Sexual Abuse-or Mimic?

A 13-year-old boy and his father presented to an emergency department (ED) stating that something was lodged in the teen’s rectum. The father, who was the boy’s primary care giver, stated that the teen had spent the weekend with his mother and her boyfriend. After the teen arrived at his father’s home, he divulged that he had had something in his rectum for 3 hours or more. The father immediately alluded to concerns of abuse by the mother’s boyfriend.

The teen stated in his father’s presence that he had been showering and then slipped on something and fell. He reported that something had gone into his rectum when he fell. He thought it was a toothpaste dispenser. His story changed a few seconds later. This time he said that when he got out of the shower he inadvertently sat on a toothpaste dispenser that was on the toilet seat. The teen gave yet another account to the radiologist when x-rays films (Figure-click to enlarge) were being obtained and when his father was not present. That version of the story was equally unbelievable.

Multiple attempts to remove the object failed in the ED. Surgery was consulted.

As the hospital social workers began their investigation, the father recalled that his son had stated multiple times over the years that he did not want to go to his mother’s home. Child Protective Services was notified. 

Has this teen been abused, or is there another possible explanation?

Click here for answer and discussion.

Answer: This is not a case of sexual abuse: the foreign body was an attempt at self-stimulation.

The teen was taken to the operating room and a toothpaste dispenser was recovered from his rectum. After interviewing the parents, the mother’s boyfriend, and the teen, there were no red flags in their interviews. The story as relayed by the mother and boyfriend fit the timeline in the teen’s disclosure. The teen’s final statement was that this had been an attempt at self-stimulation. The case was closed as non-abuse. The teen was discharged to his mother’s home for convalescence.

A review article surveyed the world literature of anorectal trauma and autoeroticism.¹ One of the primary complications in a scenario like the one described in this case is perforation or pressure necrosis causing sigmoid perforation and its many ramifications. Anal stimulation is performed for sexual gratification in 60% to 78% of cases; however, up to 40% of those cases were related to sexual assault.¹ Of the cases reviewed, 99.1% were in males aged 16 to 80 years. In one study reviewed, only a third of the men who presented for medical care stated that they had inserted an anal foreign body. The other two-thirds of patients had only vague complaints of rectal or abdominal pain. 

As with most cases of abuse or mimics, a high index of suspension is necessary to make the diagnosis.

Reference:
1. Yacobi Y, Tsivian A, Sidi AA. Emergent and surgical interventions for injuries associated with eroticism: a review. J Trauma. 2007;62:1522-1530.