Sexual Dysfunction -- Rectal Insertion of Foreign Bodies

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Chip — Yesterday at 06:12:46 PM

https://www.psychiatrist.com/pcc/rectal-insertion-foreign-bodies-motivations-complications-management

Ha, I thought this was both funny and sad ...

PSYCHIATRY / Sexual Dysfunction

Rectal Insertion of Foreign Bodies: Motivations, Complications, and Management

September 29, 2026

To the physician:

Have you ever felt a wave of discomfort, surprise, or even disbelief upon learning that a patient has inserted an object into their rectum? Have you wondered why they did it (eg, sexual curiosity, self-harm, or in response to psychosis)? Have you questioned whether your reactions might influence the care you provide? If so, you are not alone, and the following case vignette and discussion should prove useful.

CASE VIGNETTE

Mr R, a 34-year-old man with no prior psychiatric history, presented to the emergency department (ED) after reporting persistent rectal discomfort and difficulty defecating for approximately 12 hours. He initially attributed his symptoms to constipation, offering a vague and minimizing history.

After gentle, nonjudgmental questioning by the treating clinician, he disclosed that he had inserted a glass bottle during solo erotic activity and was unable to remove it. He reported no prior similar episodes, denied any psychiatric symptoms, and had not attempted self-removal. He denied abdominal pain, fever, nausea, or vomiting. He reported drinking alcohol earlier in the evening but denied other substance use. He was hemodynamically stable and in mild distress.

On physical examination, his abdomen was soft with mild lower abdominal discomfort on deep palpation and no peritoneal signs. Digital rectal examination confirmed the presence of a retained object. Plain abdominal radiographs (anteroposterior and lateral views) identified a smooth, radiopaque cylindrical object in the mid-rectum without evidence of free air or bowel obstruction.

DISCUSSION

What Is Rectal Foreign Body Insertion, and How Common Is It?
Rectal foreign body insertion refers to the intentional or accidental placement of objects into the rectum. Patients most often present when the object cannot be removed without assistance or when complications (eg, pain, rectal bleeding, or obstruction) arise. Rectal foreign bodies are encountered regularly in EDs, with the incidence increasing from 1.2 to 1.9 per 100,000 persons annually in the United States between 2012 and 2021.

Although historically considered to be rare, the rising incidence likely reflects both increased recognition and broader behavioral and social trends.

Anal erotic stimulation is the most common cause of retained rectal foreign bodies, followed by assaults, accidental insertions, ingestion of objects, psychiatric conditions, and drug trafficking.4 Epidemiologic reviews have consistently indicated that men account for most of the reported cases, with 77%–85% of cases occurring in men, with a male-to-female ratio that reaches as high as 37:1.

The age distribution of those who insert foreign bodies into their rectum is broad, but it demonstrates a bimodal pattern, with peaks in the second and fifth decades of life; data from US EDs reveal that the average age is approximately 43 years.

A wide variety of inserted objects has been reported, most commonly sexual devices (55.4% in 1 large US series), glass bottles, and other household items.

Approximately 40.8% of ED presentations required inpatient management.

The characteristics of these objects (eg, shape, fragility, and the potential to create a suction effect within the rectum) can significantly alter management and may complicate extraction. Glass objects, in particular, present distinct challenges to removal, as their smooth surface, fragility, and tendency to generate intrarectal suction increase the technical difficulty of removal and the risk of complications.

Certain populations (eg, those with psychiatric or behavioral conditions) are at higher risk of rectal insertions, with more than one-third (up to 37% of cases) having concurrent psychiatric illness, substance use, or intentional self-injury. Individuals in jails/prisons and those involved in drug trafficking may present due to their concealment practices, while older adults may insert objects for self-treatment of constipation or prostate stimulation.

Pediatric cases are rare; when they occur, these individuals should undergo careful assessments for assaults or abuse.

Importantly, the prevalence is almost certainly underestimated. Many patients delay seeking care due to embarrassment and attempt to remove objects from their rectum prior to presentation. When they arrive in the ED, their histories may initially be incomplete or misleading, with vague complaints (eg, abdominal pain, rectal bleeding).

How Should Patients Who Insert Foreign Bodies Into Their Rectum Be Assessed ?

