|Year : 2020 | Volume
| Issue : 2 | Page : 66-68
Self-inflicted urethral and vesical foreign bodies – Case report
Jayant Nikose, Mayank Agrawal, Venkat A Gite, Prakash Sankapal
Department of Urology, Grant Government Medical College and Sir JJ Hospital, Mumbai, Maharashtra, India
|Date of Submission||06-Aug-2020|
|Date of Acceptance||19-Oct-2020|
|Date of Web Publication||20-May-2021|
Dr. Venkat A Gite
Swastik Building No 4, House No 6 - Ist Floor, Grant Medical College and Sir JJ Hospital, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
Foreign bodies in the lower urinary tract are rare with self-infliction for sexual gratification as the commonest reason. Presenting complaints are lower urinary tract symptoms, abdominal pain, and haematuria. We report two cases of self-inflicted foreign bodies in the lower urinary tract of adult male patients; one by an electrical wire and another by Bengal grams. Bengal gram as the foreign body has never been reported previously. X-ray, ultrasound, and computed tomography of the KUB region help to confirm the diagnosis. The primary goals of treatment are safe removal of foreign bodies, avoiding iatrogenic injuries to the lower urinary tract, and preservation of the sexual function. Endoscopic management is the commonest procedure performed and described in such cases. We were able to manage both cases endoscopically. Psychiatric consultation and appropriate counselling should be given to prevent further repetitions of such acts in the future.
Keywords: Bengal gram, case report, electrical wire, foreign body, urethra, urinary bladder
|How to cite this article:|
Nikose J, Agrawal M, Gite VA, Sankapal P. Self-inflicted urethral and vesical foreign bodies – Case report. Arch Int Surg 2020;10:66-8
| Introduction|| |
Foreign bodies in the urethra and the urinary bladder are uncommon., Self-infliction for sexual gratification is the commonest reason.,,, Common presenting complaints are lower urinary tract symptoms, abdominal pain, and haematuria.,, Treatment is careful removal while avoiding trauma to the urethra and bladder.,
We report two such cases. In one of the cases, we found 'Bengal grams', which is unreported previously.
| Case Reports|| |
A 36-year-old male presented to the emergency department with complaints of abdominal pain, straining, thinning of the urinary stream, and dysuria for one day. One day ago, while masturbating, he inserted around seven to eight Bengal grams into his penis.
On examination, the bladder was not palpable. External genitalia and meatus were normal without visible foreign body. On palpation four non-tender, nodular swellings with irregular surface, each of size approximately one cm were palpable in the urethra. X-ray of Kidney Ureter and Bladder (KUB) did not reveal any radio-opaque shadow. Ultrasonography revealed multiple echogenic lesions with acoustic shadowing in the urethra. Consent was obtained for the emergency surgical intervention.
Under spinal anaesthesia cystourethroscopy revealed the presence of multiple (seven) swollen Bengal grams in the penile and bulbar urethra. The pressure of the irrigation fluid resulted in their proximal migration into the bladder [Figure 1]a. Cystoscopy grasping forceps were used and grams were removed intact. Due to friability few grams got broken which were removed successfully by giving bladder wash [Figure 1]b.
|Figure 1: (a) Cystoscopy view showing the presence of multiple swollen Bengal grams inside the urinary bladder. (b) Removed Bengal grams – intact and broken pieces|
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A 25-year-old male presented to the emergency department with only severe dysuria as the presenting complaint. Three days back while masturbating he had introduced an electrical wire of approximately ten cm in length into his penis and he failed to pull it out.
On examination, external genitalia and meatus were normal without visible or palpable foreign body. The bladder was not palpable. X-ray KUB showed a faint radio-opaque shadow of the foreign body [Figure 2]a. Three dimensional (3D) reconstructed images on non-contrast computerized tomography (NCCT) revealed a single curved wire of length 12 cm and 2.2 mm behind the pubic symphysis (bulbar urethra) mimicking broken DJ stent [Figure 2]b.
