A unique challenge overcome: Clay foreign body extracted from the bladder endoscopically; A case report

Abstract

Introduction

Urethral foreign bodies are uncommon clinical entities typically associated with psychiatric disorders or self-erotic stimulation. They present unique challenges, especially when involving malleable materials.

Case presentation

A 26-year-old male presented with urinary retention and brown urethral discharge after inserting an 8 cm clay-like foreign body. Cystoscopy revealed migration to the bladder. Initial bedside flexible cystoscopy under local anesthesia removed 40 % of the material using a 4.5 mm basket. Complete extraction was achieved in the operating room using a 17 Fr rigid cystoscope under general anesthesia. The patient received prophylactic antibiotics and was discharged uneventfully with oral antibiotics and analgesics.

Discussion

Management of urethral foreign bodies requires consideration of object composition and location. In this case, the malleable clay-like material presented unique challenges but was successfully managed using endoscopic fragmentation techniques. This avoided more invasive open surgical intervention while effectively addressing the clinical presentation. Literature documents various foreign objects in the urethra, but clay-like materials are less commonly reported and present specific challenges due to their malleable nature and fragmentation potential.

Conclusion

Prompt endoscopic intervention can successfully manage even challenging cases of migrated urethral foreign bodies. A multidisciplinary approach addressing both physical and psychological aspects is essential for comprehensive care and prevention of recurrence.

Highlights

• •Rare case of malleable clay-like material migration from urethra to bladder presenting unique challenges.
• •Novel application of 4.5 mm basket for fragmentation of malleable material migrated to bladder.
• •Stepped approach combining bedside flexible cystoscopy followed by OR rigid cystoscopy.
• •Complete removal achieved without open surgical intervention despite material's challenging properties.
• •Case demonstrates importance of prompt minimally invasive management to prevent complications.

1. Introduction

Urethral foreign bodies are a rare clinical occurrence that present notable diagnostic and therapeutic challenges [1]. Such foreign objects are often introduced for various reasons, including psychiatric disorders, age-related factors, intoxication, or self-erotic stimulation [1,2]. Patients frequently delay seeking medical attention due to embarrassment or social stigma associated with the condition [1,2]. The clinical presentation typically includes dysuria, urinary frequency, hematuria, suprapubic pain, swelling of the external genitalia, and potential complications such as extravasation or abscess formation [[1], [2], [3]]. Diagnosis is primarily based on detailed patient history and clinical examination, with radiological imaging and cystoscopy serving as essential tools for confirmation and management planning [1,2].

This case report aims to detail a rare presentation of urethral foreign body insertion, describe the clinical course, and outline the management strategy that led to successful resolution.

2. Methods

This case report has been reported in line with the SCARE (Surgical CAse REport) criteria [4]. Patient consent was obtained for publication of this case report. Clinical data were collected from medical records, and the case was managed according to standard institutional protocols for urethral foreign body management.

3. Case presentation

We report the case of a 26-year-old single Saudi male with an unremarkable medical history. His surgical history is significant for bariatric surgery performed four years prior to presentation. He denies any history of substance abuse. The patient presented to the Emergency Department with complaints of inability to urinate. Two days prior to presentation, he reported experiencing urethral itching and subsequently attempted to insert a clay-like foreign body measuring approximately 8 cm into his urethra. He was unable to retrieve the object following insertion.

Additionally, the patient reported a brown-colored urethral discharge and mild urethral discomfort. On the day of presentation, he complained of odynophagia but denied experiencing fever, chills, rigors, or dysuria.

Upon examination of this Saudi patient with a BMI of 29, vital signs were found to be stable. Abdominal assessment revealed a distended bladder with mild tenderness, while focused urological examination elicited minimal bluish urethral discharge upon compression, with no skin changes or tenderness noted in the surrounding area.

Laboratory investigations ordered by the emergency department team revealed no pathological findings in the complete blood count, renal function tests, or coagulation parameters. No imaging studies were performed at this time. Given the patient's clinical history and presentation, the decision was made to proceed with flexible cystoscopy under local anesthesia for further diagnostic evaluation.

The patient underwent a bedside flexible cystoscopy, which revealed a normal urethra, bladder neck, and bladder walls, along with normal bilateral ureteric orifices (Fig. 1).

Fig. 1.

Normal anterior urethra.

