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A 69-year-old married gentleman was referred to the surgical on-call team by his general medical practitioner with a rather embarrassing problem.

The patient had suffered from a long history of haemorrhoids with bouts of pruritus ani. That evening the symptoms were so severe that simple scratching with his fingers did not provide adequate relief. It was while he was in the bathroom he had the idea of using his toothbrush to augment his action. Unfortunately, he claims the toothbrush slipped and entered his rectum. Neither he, nor his general practitioner were able to rescue the item. It was decided it would need surgical removal.

The patient's medical history was unremarkable except for a history of diverticular disease which had been confirmed on barium enema studies and constipation. He had had a laparotomy for a perforated stomach ulcer 20 years ago.

The medication he was prescribed was a H2 antagonist for peptic ulcer disease, an anti-spasmodic for his abdominal symptoms and laxatives for chronic constipation.

He did not admit to any past psychiatric or psychosexual problems.

He was a married man with two children, non-smoker and only occasionally drank alcohol.

On examination, the patient appeared anxious but blood pressure, pulse, respiratory rate and temperature were within normal range. His abdomen was soft and not tender on palpation. On inspection of his anus external piles were seen but no foreign body was evident on digital rectal examination. However plain abdominal radiographs were undertaken and a foreign body was located (Figures 1 and 2).

Figure 1: An anteroposterior radiograph of the pelvis showing the foreign body in the rectum.
figure 1

Note the radioopaque bristles of the toothbrush

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Figure 2
figure 2

A lateral radiograph of the pelvis

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The patient subsequently underwent a rigid sigmoidoscopy without anaesthetic. After much difficulty the toothbrush was recovered from the rectosigmoid junction using biopsy forceps. After a period of observation the rigid sigmoidoscopy was repeated to see if there was any evidence of perforation or bleeding. This was unremarkable and he was discharged to his general medical practitioner for a more conventional management of his haemorrhoids.

Discussion

There have been many publications in the literature on rectal foreign bodies.1,2,3,4 This is the first reported case of a toothbrush being used by a patient in the treatment of pruritus ani and subsequently lost into the rectum. There is only one previous report in the literature of a toothbrush being inserted into the rectum and the circumstances surrounding its presence were not mentioned.5 Other dentally related objects include a toothbrush holder,6 toothbrush package7and a part of a toothpick.3

The main reasons given for the presence of foreign bodies include pruritus ani,3 accidental insertion,3alleged assault,8,9 drug smuggling,3 iatrogenic (eg migration of colonic stents)10 and psychosexual motives.1,11 Dentally related objects may be used because of the shape and availability as commonly these activities occur in the bathroom.

Many different objects have been noted in the literature varying from bottles,1,4,5 vibrators,6 fruits6 and vegetables,8 tools,12 and miscellaneous items eg lightbulbs,13 candles,14 balls,15 and flashlights.16

The age of patients ranges from young to middle-aged.1,3 Men are more likely to present than women.3 Women are more likely to have vaginal foreign bodies.13 The complications of insertion of these materials include rectal bleeding, mucosal lacerations, anorectal pain, bowel perforations, abscesses and rarely death.13 The management of these cases varies from simple manual retrieval with or without general anaesthetic or using a sigmoidoscope, foley catheters17 or even cyanoacralate adhesive attached to the object to aid removal.18 Laparotomy may need to be performed depending on the object's size, shape, composition and position.