A rare and unusual case of urethral bleeding

Abstract

A 46-year-old man presented with urethral trauma following the unusual sexual practice of urethral sounding. He was able to urinate freely and was treated conservatively. He did not require any follow-up. Urethral sounding is uncommon sexual practice, where commonly a metal object is inserted per urethra for gratification. This practice is actively discouraged because of the long-term risks from urethral trauma.

Background

This case highlights a very unusual cause of urethral bleeding and is very rarely encountered, and not, in recent memory, at this teaching hospital urology department.

Although the literature has highlighted the clinical challenges of inserted objects through the urethra and the clinical challenges of removal, this case brings to the forefront a lifestyle choice that has considerable and significant urological morbidity. A significant proportion of people use this practice. It is also a very poorly researched area, with only a handful of relevant literature.

Case presentation

A 46-year-old man presented to the emergency department of urology with urethral bleeding. On questioning, the bleeding was found to be the direct result of the sexual practice of urethral sounding. He was able to pass water freely and a pelvic x-ray did not reveal any retained metal products in his bladder or urethra. There was no indication for catheterisation to tamponade any urethral bleeding and so he was treated conservatively. He was actively discouraged from continuing this practice. A week later, he said that bleeding had completely stopped a few days earlier and that he was asymptomatic. It was decided that there was no need to follow-up the patient with any further investigations such as flexible cystoscopy.

Outcome and follow-up

There was no indication for catheterisation to tamponade any urethral bleeding and so the patient was treated conservatively. He was actively discouraged from continuing the sexual practice of urethral sounding. A week later, he said that bleeding had stopped a few days earlier. It was decided that he did not need any follow-up such as flexible cystoscopy.

Discussion

Urethral dilatation with metal dilators is a very common urological procedure; however, it is performed in a controlled setting with the options of cystoscopy and emergency urethral catheterisation available. Intermittent self-dilatation with a catheter is also a commonly used technique to manage complex urethral strictures.

Urethral sounding, however, is the sexual practice of inserting metal objects into the urethra for gratification. The metal instruments, which are typically commercially bought surgical urethral dilators, can be inserted to just past the glans or to just distal to the prostate. It is a relatively uncommon sexual practice. In a recent study with over 2000 men who have sex with men, around 10% confirmed they used this technique.¹ In another internet study on the sexual practices of over 400 men with genital piercings, urethral sound was the most commonly inserted object into the urethra.² It is also interesting to note that there is conflicting evidence on the demographics of urethral sounding practitioners: the Breyer study¹ concentrated exclusively on men who have sex with men, but the Rinard study² focused on heterosexual, relatively affluent, white men. No statistics have been reported for female urethral sounding.

Breyer and Shindel¹ found an increased incidence of lower urinary tract symptoms in their study; they scored higher in the International Prostate Symptom Score compared to the non-sounding group (7.3 vs 6.5, p = 0.03), but unfortunately they do not elaborate on whether they found irritative or storage symptoms. This is certainly possible as the result of urethral trauma, which is exacerbated by the continuation of this sexual practice. Repeated sounding, which is akin to intermittent catheterisation, can lead to long-term sequelae such as urethral stricturing and false passages in the urethra.³

Evidence suggests that men who perform urethral sounding are 70% more likely to suffer from a urinary or sexual infection.¹ The study also found statistically significant higher incidences of HIV, chlamydia, herpes and gonorrhoea in these men.

Urethral sounding in the hands of a non-medical person is an inherently dangerous technique. Unfortunately and possibly because of the taboo nature of this uncommon sexual technique, little research has been done on this issue. No long-term studies have been reported on the urological sequelae of these patients. We would advise that these patients should be actively discouraged from continuing this practice.

Learning points.

• Urethral sounding is a very uncommon presentation of urethral trauma. It is probably an underreported sexual practice due to its taboo nature.

• One study has suggested a 70% greater risk of this group of urinary or sexual infection.

• It is associated with urethral trauma, which can lead to infection, stricturing and false passages.

• If encountered in clinical practice, patients should be actively discouraged from this practice.