Original Article Annals of

Coloproctology
Ann Coloproctol 2020;36(5):335-343 pISSN 2287-9714 eISSN 2287-9722
https://doi.org/10.3393/ac.2019.10.03.1 www.coloproctol.org

The Management of Retained Rectal Foreign Body

Ju Hun Kim, Eunhae Um, Sung Min Jung, Yong Chan Shin, Sung-Won Jung, Jae Il Kim, Tae Gil Heo,
Myung Soo Lee, Heungman Jun, Pyong Wha Choi
Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea

Purpose: Because insertion of a foreign body (FB) into the anus is considered a taboo practice, patients with a retained
rectal FB may hesitate to obtain medical care, and attending surgeons may lack experience with removing these FBs. We
performed this study to evaluate the clinical characteristics of Korean patients with a retained rectal FB and propose man-
agement guideline for such cases based on our experience.
Methods: We retrospectively investigated 14 patients between January 2006 and December 2018. We assessed demo-
graphic features, mechanism of FB insertion, clinical course between diagnosis and management, and outcomes.
Results: All patients were male (mean age, 43 years) and presented with low abdominal pain (n = 2), anal bleeding (n = 2),
or concern about a retained rectal FB without symptoms (n = 10). FB insertion was most commonly associated with sexual
gratification or anal eroticism (n = 11, 78.6%). All patients underwent general anesthesia for anal sphincter relaxation with
the exception of 2 who underwent FB removal in the emergency department. FBs were retrieved transanally using a clamp
(n = 2), myoma screw (n = 1), clamp application following abdominal wall compression (n = 2), or laparotomy followed by
rectosigmoid colon milking (n = 2). Colotomy and primary repair were performed in four patients, and Hartmann opera-
tion was performed in one patient with fecal peritonitis. No morbidity or mortality was reported. All patients refused
postextraction anorectal functional and anatomical evaluation and psychological counseling.
Conclusion: Retained rectal FB is rare; however, colorectal surgeons should be aware of the various methods that can be
used for FB retrieval and the therapeutic algorithm applicable in such cases.

Keywords: Foreign body; Rectum; Management

INTRODUCTION tion, resulting in delayed presentation [1, 2]. Moreover, history

collection may not provide accurate information because patients
A retained rectal foreign body (FB) is one of the most unusual may be too embarrassed to honestly disclose details regarding a
clinical presentations in the emergency department. In most self-inserted rectal FB. Despite the reluctance of patients with a
cases, the FB (commonly, phallic substitutes) are purposely in- retained rectal FB to seek medical attention, timely and accurate
serted for self-gratification associated with anal eroticism. Regard- diagnosis is important, and physicians should refer the patient to
less of purpose, FB insertion into the anus is considered taboo; a colorectal specialist.
therefore, most patients are reluctant to seek medical attention Retained rectal FB is readily diagnosed via digital rectal exami-
and attempt self-retrieval via digital or instrumental manipula- nation or imaging studies, such as plain radiography and/or com-
puted tomography (CT). However, management of retained rectal
Received: Aug 29, 2019 • Revised: Sep 30, 2019 • Accepted: Oct 3, 2019
FBs requires an individualized approach based on size, shape, na-
Correspondence to: Pyong Wha Choi, M.D., Ph.D.
Department of Surgery, Ilsan Paik Hospital, Inje University College of ture, and location of the impacted FB and the degree of FB-in-
Medicine, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea duced rectal injury (which can range from mucosal injury to
Tel: +82-31-910-7622, Fax: +82-31-910-7319 colorectal perforation) [3, 4]. Therapeutic algorithms addressing
E-mail: eacechoi@hanmail.net this issue have been reported in the literature [5-7]. Most reports
ORCID: https://orcid.org/0000-0001-5777-8436 describe patients from Western countries, although there are 2
© 2020 The Korean Society of Coloproctology case reports from Asian countries [8, 9].
This is an open-access article distributed under the terms of the Creative Commons Attribution Non- We performed the present study to assess the clinical character-
Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-
commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. istics of Korean patients with a retained rectal FB and propose

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 Annals of The Management of Retained Rectal Foreign Body
Coloproctology Ju Hun Kim, et al.

