Transrectal excision of a foreign body lodged in the retrorectal space in a pediatric patient

Penetrating injuries to the gluteal and perineal regions are uncommon in pediatric patients, and involvement of the presacral (retrorectal) space is particularly rare. Due to its anatomically concealed nature and capacity to accommodate injury with minimal early symptoms, diagnosis and management can be challenging. There is no standardized approach for surgical access or consensus regarding the role of mechanical bowel preparation in cases involving transrectal intervention.

We report the case of an 11-year-old female who sustained a transgluteal impalement injury after accidentally sitting on a sharpened pencil, resulting in a retained fragment within the presacral space. Initial evaluation revealed a hemodynamically stable patient with minimal symptoms despite significant injury. Imaging demonstrated a fractured pencil with one segment lodged deep in the presacral space. A staged surgical approach was employed. The first procedure included examination under anesthesia, flexible sigmoidoscopy confirming an intact rectum, and removal of the externally accessible fragment. Following bowel preparation and continued antibiotic therapy, a second operation was performed using a transrectal approach with posterior rectal wall incision to retrieve the retained fragment. The rectal wall was repaired primarily. The patient had an uncomplicated postoperative course and complete recovery without evidence of infection or functional impairment.

This case highlights the diagnostic and management challenges of presacral foreign bodies in pediatric trauma. The transrectal approach provided direct access to a low-lying presacral object while avoiding more invasive abdominal or posterior approaches. Staging the intervention allowed confirmation of rectal integrity and optimization of surgical conditions with bowel preparation, potentially reducing infectious risk. Given the rarity of such injuries, management must be individualized, with careful consideration of anatomy, injury trajectory, and patient stability.

Transrectal retrieval of presacral foreign bodies is a safe and effective option in select pediatric cases with low-lying pathology and intact rectal wall. A staged approach incorporating initial assessment and delayed definitive management may optimize outcomes. This case underscores the importance of thorough evaluation of seemingly minor penetrating injuries and contributes to the limited literature guiding management of pediatric presacral trauma.