|Figure 2: (a) X-Ray-KUB showing the faint radio-opaque shadow of the foreign body with proximal coiled end in the bladder region (white arrow) and the distal end in the urethra (black arrow). (b) 3D-reconstructed image of the computed tomography showing single curved wire behind the pubic symphysis mimicking a broken DJ stent|
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Consent was obtained for the emergency surgical intervention. Under spinal anaesthesia on cystourethroscopy, there was evidence of single electrical wire (no knots) in the bulbar urethra extending into the bladder. Cystoscopy grasping forceps were used to deliver the wire out in one piece [Figure 3]a [Figure 3]b [Figure 3]c.
|Figure 3: (a) Cystoscopy view showing an electrical wire inside the urinary bladder. (b) Cystoscopy view – while grasping the copper end of the electrical wire using cystoscopy grasping forceps. (c) Wire after retrieval from the urinary bladder|
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In both the cases, on re-inspection, there were no remnant of foreign bodies or mucosal erosions. 14 Fr per urethral catheter was placed which was removed on the post-operative day one. Both patients voided well and were discharged. Both the cases had presented late fearing embarrassment. Although pre-operative psychiatric evaluation did not reveal any major underlying disorder nonetheless, both patients underwent psychiatric counselling in the post-operative period. At three months' follow up, there were no urinary or sexual complaints.
| Discussion|| |
The most common motive behind foreign bodies inside the lower urinary tract is sexual in nature. Other reasons are iatrogenic, accidental insertion, sexual assault, and migration from other organs.,,, In our study, both cases were self-inflicted for sexual gratification. Some of the reported foreign bodies inside the urethra and bladder are needles, pencils, pens, wires, pins, toothbrushes, batteries, kidney beans, thermometers, toys, tampons, pessaries, etc.,,,, However, there are no previously reported cases of Bengal gram.
The presentation in such cases is delayed due to guilt and embarrassment, as in our cases.,,,, Patients usually present with dysuria, lower abdominal pain, frequency, urgency, weak stream, acute urinary retention, incontinence, haematuria, or asymptomatic.,,,
Detailed history and examination give an idea about the number, shape, size, and location of the foreign body. X-ray and ultrasound of the KUB region help in the diagnosis.,, Radiolucent foreign bodies are better visualised on NCCT-KUB. In case two of our study, 3D reconstructed CT images gave us clear idea about the location and orientation of the foreign body.
The primary treatment goals are safe removal of foreign bodies, avoiding injuries to the lower urinary tract, and preservation of the sexual function., When the foreign body is visible through the external urethral meatus, one attempt of gentle traction may be applied to deliver them out but use of excessive force may lead to damage to the lower urinary tract., In both of our cases, foreign bodies were not visible through the external meatus so we resorted to the endoscopic technique. The commonest procedure described for foreign body removal is endoscopic retrieval which may require instruments like grasping forceps, stone baskets, and snares.,, Post retrieval of the foreign body out of the body, cystourethroscopy must be done to rule out associated injuries to the lower urinary tract and ensure complete removal of the foreign bodies. Other procedures like meatotomy, internal or external urethrotomy, or suprapubic cystostomy are needed in case of failure or difficulty during endoscopic procedure.,,
Complications may occur because of the long-standing foreign bodies like urinary tract infections, urethritis, stone formation, and urosepsis. Thus, perioperative broad-spectrum antibiotics must be used as inserted foreign objects are unsterile.,,, Iatrogenic injuries while removing or manipulating the foreign body can result in urethral tear and strictures.
There have been theories that have tried to highlight the underlying psychological reasons explaining such behaviours. According to Kenney's theory, the initiating event is the coincidentally discovered pleasurable stimulation of the urethra, followed by the repetition of this action with objects of unknown danger, driven by a psychological predisposition to sexual gratification. Thus, psychiatric consultation should be done, and appropriate treatment/counselling should be given to prevent further repetitions of such acts in the future.,,, In our study, both cases underwent appropriate psychiatric counselling.
| Conclusion|| |
Sexual gratification remains one of the commonest motives behind the foreign bodies in the lower urinary tract. We describe previously unreported Bengal gram as the self-inflicted foreign body inside the urethra and urinary bladder.
Endoscopic interventions can safely remove the small objects from the lower urinary tract. Appropriate psychiatric counselling must be provided to avoid the repetition of such acts in the future.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]