guidelines for management of such patients. findings (plain radiography or CT). FB size was defined in terms
of its largest diameter. Based on location, FBs were classified as
METHODS low- or high-lying objects depending on whether they were pal-
pable on digital rectal examination. The grade of rectal injury was
We retrospectively investigated 14 patients diagnosed with re- assessed based on the Rectal Organ Injury Scale (ROIS) of the
tained rectal FB between January 2006 and December 2018, ex- American Association for the Surgery of Trauma (AAST) as fol-
cluding cases secondary to oral ingestion of a FB. The following lows: grade I, contusion or hematoma without devascularization
data were obtained from medical chart review: patient demo- and/or partial-thickness laceration; grade II, laceration involving
graphics; clinical presentation; cause of FB insertion; time interval <50% of the rectal wall circumference; grade III, laceration in-
between FB insertion and emergency department visit; nature, volving >50% of the rectal wall circumference; grade IV, full-
size, and location of the FB; grade of rectal injury; radiological thickness laceration with extension into the perineum; grade V,
findings; FB-induced complications; methods used for FB re- devascularized segment [10]. This study was approved by the In-
moval including operative details; and length of hospitalization. stitutional Review Board of Ilsan Paik Hospital (No. 2019-04-012-
Initial evaluation after rectal FB insertion included history collec- 002) and was exempted from the requirement for informed con-
tion, physical examination, and laboratory investigations. During sent.
history collection, if the patient did not acknowledge anal eroti-
cism but provided an unrealistic reason for anal insertion of the RESULTS
FB, the case was categorized as FB insertion secondary to anal
eroticism. Retained rectal FB was diagnosed based on clinical evi- Patient demographics
dence obtained via history, physical examination, and radiological The mean age of the 14 patients was 43 years (range, 19 to 57

Table 1. Clinical features of patients with retained rectal foreign body (FB)
Age Reason provided Colorectal Retrieval Hospital
No. Year Presentation cause Inserted FB Extraction modality
(yr) for insertion location location stay (day)
1 2006 49 Concern about retained Relief of constipation Low Drinking glass OR Colotomy and primary repair 9
rectal FB
2 2006 48 Abdominal pain Anal eroticism Low Cosmetic container OR Transanal extraction after 7
laparotomy and milking
3 2007 49 Concern about retained Anal eroticism Low Drinking glass OR Colotomy and primary repair 8
rectal FB
4 2008 29 Concern about retained Anal eroticism Low Coffee can OR Transanal extraction with 9
rectal FB Kelly clamp
5 2009 44 Concern about retained Anal eroticism Low Cosmetic lid ER Transanal manual extraction 0
rectal FB
6 2011 19 Concern about retained Anal eroticism Low Perfume bottle ER Transanal manual extraction 0
rectal FB
7 2013 47 Concern about retained Relief of hemorrhoid High Electric toothbrush OR Transanal extraction with 3
rectal FB Kelly clamp
8 2014 51 Concern about retained Anal eroticism Low Radish OR Transanal extraction with 3
rectal FB myoma screw
9 2014 55 Anal bleeding Anal eroticism High Sexual device OR Colotomy and primary repair 6
10 2015 57 Concern about retained Anal eroticism Low Cosmetic container OR Colotomy and primary repair 9
rectal FB
11 2015 42 Concern about retained Anal eroticism Low Cosmetic container OR Transanal extraction after 3
rectal FB abdominal compression
12 2016 44 Abdominal pain Idiopathic High Twig OR Hartmann operation 11
13 2018 22 Anal bleeding Anal eroticism Low Sexual device OR Transanal extraction after 2
abdominal compression
14 2018 42 Concern about retained Anal eroticism High Sexual device OR Transanal extraction after 4
rectal FB laparotomy and milking
OR, operating room; ER, emergency room.

