Description

A patient with chronic pain on methadone presented with difficulty passing stools and left lower abdominal discomfort for 7 days. His medical history was unremarkable. Abdominal examination demonstrated mild tenderness in the left lower quadrant. A routine rectal examination revealed a mobile object with a blunted end without blood on the examining glove. Blood work showed a normal complete blood count. Abdominal radiograph identified a rectal object. Endoscopy showed a pink-coloured rounded object with a smooth surface at 10 cm from the anal verge nearly obstructing the lumen without mucosal lacerations or other complications (figure 1A). A loop snare was used to remove the rectal object which measured 8×3 cm and was tapered at one end (figure 1B). The pink wrapping was cut open, revealing a plastic bottle, which was emptied yielding a clear yellow liquid (figure 1C). On further questioning, the patient revealed that he had filled an eye drop container with a friend's ‘clean’ urine, wrapped it inside a condom, and voluntarily inserted it into his rectum to maintain the urine at body temperature for later retrieval at a methadone dispensing centre in order to evade regular screening of recreational drug use.

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Figure 1

Rectal foreign body (A) on endoscopy at 5 cm from the anal verge, (B) being removed with a loop snare, and (C) yielding a yellow-coloured liquid on emptying.

Our patient's rectal foreign body presentation is characteristic: young male; delay in disease presentation after failed self-removal; and reluctance for full disclosure.1 Physicians require a high index of suspicion when evaluating patients for bowel obstruction, rectal bleeding, peritonitis and drug toxicity; order radiographic imaging to localise and size the object; and consider endoscopic visualisation.1 Extraction techniques include trans anal manual removal; endoscopic extraction with snares, forceps, catheters and balloons; and laporatomy with repair of complications.2 ,3 Using the rectum to maintain ‘clean’ urine at body temperature for drug screen evasion has not been previously described, adding to drug smuggling, sexual gratification and involuntary acts as causes of rectal foreign bodies.1