Laparoscopic management of a rectal foreign body complicated by rectovaginal fistula and pelvic abscess

Abstract

Rectal foreign bodies (RFBs) are relatively rare clinical occurrences; however, patient concealment of essential medical information may result in diagnostic delays and complicate subsequent retrieval procedures. This case report describes a 23-year-old female patient whose delayed presentation, attributed to embarrassment and shame, resulted in the development of a rectovaginal fistula, further complicated by pelvic and abdominal wall abscess formation. Given the deeply embedded nature of the foreign body and the severity of the associated complications, laparoscopic posterior colpotomy was performed, leading to successful removal. Postoperative follow-up demonstrated complete resolution of inflammatory symptoms and satisfactory healing of the incision site for the left lower abdominal abscess. In cases where RFBs are associated with severe complications or where essential clinical information is unavailable, laparoscopic surgery may represent a safe and effective alternative in selected cases.

Introduction

Rectal foreign bodies (RFBs) are uncommon but potentially serious clinical conditions that may lead to mucosal injury, sphincter damage, perforation, or intestinal obstruction. They are most frequently associated with sexual activity, accidental insertion, or ingestion [1, 2]. A wide variety of objects has been reported, including fruits, plastic bottles, medication packaging, and batteries [3]. The clinical presentation ranges from mild discomfort to life-threatening sepsis, depending on the duration of retention and the nature of the object.

Diagnosis relies on careful history-taking and physical examination. However, patients often withhold information due to embarrassment, resulting in delayed diagnosis and increased complication rates. Digital rectal examination and anoscopy assist in determining the location and accessibility of the foreign body. When complications are suspected, laboratory testing and imaging studies are essential to evaluate perforation, abscess formation, and the relationship between the foreign body and adjacent pelvic organs [4].

Transanal extraction is the first-line treatment for stable patients without perforation. Surgical intervention is indicated when transanal removal fails or when perforation, ischemia, or peritonitis is present [5]. We report a young female patient with prolonged retention of a medicine bottle cap complicated by rectovaginal fistula and pelvic–abdominal wall abscesses, successfully managed using a laparoscopic approach.

Case presentation

A 23-year-old nulligravida woman presented with a left lower abdominal mass, intermittent abdominal pain, and fever of 1 week’s duration. Physical examination revealed a tender palpable mass in the left lower quadrant. Due to embarrassment and privacy concerns, the patient initially withheld detailed information regarding the retained object. Digital rectal examination identified a hollow plastic object ~5–6 cm from the anal verge with limited mobility, and safe transanal extraction was considered unlikely. Gynecological examination revealed significant vaginal narrowing that restricted adequate visualization.

Pelvic radiography demonstrated an object within the pelvic cavity (Fig. 1A). Computed tomography (CT) revealed a 3 × 4 cm square-shaped object located between the rectum and uterus, associated with a rectal wall defect measuring ~1 cm and irregular pelvic and abdominal wall abscess formation (Fig. 1B). Magnetic resonance imaging (MRI) further demonstrated the foreign body within the rectovaginal space and confirmed subcutaneous extension of infection into the left abdominal wall (Fig. 1C and D).

Laboratory evaluation revealed marked leukocytosis, with a white blood cell count of 23.06 × 10⁹/l (reference range: 3.5–9.5 × 10⁹/l). The absolute neutrophil count was 20.91 × 10⁹/l (reference range: 1.8–6.3 × 10⁹/l). Other laboratory parameters, including hemoglobin level, platelet count, coagulation profile, and serum electrolytes, were within normal reference ranges.

Under general anesthesia in the lithotomy position, anal dilation confirmed a bottle cap–shaped plastic object embedded in the anterior rectal wall with associated perforation. Transanal fragmentation was attempted; however, the rigid and sharp edges of the object posed a high risk of further tissue injury, and the procedure was converted to laparoscopic exploration.

Laparoscopic exploration revealed that the infectious focus within the pelvis and abdominal wall was encapsulated by the greater omentum and adjacent tissues on the left side of the pelvis. The foreign body was observed protruding through the posterior vaginal fornix into the pelvic cavity (Fig. 2A). Adhesiolysis between the greater omentum, the abdominal wall, and adjacent pelvic structures was carefully performed using an ultrasonic scalpel. A controlled incision was made at the site of protrusion along the posterior vaginal fornix, through which the foreign body was successfully retrieved (Fig. 2B). The foreign body was then placed into a retrieval bag and extracted through the sigmoid colostomy site. The vaginal incision was thoroughly irrigated with antiseptic solution and closed with inverted sutures (Fig. 2C). Subsequently, the sigmoid colon was exteriorized, and a loop sigmoid colostomy was created in the left lower abdomen through the rectus abdominis muscle. The left lower abdominal abscess was incised, and ~400 ml of grayish-white purulent fluid was drained. Exploration confirmed a large abscess cavity, and a counter-incision was created to facilitate dependent drainage (Fig. 2D).

The patient recovered without intraoperative or postoperative complications. At 1-month follow-up, inflammatory signs had completely resolved, the abdominal incision demonstrated satisfactory healing, and digital rectal examination confirmed closure of the rectovaginal fistula.

Discussion

Delayed presentation due to embarrassment is a well-recognized challenge in the management of RFBs and significantly increases the risk of complications. In this patient, prolonged retention and the rigid edge of the bottle cap likely caused continuous pressure on the rectal wall, resulting in ischemia, tissue necrosis, and perforation. The subsequent formation of a rectovaginal fistula allowed contamination of the pelvic cavity, leading to secondary abscess formation. Similar mechanisms have been described in previous reports [5].

Imaging played a critical role in surgical planning. CT and MRI clearly delineated the size, location, and extent of infection, as well as the involvement of adjacent structures. In complex cases, detailed imaging reduces uncertainty and assists in determining whether transanal extraction is safe. Delayed intervention may result in severe complications, including septic shock [6], underscoring the importance of timely management.

Although ~80% of RFBs can be successfully removed transanally [7], surgical intervention becomes necessary in the presence of perforation, fistula formation, extensive infection, or unclear foreign body characteristics. In the present case, penetration of the rectovaginal septum, vaginal stenosis, and multifocal abscesses made transanal removal hazardous and potentially incomplete. Laparoscopic surgery provided direct visualization, enabled controlled removal through posterior colpotomy, allowed thorough drainage of infected collections, and minimized additional trauma. Furthermore, fecal diversion reduced the risk of ongoing contamination and promoted fistula healing.

Although transanal extraction remains the standard management for most RFBs, laparoscopic surgery may offer greater safety in selected complex cases, particularly when severe complications are present or when essential clinical information is unavailable. Careful preoperative assessment and individualized surgical planning are essential to optimize patient outcomes.

Conclusion

The management of RFBs requires individualized assessment. In cases with severe complications or incomplete clinical information, laparoscopic surgery may offer a safe and effective alternative. Early recognition and proper surgical planning are key to optimizing outcomes.

Conflicts of interest

None declared.

Funding

None declared.

References