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years), and all patients were men. Most patients (11 of 14, 78.6%) patients in whom FB insertion was associated with sexual gratifi-
denied a history of underlying disease. Hypertension and chronic cation or anal eroticism, only 1 (7.1%) admitted to this history
alcoholism were observed in 1 patient (7.1%) each, and 1 patient and divulged that the present episode was the fourth instance of
presented with mental retardation and a history of Behcet disease. anal FB insertion. Ten patients (71.4%) were reluctant to reveal
No patient reported a history of homosexuality or bisexuality. details regarding FB insertion, and 3 of these 10 patients admitted
Clinical patient features are summarized in Table 1. to anal eroticism when the retained rectal FB was identified on
plain radiography. However, the remaining 7 patients denied anal
Clinical presentation and diagnosis of a retained rectal FB eroticism, and FB insertion was attributed to several seemingly
Low abdominal pain and anal bleeding were the presenting com- implausible mechanisms including accidentally sitting on the ob-
plaints in 2 patients (14.3%) each. Ten patients (71.4%) were as- ject, anal massage, curiosity, and pranks during showering in 4
ymptomatic but presented with concerns regarding a retained (28.4%), 1 (7.1%), 1 (7.1%), and 1 patient (7.1%), respectively.
rectal FB. Reasons provided for anal FB insertion included sooth- All except the patient with mental retardation attempted self-re-
ing hemorrhoids, relieving constipation (1 patient each, 7.1%), trieval of the rectal FB before visiting the emergency department.
and sexual gratification or anal eroticism (11 patients, 78.6%). The mean interval between FB insertion and presentation was 10
The cause of FB insertion in the patient with mental retardation hours (range, 1 to 48 hours). On digital rectal examination, the
was categorized as idiopathic because communication with the retained rectal FB could be palpated in 10 patients (71.4%) at dis-
patient and accurate history collection were not possible. Among tances of 4 to 8 cm from the anal verge. The retained FB was pal-

A B C

D E F

G H I

Fig. 1. Plain abdominal radiographs showing radiopaque retained rectal foreign bodies of various size and shape.

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 Annals of The Management of Retained Rectal Foreign Body
Coloproctology Ju Hun Kim, et al.

A B

Fig. 2. Abdominopelvic computed tomography scans showing a retained rectal foreign body (plastic cosmetic container) with edema and
thickening of the rectal wall: (A) sagittal and (B) axial views.

pated on abdominal examination in four patients (28.4%). Only performed in 7 (58.3%). Transanal extraction using only a Kelly
the patient with mental retardation developed signs of peritoneal clamp was successful in two patients; however, a myoma screw
irritation. Plain radiography was performed in all patients, and was required for FB retrieval in one patient with a retained radish
radiopaque FBs of various sizes and shapes were identified in 10 (Fig. 3A). Transanal extraction using a Kelly clamp after lower ab-
patients (71.4%) (Fig. 1). Retained rectal FBs ranged from 5 to 40 dominal compression and transanal extraction after laparotomy
cm in size, with a mean (standard deviation, SD) size of 13.5 cm and milking of the rectosigmoid colon were performed in 2 pa-
(±9.1 cm). CT was performed in 8 patients (57.1%), 6 of whom tients (16.7%) each. Transabdominal retrieval of the FB was per-
had a radiopaque FB, while the other 2 patients had a radiolucent formed in 5 patients (41.7%). Colotomy and primary repair were
FB. In addition to the impacted rectal FB, we observed active performed in 4 patients (33.3%), 2 of whom harbored an im-
bleeding and hematoma at the rectosigmoid junction in 2 patients pacted drinking glass (Fig. 3B). In the patient with mental retar-
(14.2%) and pneumoperitoneum with panperitonitis in 1 patient dation, the FB was a twig measuring 40 cm in length that had
(7.1%). No complications were observed in the other 5 patients penetrated the sigmoid colon with regional fecal contamination.
(35.5%) (Fig. 2). Based on the AAST classification, 3 patients Thus, Hartmann operation was performed, and colostomy take-
(21.4%) had grade II rectal injury, while the other 11 had grade I down was performed 4 months postoperatively. Operative time
rectal injury. ranged from 10 to 120 minutes, with a mean (SD) of 67 minutes
(±35.6 minutes). Rectal FBs in the 14 patients in this study were
Management of retained rectal FBs and outcomes categorized as follows: object of sexual gratification (3 patients),
All patients were referred to a colorectal surgeon immediately af- cosmetic container (3 patients), cosmetic container covered with
ter diagnosis. FB extraction without anesthesia was attempted at a condom (1 patient), drinking glass (2 patients), cosmetic lid (1
the emergency room in 3 patients (21.4%). The FB was success- patient), coffee can (1 patient), electric toothbrush (1 patient),
fully retrieved manually in 2 patients, while such retrieval failed in radish covered with a plastic bag (1 patient), and a twig (1 patient)
1 patient. Sigmoidoscopic extraction was attempted in 1 patient; (Fig. 4). No postoperative morbidity or mortality was observed.
however, the FB could not be retrieved with grasping forceps. Overall mean length of hospitalization, excluding the two patients
Therefore, 12 patients (85.7%) were transferred to the operating who underwent FB removal at the emergency department, was
room. Transanal extraction using a Kelly clamp was attempted 6.2 days (range, 2 to 11 days), and a liquid diet was initiated 2.5
under spinal anesthesia in 1 patient; however, failure to retrieve days (mean) postoperatively (range, 1 to 5 days). Postextraction
the FB necessitated induction of general anesthesia. Thus, general sigmoidoscopy was performed in only 1 patient during hospital-
anesthesia was used in all patients transferred to the operating ization, and 2 patients (16.7%) were referred to a psychologist, al-
room. Among these patients, transanal retrieval of the FB was though both refused psychological consultation. The overall

