Although some foreign bodies can be removed in the ED, many require surgical intervention, particularly if they are made of glass or have sharp edges. If the foreign body is removed in the emergency department and is of a size or shape that could cause perforation, a follow-up proctoscopic examination and x-ray studies must be performed. In questionable cases, observations for at least 12 h should be done to ensure that perforation has not occurred. Rectal and anal lacerations may be present and require repair.

Sphincter relaxation is mandatory for removal of large foreign bodies. If the patient's sphincters are taut or otherwise not sufficiently relaxed, local infiltrative anesthesia must be administered to achieve proper relaxation. After the patient has been sedated and placed in the lithotomy position, local anesthetic is injected through a fine, 30-gauge needle to raise an intradermal wheal at the 6- and 12-o'clock positions. Ihe index finger of the physician's nondominant hand is then

inserted into the anal canal to act as a guide for a 1 2-in., larger-gauge needle through which anesthetic is injected circumferentially along the internal sphincter muscles as they course along the anal canal. Five milliliters of anesthetic should suffice for each quadrant of infiltration. Large bulbar objects create a vacuumlike effect in the rectal ampulla, making it difficult to retrieve the object by simple traction. Ihe vacuum can be overcome by passing a catheter beyond the object and injecting air. A modification of this technique is to insert Foley catheters around the foreign body and, after the vacuum is relieved by injecting air, inflate the balloons of the Foley catheters and use the catheters as traction devices to deliver the foreign body or manipulate it into a more accessible position.

If there is a risk of perforation or if excess manipulation (potential for bacteremia) will be needed to remove the foreign body, the patient should be prepared for emergency surgery, which includes obtaining appropriate laboratory studies, initiating intravenous therapy with crystalloid solution, and administering a loading dose of broad-spectrum (second-generation cephalosporin) antibiotics.

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