Not your typical pain in the butt

An 18 year-old female presents with rectal pain for one day. She states she was constipated for the past couple days and now has diarrhea. She started to experience painful stooling on the day of presentation. Stools are brown, loose in consistency, and non-bloody. She also complains of feeling pain when she sits but no burning on urination. She recently started her menses on the day of presentation and is experiencing vaginal bleeding and abdominal cramping.

She denies a previous history of diarrhea or constipation, bloody stools, fever, or vomiting. She denies weight loss or skin rash. She denies any rectal penetration with foreign bodies or anal intercourse. She denies rectal discharge.

 

Point-of-care tests: Negative UCG

On examination she is in no acute distress, lying comfortably in bed.

Abdomen: Soft non-tender, non-distended, no rebound or guarding

Rectal exam: Normal external exam without lesions, normal rectal tone, no visible or palpable hemorrhoids. Firm, smooth protruding mass in anterior/cephalad position approximately 3cm into rectum; no blood on digital exam.

Differential diagnosis: Anal fissure, hemorrhoids (internal or thrombosed), polyp, IBD with stricture, malignancy

 

Consider imaging? CT abd/pelvis? Anoscopy? GI consult for sigmoidoscopy?

But first….do a pelvic exam!

Pelvic exam – Normal external genitalia, no lesions. Speculum exam – visualized a pink firm conical structure. Normal appearing cervix. No CMT. No tenderness or masses on bimanual exam. No discharge, small amount of blood from os.

On further questioning, patient reports that she and her boyfriend were using a toy and she was unaware that something was left behind!! Pain is resolved after removal of foreign body!

 

Learning points:

Vaginal foreign bodies although generally uncommon, may present as rectal pain, and a pelvic exam would be recommended.

What are possible complications of a retained vaginal foreign body?

In reviewing the literature, cases of vaginal foreign bodies and complications are rare and discussed in case reports. Complications listed included infections, vaginal or rectal bleeding and discharge, as well as more severe cases describing obstructive uropathy and vesicovaginal fistulas. One case report also reviewed 76 full text articles on the subject and found 4 cases of obstructive uropathy and 44 cases of vesicovaginal fistula secondary to foreign body. Typical objects found included pessaries, plastic caps, and sexual toys. Most of the case reports involved surgical intervention for removal, while some were removed with fine forceps.

 

Our differential included hemorrhoids….What should we known about them?

Painful defecation is NOT associated with hemorrhoids (unless it is thrombosed) and is suggestive of an anorectal fissure, proctitis, perirectal fistula, abscess, solitary rectal ulcer syndrome, rectal cancer, or anal polyp.

Thrombosed Hemorrhoids:

  • Acute onset of perianal pain and a palpable perianal “lump” with tenderness and bluish discoloration at times; whereas non-thrombosed hemorrhoids tend to present with less or minimal tenderness and no palpable “mass” or lump
  • More common with external hemorrhoids as compared with internal hemorrhoids.
  • May be associated with excruciating pain as the overlying perianal skin is highly innervated and becomes distended and inflamed
  • Thrombosed internal hemorrhoids can also cause pain but to a lesser degree than external hemorrhoids; an exception is when internal hemorrhoids become prolapsed, strangulated, and develop gangrenous changes due to the associated lack of blood supply.

Is this a case of IBD?

  • Consider if patient has red flag symptoms such as weight loss, recurrent bouts of diarrhea/constipation/cramping, and/or bloody stools.

What about rectal pain during menses?

  • This can be a symptom of endometriosis
  • Rectovaginal or bowel involvement is estimated to be present in 5-12% of women with endometriosis
  • The rectosigmoid colon is the most common site of bowel endometriosis

If the patient were to have rectal discharge?

  • Consider rectal abscess or sexually transmitted infections such as chlamydia, gonorrhea, herpes.

What did we learn?

  • A female patient with rectal complaints may need a pelvic exam
  • Keep a broad differential….including foreign bodies!!

 

Written By Dr. Caitlin Feeks

 

References:

http://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm

http://www.cdc.gov/std/gonorrhea/default.htm

Up to date: rectal pain, vaginal foreign bodies, inflammatory bowel disease, hemorrhoids, endometriosis

Donaldson et al. Obstructive Uropathy and Vesicovaginal Fistula Secondary to a Retained Sex Toy in Vagina. The Journal of Sexual Medicine. Volume 11, Issue 10:2595-2600. 2014.

Shiryazdi et al. Rectorrhagia and Vaginal Discharge Caused by a Vaginal Foreign Body – Case Report and Review of Literature. Journal of Pediatric & Adolescent Gynecology. Vol 26. Issue 3:73-75. June 2013.

Treatment of hemorrhoids: A coloproctologist’s view. Varut Lohsiriwat. World J Gastroenterol. 2015 Aug 21:21 (31):9245-9252.

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JJaramillo

Emergency Medicine PGY-2

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