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A B

Fig. 3. Intraoperative images showing retrieval of a rectal foreign body. (A) A myoma screw was used for transanal retrieval of the rectal for-
eign body (radish). (B) A drinking glass (arrow) was extracted after colotomy at the rectosigmoid junction.

A B C D

E F G

Fig. 4. Images showing a variety of extracted rectal foreign bodies. (A) A perfume bottle, (B) a phallic substitute for sexual gratification, (C) a
radish covered with a plastic bag, (D) a twig, (E) a coffee can, (F) a drinking glass, and (G) an electric toothbrush.

mean follow-up was 2.6 weeks (range, 0 to 24 weeks), and 3 pa- study to report management guidelines for patients with retained
tients (21.4%) were lost to follow-up. During follow-up, no patient rectal FB in Korea.
underwent postextraction anorectal functional and anatomical Although a retained rectal FB is one of the most uncommon
evaluation with manometry and transanal ultrasonography or clinical presentations in emergency departments, it can no longer
psychological consultation. be considered a rare entity due to the increasing number of stud-
ies being reported in Western countries. However, the incidence
DISCUSSION of this condition in Asian countries remains unclear [11]. Cultural
differences and attitudes toward patients with retained rectal FB
Management guidelines for retained rectal foreign bodies are not may affect the incidence of presentation with a retained rectal FB
well established, and most of the existing therapeutic algorithms in clinical practice; the true incidence in Asians may be higher
are from Western countries. Because cases from Asia are particu- than previously reported because of the diversity of sexual prefer-
larly rare, we performed this study to establish management ences in Asian societies. Even though retained rectal FB is rare,
guideline for Koreans with a retained rectal FB; this is the first and the number of the patients observed over a period of 13 years

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 Annals of The Management of Retained Rectal Foreign Body
Coloproctology Ju Hun Kim, et al.

