry and Gottesman, 1996). Crass et al (1981) say the main risk associated with klismaphilia is perforation or laceration of the rectal mucosal lining and describe the death of one man who died from sepsis following this type of injury.
Perforation of the bowel due to anal sexual trauma is a rare but serious risk necessitating emergency surgery (Irizarry and Gottesman, 1996). Most patients need a temporary colostomy to divert faeces while the perforation heals but bowel continuity is usually restored about six weeks postoperatively (Crass et al, 1981). Chest X-ray will show air under the diaphragm, while abdominal X-ray may show pneumoperitoneum if the bowel is perforated - the patient may also have signs of peritonitis. The patient should be resuscitated with intravenous fluids and given antibiotics (Irizarry and Gottesman, 1996).
Documented disruption due to penile anorectal perforation is rare. Most cases are due to fist fornication or the insertion of other large objects (Irizarry and Gottesman, 1996). Crass et al (1981) describe a case of severe disruption of the sphincter due to insertion of pliers and show that the risk of temporary incontinence is high.
Most patients present to A&E when their own efforts to remove the retained object have failed. They may present with rectal pain, bleeding, abdominal pain, obstipation or even peritonitis (Shah et al, 2002; Cohen and Sackier, 1996; Crass et al, 1981). Presentation may be delayed due to embarrassment and fear, or because recent drug or alcohol use may cause a decreased sensation of pain so that they do not become aware of the seriousness of the situation for some time (Irizarry and Gottesman, 1996).
Taking a thorough history is essential to diagnosis, which may also require the following tests:
- Digital rectal examination must be performed to determine the nature and position of the foreign body;
- Abdominal X-rays are usually undertaken to identify the location, size and shape of the object;
- Erect chest X-ray is undertaken if there is the possibility of perforation, as free air will be seen under the diaphragm (Shah et al, 2002).
In most cases, after intravenous sedation and sphincter dilation manual extraction of the retained object is possible in the A&E department. If this fails the patient may need a general anaesthetic so that large objects can be extracted safely. It is usually possible to safely insert a whole hand into the rectum to retrieve the object from an anaesthetised patient (Crass et al, 1981). Enemas and laxatives should not be used to remove most foreign bodies, due to the risk of bowel perforation (Shah et al, 2002) - although they have been used successfully to remove bars of soap (Cohen and Sackier, 1996).
On some occasions the object cannot be removed manually as it cannot be gripped firmly enough. Other objects that have been used successfully in such situations include anoscopes, sigmoidoscopes, tenaculums and vaginal spatulas. Hollow foreign bodies such as bottles and cups can create a suction effect in the rectum, which can be broken by inserting a tube such as a Foley catheter proximal to the foreign body and instilling air (Cohen and Sackier, 1996).
Less commonly the patient may need to have a laparotomy and where possible the surgeon ‘milks’ the object through the bowel manually so it can be removed transanally (Shah et al, 2002). If this is unsuccessful a colotomy may be necessary, in which a small longitudinal incision is made in the bowel, the object is removed, and the incision closed (Busch and Starling, 1986). Objects that may need to be removed by colotomy include those that are too large or too fragile to be removed safely transanally. Patients usually recover from a laparotomy and/or colotomy uneventfully and require a very short hospital stay if any.
The role of the nurse
The nurse’s role in caring for patients with retained foreign bodies or rectal trauma will depend on the scale of the injury. If transanal removal of the retained object in A&E is possible, involvement will be minimal, but more will be required if trauma is present. The main role may be in giving support and comfort, usually for a short period, as most patients are discharged quickly. Most patients will be embarrassed and should be reassured that they are in a safe environment and treated with concern and tact, while their dignity and confidentiality should be protected. Not all health professionals behave in a non-judgemental manner towards these patients. The author has seen a surgical registrar tell a young male who needed surgery to retrieve a vibrator that he wished to never see him in this situation again as it was using up his time for patients who needed ‘proper’ surgery. No purpose is served by humiliating the distressed patient (Busch and Starling, 1986), and it is both unprofessional and unethical. It is not appropriate for health professionals to express their opinions in such a way.
If the bowel is perforated the patient will need intravenous fluids, antibiotics and analgesia. Observations of temperature, pulse, oxygen saturations and blood pressure will need to be recorded, and depending on the object used the patient may need to be given tetanus toxoid intramuscularly. Ideally the removal procedure should be explained to the patient, however this may not be possible if emergency surgery is performed. In rare cases discussion of a stoma may be needed - in these situations a stoma nurse specialist is best placed to give the explanation and answer any questions the patient may have. Nurses may also take the opportunity to give advice to help patients to prevent future injuries, for example suggesting that in future the use of objects with wider bases than necks would be safer, and emphasising the dangers of fist fornication.
Retained foreign bodies and rectal trauma are taboo subjects and the cause of embarrassment and distress to most patients. It is vital that they are treated in a professional manner that respects their dignity, and that clinical care is aimed at correcting the situation as safely and painlessly as possible. Nurses have a key role in supporting patients in situations that are at best embarrassing and at worst life-threatening, and it is vital that they do so in a sensitive and supportive manner. This article has been double-blind peer-reviewed.