A large clay-like foreign body was identified filling most of the bladder. Utilizing a 4.5 mm basket, approximately 40 % of the foreign body was fragmented and removed. However, the patient was unable to tolerate this procedure. The decision was made to take the patient to the operating room as an emergency for cystoscopy under general anesthesia, where a 17 Fr 30-degree cystoscope was used to successfully remove the remaining fragments of the foreign body (Fig. 2A and B). A 16 Fr Foley catheter was placed after the procedure, and no complications occurred during the intervention. The Foley catheter was maintained for two hours postoperatively and subsequently removed prior to patient discharge.

Fig. 2.

Clay-like foreign body after endoscopic removal. 2A: Multiple fragments of the bluish-green clay-like foreign body after endoscopic removal. 2B: The retrieved bluish-green clay-like material (approximately 8 cm in length) placed on sterile gauze next to a 10 ml syringe for size reference.

Throughout the hospitalization, the patient received prophylactic intravenous antibiotics prior to the procedure. The cystoscopy was performed successfully without any complications, and the patient tolerated the intervention well. Both the intraoperative and postoperative periods were uneventful. On the first postoperative day, the patient showed satisfactory recovery with stable vital signs and was voiding freely after Foley catheter removal. He was discharged home on oral antibiotics and analgesics for pain management. At discharge, a psychiatric consultation referral was provided for continued outpatient follow-up and comprehensive care management.

4. Discussion

Foreign bodies in the urethra, though relatively rare, present significant diagnostic and therapeutic challenges. The majority of cases are associated with psychiatric disorders, self-erotic stimulation, senility, or intoxication [1]. This case of a 26-year-old male who inserted a clay-like foreign body represents a common etiology of urethral foreign body insertion for self-stimulation.

The clinical presentation of urethral foreign bodies typically includes hematuria, dysuria, urinary frequency, and urinary retention [[1], [2], [3],[5], [6], [7], [8]], consistent with our patient's presentation of weak urinary flow, urinary retention, bladder distention, and urethral discharge. The absence of fever in our patient was fortunate, suggesting that infection had not yet developed despite the presence of the foreign body for two days.

Diagnosis of urethral foreign bodies often relies on imaging techniques, as clinical examination alone may be insufficient [9]. In our case, cystoscopy provided both diagnostic confirmation and therapeutic intervention, revealing the clay-like foreign body throughout most of the bladder.

The literature documents a wide variety of objects found in the urethra, including pins, electrical wires, screws, seeds of olives, and ballpoint pens [[1], [2], [3],[5], [6], [7], [8]]. Clay-like foreign bodies, as in our case, are less commonly reported but present unique challenges due to their malleable nature and potential to fragment.

Treatment approaches for urethral foreign bodies typically involve endoscopic or surgical intervention. Endoscopic removal is generally preferred for smaller items [[10], [11], [12], [13]], while surgical exploration may be necessary for larger or irregularly shaped objects [11,12]. In our patient, endoscopic fragmentation using a 4.5 mm basket allowed for complete removal of the clay-like material without the need for more invasive surgical intervention.

Prophylactic antibiotics are a standard component of management to prevent urinary tract infections, as employed in our case with intravenous cefazolin and ceftriaxone followed by oral cefuroxime upon discharge.

When considering the psychological aspects of foreign body insertion, psychiatric evaluation is recommended, particularly in recurrent cases [14]. Although our patient had no documented psychiatric history, the nature of this self-inflicted injury suggests that psychological assessment and counseling might be beneficial to address any underlying issues and prevent recurrence.

5. Conclusion

This case highlights the importance of prompt intervention in managing urethral foreign bodies to prevent complications such as infection, urethral injury, or bladder perforation. The successful endoscopic management demonstrates that minimally invasive approaches can be effective even for challenging cases involving malleable materials that have migrated to the bladder. Multidisciplinary care, including urologists and mental health professionals, is crucial to address underlying causes and prevent recurrence.

CRediT authorship contribution statement

We certify that all authors,

• •Have made substantial contributions to the conception and design, acquisition of data, and analysis and interpretation of data.
• •Been involved in drafting the manuscript or revising it critically for important intellectual content.
• •Given final approval of the version to be published.
• •Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.

Consent to participate

Written informed consent was obtained from the patient for publication and any accompanying images.

Guarantor

Dr. Basmah Al Ghanim

Ethical consideration

Ethical approval is not required at our institution to publish an anonymous case report.

Funding

None.

Declaration of competing interest

The authors declare that they have no conflict of interest regarding the publication of this case report.