in a single Korean institute was only 14, clinicians at emergency vegetables may not be readily visualized [2, 13]. Even though the
departments, particularly colorectal surgeons, should ensure ac- indications for CT are not conclusively established in such cases,
curate history collection and imaging studies for prompt diagno- patients with complications such as perforation or high-lying rec-
sis and optimal therapeutic intervention in patients with retained tal FB that cannot be confirmed by plain radiography require CT.
rectal FB. In addition to radiographic examination, sigmoidoscopy is useful
Reasons for anal FB insertion vary widely and include relief to confirm rectal FB [3, 4]. However, endoscopic evaluation may
from hemorrhoids or constipation, concealment of drugs, sec- be of limited diagnostic utility in patients with complications, and
ondary gains in patients with psychiatric disorders, assault, and this modality may be more useful as a therapeutic intervention. In
sexual gratification or anal eroticism. Autoeroticism for sexual the present study, CT was performed in eight patients. Excluding
gratification appears to be the most common reason for FB inser- patients with radiolucent FB or peritonitis, the indications for CT
tion, and most patients are sexually active males between 20 and were not documented in detail. Nonvisualization of an FB on
40 years of age, as observed in the present study [1-6]. Careful his- plain radiography does not exclude its presence. Thus, CT is indi-
tory collection is important for accurate diagnosis in the emer- cated in rare instances for diagnosis; however, routine CT may
gency department. However, anal FB insertion for sexual gratifi- not be justified in patients with retained rectal FB.
cation is considered taboo; because of the embarrassment associ- Management of retained rectal FB should be individualized de-
ated with this practice, most patients do not provide an accurate pending on size, shape, nature, location, and interval between in-
history. Therefore, such cases are diagnostic challenges. Patients sertion and diagnosis of the FB and complications. Hemodynami-
may fabricate a history and attribute the retained rectal FB to false cally unstable patients or those with signs of peritonitis, indicating
causes. Previous studies have reported that only 10% to 30% of perforation, should be transferred to the operating room for lapa-
patients provide an accurate history because of embarrassment [1, rotomy. In hemodynamically stable patients without evidence of
2, 5, 11]. Our findings concur with those of previous studies; only peritonitis, extraction methods should be determined based on
1 patient was forthcoming about the reason for FB insertion, and the attributes of the FB. Transanal or transabdominal approaches
most patients denied a history of sexual practices that could have are most commonly used for FB retrieval. Transanal extraction is
contributed to rectal FB insertion. Therefore, in patients with a the most common approach used in patients with rectal FB, and
high index of clinical suspicion for retained rectal FB associated 60% to 70% of FBs can be successfully removed transanally [14].
with anal eroticism or sexual gratification, physicians should be If the rectal FB can be palpated by digital examination, it may be
mindful of patient confidentiality. A nonjudgmental attitude and possible to remove it manually transanally or with instruments
respect for the patient’s privacy are imperative to establish and such as a Kelly clamp, Kocher clamp, and ring forceps. However,
maintain rapport with such a patient. Gaining patient trust is es- despite palpation of a rectal FB on digital rectal examination, FB
sential to obtain sensitive but valuable information pertaining to retrieval may be challenging depending on size, shape, and con-
retained rectal FB to enable prompt diagnosis and management. tour of the FB. Therefore, various extraction devices and methods
Patients with retained rectal FB usually present with anal or pel- have been reported, including an obstetric vacuum device, a Foley
vic pain, anal bleeding, constipation, and acute abdomen in cases catheter, Sengstaken-Blakemore probes, and electromagnets to
with infection or perforation [1-3, 11]. The incidence rate of per- extract metallic FBs [12, 15-18]. Regardless of the technique used,
foration is approximately 10% [5, 12]. Most patients attempt self- adequate relaxation of the anal sphincter prior to removal is im-
retrieval of FBs, which leads to delayed presentation and can portant for successful FB retrieval. Small low-lying FBs may be
cause perforation due to pressure necrosis or penetrating injury of removed manually without anesthesia; however, spinal or general
the rectosigmoid colon. The perforation rate observed in the pres- anesthesia is necessary in most cases. Anesthesia reduces anal
ent study was similar to the rates observed in previous studies, sphincter spasm and facilitates the use of an anal retractor for en-
and most patients were asymptomatic, presenting only with con- hanced visualization and exposure of the field, thereby improving
cerns associated with a retained rectal FB. the FB retrieval rate [2, 4, 18, 19]. Moreover, downward compres-
Accurate history collection provides important diagnostic clues sion of the lower abdomen to milk the FB for transanal extraction
in patients with retained rectal FB, and detailed physical examina- is easier in anesthetized patients. Excluding 2 patients who under-
tion including digital rectal examination and imaging is necessary went FB removal at the emergency department, all patients un-
for diagnostic confirmation even in the absence of an accurate derwent general anesthesia in the operating room. Kelly clamp
history [3, 4, 6]. Abdominal examination can detect perforation- was used to grasp the FB in all except the patient in whom a my-
induced peritonitis, and occasionally, a large high-lying FB may oma screw was used because the FB was a radish that could not
be palpated, as was observed in this case series. In patients with a be grasped easily using the Kelly clamp. Thus, from our experi-
high-lying FB, plain radiography is useful, particularly in those ence, colorectal surgeons should be familiar with a variety of ex-
with an uncertain history. Plain radiography enables visualization traction methods and be willing to improvise for transanal re-
of most rectal FBs to determine size, shape, and location [2, 6, 13]. trieval of rectal FBs.
However, radiolucent FBs such as fish bones, plastic objects, and Sigmoidoscopic retrieval using polypectomy snare or biopsy

