Bailing out the bowel and bladder - A rare case report of rectal impalement injury with iatrogenic bladder rupture.

Introduction And Importance: Rectal perforations due to foreign body impalement are infrequently encountered in practice. Accidental or intentional foreign body insertions pose a diagnostic challenge to surgeons and put them in demanding circumstances for successful extraction.

Case Presentation: We report a case of a 60-year-old male with alleged history of accidental foreign body insertion into the rectum. Radiographs showed a linear metallic foreign body with crooked end. Computed Tomography (CT) with rectal contrast revealed contrast extravasation indicating anterior wall perforation of upper rectum. Patient was taken urgently for exploration and foreign body removal. Intra-operatively, bladder was injured inadvertently. Primary repair of enterotomy and loop sigmoid-ostomy was done besides bladder repair. Patient tested positive for COVID-19. Patient was observed in critical care unit for two days. Post-operative period was unremarkable apart from midline abdominal wound gape for which secondary closure was done. Patient was discharged with urinary catheter in-situ. Patient followed-up with a normal cystourethrogram and a well-functioning stoma. Stoma closure after two months was uneventful.

Clinical Discussion: A thorough history and clinical examination is required and one should raise a high index of suspicion of perforation in patients with rectal foreign bodies, which should be managed appropriately and promptly to prevent sepsis and multi-organ dysfunction. Inadvertent bladder injuries are common with lower-midline incisions. However, give good results when repaired suitably.

Conclusion: The rationale behind this report is to explicate the complexity and hurdles in the surgical management of rectal foreign bodies causing impalement injury.