Rosen & Barkin's 5-Minute Emergency Medicine Consult (282 page)

• Ampicillin–sulbactam (Unasyn): 3g IV q6h (peds: 100–200 mg/kg/d div. q6h)
  
• Ceftriaxone (Rocephin): 1–2 g IV q12h (peds: 50–75 mg/kg IV daily)
  
• Ciprofloxacin (Cipro): 400 mg IV q8–12h
  
• Clindamycin: 600–900 mg (peds: 20–40 mg/kg/24h) IV q8h
  
• Levofloxacin (Levoquin): 500 mg IV q24h
  
• Metronidazole: 15 mg/kg IV once, then 7.5 mg/kg IV q6h
  
• Piperacillin–tazobactam (Zosyn): 3.75 g IV q6h or 4.5 g IV q8h (peds: 240–400 mg/kg/d div. q6–8h)
  

• Removal under general anesthesia for children who are too young to cooperate
  
• It is probably child abuse if FB other than enema tips or thermometer is present.
  

FOLLOW-UP

• Failed extraction in ED requires surgical removal in the operating room.
  
• Evidence of mucosal tear on proctoscopy should be observed for 24 hr (no antibiotic indicated).
  
• Symptom of rectal pain associated with removal of sharp FB indicates possibility of small perforation with developing abscess and requires exam under anesthesia.
  

• Reliable patient with atraumatic insertion and removal of rectal FB
  
• Instruct to return for rectal pain, abdominal pain, fever, or massive rectal bleeding.
  

GI or surgery consult if unable to remove FB in ED

Flexible sigmoidoscopy or rigid proctoscopy to evaluate for mucosal injury following retrieval of rectal FB regardless of method used is recommended.

• Passage of Foley catheter beyond object with insufflation of air breaks vacuum and permits retrieval.
  
• Provide adequate sedation/analgesia when attempting FB removal in the ED.
  

• Clarke DL, Buccimazza I, Anderson FA, et al. Colorectal foreign bodies.
  Colorectal Dis
  . 2005;7:98–103.
  
• Coskun A, Erkan N, Yakan S, et al. Management of rectal foreign bodies.
  World J Emerg Surg.
  2013;8:11.
  
• Hellinger MD. Anal trauma and foreign bodies.
  Surg Clin North Am
  . 2002;82:1253–1260.
  
• Rodriguez-Hermosa JI, Codina-Cazador A, Ruiz B, et al. Management of foreign bodies in the rectum.
  Colorectal Dis
  . 2007;9:543–548.
  
• Smith MT, Wong RK. Foreign bodies.
  Gastrointest Endosc Clin N Am
  . 2007;17:361–382.
  

See Also (Topic, Algorithm, Electronic Media Element)

Rectal Trauma

CODES

937 Foreign body in anus and rectum

BASICS

• Inadequate hygiene leads to scrotal skin maceration and excoriation:
  
  • Portal of entry for bacteria in tissue
    
• Once skin barrier is broken, polymicrobial flora spread along
  fascial planes
  of perineum.
  
• Colles fascia fuses with urogenital diaphragm, slowing propagation posteriorly and laterally.
  
• Anteriorly, Buck and Scarpa fascia are continuous, allowing rapid extension to anterior abdominal wall and laterally along fascia lata.
  
• Testes and urethra are usually spared.
  
• 3 anatomic origins account for most cases:
  
  • Lower urinary tract (40%): Urethral strictures, indwelling catheters
    
  • Penile or scrotal (30%): Condom catheters, hydradenitis, balanitis
    
  • Anorectal (30%): Fistulas, perirectal infections, hemorrhoids
    
• Rarely, intra-abdominal sources such as perforating appendicitis, diverticulitis, or pancreatitis have produced Fournier gangrene by dependent contiguous spread.
  

• Infection by polymicrobial flora (mixed aerobic and anaerobic organisms)
  
• Mixed bacteria exert synergistic tissue-destructive effect.
  
• End arterial thrombosis in subcutaneous tissues produces anaerobic environment.
  
• Bacterial toxins and tissue necrosis factors may contribute to clinical presentation.
  
• Risk factors:
  
  • Trauma
    
  • Diabetes
    
  • Alcoholism
    
  • Other immunocompromised states
    
  • Morbid obesity
    
  • Abdominal surgery
    

DIAGNOSIS

• Rapidly progressive necrotizing infection of
  perineum
  involving subcutaneous and fascial tissues and often muscle layers:
  
  • Usually seen in diabetics or immunocompromised patients
    
• Sources of infection may be flora from genitourinary, rectal, or penile/scrotal regions.
  

• Though unusual in children, >50 cases have been described.
  
• Most often are complications of burns, circumcision, balanitis, severe diaper rashes, or insect bites
  
• Organisms are more frequently
  Staphylococcus
  or
  Streptococcus.
  
• Pediatric patients have more local disease and are less toxic.
  

• Duration of symptoms:
  
  • Fevers or chills
    
  • Pain is out of proportion to exam in early phases, but eventually dead tissue becomes insensate.
    
  • Nausea and vomiting
    
  • Urinary infection symptoms
    
• Rapidity with which symptoms are progressing
  
• Identify if diabetic or immunocompromised
  
• Lethargy and inappropriate indifference to the illness are common.
  

• Patients are often toxic in appearance with nausea, vomiting, fever, chills, and pain.
  
• Careful exam of the genitalia and perirectal region
  
• Assess for skin findings:
  
  • Bronze or violaceous discoloration of skin
    
  • Thin brown watery discharge
    
  • Ulceration, bullous vesicles
    
  • Crepitance, SC air
    
  • Frank necrosis and eschar formation
    

• Fournier gangrene is a clinical diagnosis.
  
• History and physical exam with special attention to perineum
  
• Evaluate for signs of sepsis.
  
• Early surgical consultation for emergent débridement is essential.
  
• Other workup directed toward relevant comorbid factors such as diabetes or immunocompromised status
  

• Other than Gram stain of tissue and associated drainage, there are no specific lab tests that are diagnostic of Fournier gangrene.
  
• Urinalysis should be performed.
  
• Leukocytosis, anemia, electrolyte imbalances, acidosis, and renal failure are common.
  
• Disseminated intravascular coagulation (DIC) may be present; PT, PTT, fibrin-split products, and fibrinogen levels help identify.
  
• If patient is suspected of or known to have diabetes, glucose, electrolytes, and serum ketones to evaluate for diabetes and diabetic ketoacidosis (DKA)
  
• Culture of blood, urine, and tissue (when available)
  

• Plain films of the pelvis may reveal subcutaneous emphysema and ileus.
  
• CT scanning helps if intra-abdominal or ischiorectal source is suspected.
  
• US may be useful in differentiating from other causes of acute scrotum.
  

Retrograde urethrography, anoscopy, proctosigmoidoscopy, and barium enemas may be helpful to localize anatomic sources of infection.

• Epididymitis/orchitis
  
• Insect and human bites
  
• Perirectal infections
  
• Scrotal abscess/inguinal abscess
  
• Scrotal cellulitis
  
• Testicular torsion
  
• Tinea cruris
  

TREATMENT