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forceps may be useful for retrieval of small FBs that are more over >2 days, those that are >10 cm in size or sharp objects, and
proximally located in the rectum or in the distal sigmoid colon. those that have migrated into the sigmoid colon are considered
This procedure obviates the need for anesthesia to relax the anal predictors of surgical intervention [3]. In the case of fragile FBs
sphincter and facilitates visualization of the rectal mucosa and the such as drinking glasses (with the opening directed proximally),
FB [2, 11]. However, large FBs or those without an adequate negative pressure within the glass may produce a consequent suc-
grasping edge are not easily retrievable using only sigmoidoscopy. tion effect, drawing the mucosa into the opening. In such cases,
Thus, a novel transanal approach using a single-incision laparo- Foley catheters have been used to overcome the suction effect
scopic instrument, namely a SILS port, has been reported. Al- [22]. However, this technique may not be feasible when the open-
though this approach requires induction of general anesthesia, it ing of the glass is directed distally, as was observed in 2 patients in
enables easier retrieval of FBs than with sigmoidoscopy and can our series. Furthermore, mucosal edema around the opening may
be used in obscure cases that do not meet the indications for sig- impede transanal retrieval of the FB. Therefore, we consider a
moidoscopy or surgery [9]. glass FB to be a potential indication for laparotomy because ma-
Surgical extraction through laparotomy is indicated in patients nipulation during transanal extraction can cause breakage of the
with peritonitis; however, this approach is usually considered the glass in the rectum, precipitating further injury and/or serious
last resort after failure of transanal retrieval, primarily because of complications [8].
the morbidity associated with laparotomy [2, 11, 13]. Therefore, For transanal removal of FBs that are not sharp and/or fragile in
minimally invasive approaches, such as laparoscopic pushing and patients without complications, milking the FB distally into the
milking the FB distally followed by transanal extraction, have rectum can be attempted during laparotomy, before proceeding
been reported [20, 21]. Although these techniques may be at- with colotomy [2, 13]. If this method fails or if the FB is sharp
tempted prior to laparotomy, they require laparoscopic expertise and/or fragile, colotomy is necessary for FB removal. Primary re-
and can only be used in patients with smooth FB due to risk of pair without a diversion stoma can be performed in most such
perforation [2]. cases. However, in patients with complications such as perforation
In the present study, we could not determine the risk factors for with fecal peritonitis or necrosis, Hartmann’s operation or resec-
laparotomy due to the small sample size; however, FBs retained tion and primary anastomosis with or without stoma should be

Retained rectal foreign body

Peritonitis fragile or sharp object

Felt Not felt

DRE

Attempt manual extraction at ER Attempt sigmoidoscopic extraction

Failed Failed
Under anesthesia

Failed
Abdominal compression Laparoscopic or laparotomy and milking

Transanal extraction with

Kelly or other instuments

Failed

Laparotomy and colorectomy extraction with

primary repair or diversion vs. Hartmann procedure

Fig. 5. Management algorithm for retained rectal foreign bodies. DRE, digital rectal examination; ER, emergency room.

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 Annals of The Management of Retained Rectal Foreign Body
Coloproctology Ju Hun Kim, et al.

performed depending on patient hemodynamic stability, degree cause of the limited number of patients included in this study.
of contamination, and grade of rectal injury [23, 24]. Even though Other limitations include the short follow-up period, lack of
AAST-ROIS is usually applied in cases of blunt and penetrating postextraction anorectal functional and anatomical evaluation,
trauma, it may be used in patients with retained rectal FB. Nota- and patient refusal to undergo psychological consultation. Given
bly, most injuries secondary to retained rectal FBs are categorized that the incidence rate of retained rectal FB in Koreans appears to
as grade I or II, as observed in this case series [2]. be lower than that in Westerners, large-scale multicenter studies
Several therapeutic algorithms for retained rectal FBs have been are warranted to determine the characteristics of retained rectal
published [1, 3, 5-7]. Although their fundamental principles are FB in Koreans and to establish optimal therapeutic guidelines.
similar, these algorithms are rather complex for real-world clinical In conclusion, although retained rectal FB is an unusual presen-
application. Based on our experience, we developed a simplified tation, colorectal surgeons should be familiar with the various ex-
personalized therapeutic algorithm for patients with retained rec- traction methods. Moreover, it is important to establish rapport
tal FB (Fig. 5). with the patient through a proactive and nonjudgmental ap-
Sigmoidoscopy is usually recommended following rectal FB re- proach to encourage postextraction anorectal evaluation and psy-
moval to evaluate the anorectal mucosa and the extent of injury. chological consultation to minimize postextraction sequelae and
Although a few authors have advocated sigmoidoscopy as a man- psychological trauma.
datory procedure, it may not be obligatory because it may predis-
pose to complications, and close clinical observation is adequate CONFLICT OF INTEREST
for postextraction care [3, 7, 11, 18]. In our study, postextraction
sigmoidoscopy was performed in only one patient because most No potential conflict of interest relevant to this article was re-
refused further evaluation. Although evaluation of the anorectal ported.
mucosa and determination of the extent of injury are essential,
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