The initial assessment should begin by stabilizing the situation and proceeding with caution. Clinicians should determine whether the patient is hemodynamically stable and whether there are signs of perforation, peritonitis, or sepsis. Hemodynamic instability or signs of perforation are absolute contraindications to bedside extraction, and such individuals require an emergent surgical evaluation. Table 1 consolidates the key domains of assessment.

In patients who are clinically stable, the early evaluation should clarify what was inserted, when it was inserted, whether attempts at self-removal were made, whether the object is fragile or sharp, and whether the patient has developed complications (eg, pain, bleeding, constipation, obstipation, fever, or incontinence). Because shame often delays presentation to an ED, clinicians should expect that the history initially provided may be incomplete or misleading. In some cases, patients present with vague abdominal or rectal complaints without disclosing that they have a retained object in their rectum until later in the encounter.

Physical examination should include an abdominal examination, a digital rectal examination, and proctoscopy when feasible. Imaging is also central to safe management. Plain abdominal radiographs should include lateral and anteroposterior views of the chest, abdomen, and pelvis to identify the foreign body’s position; its shape, size, and location; and the possible presence of a pneumoperitoneum^Wiki.

Computed tomography^Wiki scans can help to establish the object’s size, shape, location, and orientation and assess for free air or other complications. Objects that have migrated proximally, especially above the rectosigmoid junction, are less likely to be removed successfully at the bedside and will more likely require endoscopic or operative management.

After stabilization and imaging, the next step in management includes transanal or operative techniques of removal, as indicated. For low-lying objects in stable patients, transanal extraction may be attempted in the ED or in an operating room. Techniques used to remove foreign bodies include digital extraction, rigid proctoscopy, flexible sigmoidoscopy^Wiki, endoscopic snares^Wiki, and Foley catheter–assisted removal to relieve suction. No single transanal extraction technique has proven superior to others.

Adequate anesthesia (local, regional, or general) improves success by facilitating sphincter relaxation.

Objects that are located more proximally often require endoscopic retrieval or operative management. Overall, transanal extraction is successful in approximately 60%–75% of cases, while operative intervention is required when bedside extraction or endoscopic removal fails or when complications arise. Hemodynamically^Wiki unstable patients require an emergent laparotomy^Wiki with damage control surgery.

When bowel resection is necessary, Hartmann’s procedure (resection of the rectosigmoid colon with creation of an end colostomy and closure of the rectal stump) may be performed. Reversal is not always feasible, and some patients require a permanent stoma.

Special caution is required when drug concealment is suspected. In such cases, maneuvers that could rupture a drug-filled packet may precipitate life-threatening toxicity, and standard extraction strategies may be inappropriate. In cases of suspected drug concealment, management is typically conservative, with close monitoring and avoidance of manipulation, reserving interventions for obstruction, rupture, or toxicity.

How Can Clinicians Learn About the Motivation for Rectal Foreign Body Insertion ?

The differential diagnosis for rectal foreign body insertion is broad, and clinicians should resist coming to closure prematurely. The most common driver for foreign body insertion is sexual stimulation, which may reflect nonpathologic autoerotic emotion or, in some cases, a paraphilic disorder.

In general, paraphilic disorders are distinguishable from nonpathologic sexual behavior by the presence of “clinically significant distress or impairment in social, occupational, or other areas of functioning” for at least 6 months.

However, even in cases of nonpathologic behavior, clinicians should not assume that foreign body insertion is solely about orgasm or sexual gratification. Even when behavior is sexual, its meaning may extend beyond simple gratification. The act may also serve functions that are related to novelty-seeking, compulsivity, emotional regulation, or symbolic meanings that are not readily apparent from the history alone.

Other motivations described include psychotic disorders, in which insertion may occur in response to delusions or command hallucinations; nonsuicidal self-injury, particularly in individuals with borderline personality disorder (BPD) or other conditions that are characterized by severe emotional dysregulation; developmental or cognitive disorders that impair judgment or risk awareness; factitious disorders or malingering; curiosity or experimentation; and self-treatment (eg, attempts to relieve constipation or stimulate the prostate for sexual gratification).

Clinicians should focus on the function and context of behavior. Therefore, assessment should cover what was inserted, as well as the circumstances, intent, and perceived function of the behavior (eg, whether it was erotic, impulsive, intoxication-related, emotionally regulatory, psychotically driven, attention-seeking, or performed for external gain). This approach is especially important in recurrent or high-risk cases, where the behavior may reflect more than experimentation, as the assessment should guide risk assessment and management.

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