Unusual foreign body in the vesico-urethral; 195 cm liquid pipe

Abstract

Insertion of foreign bodies into the genitourinary system is a pathological action believed to increase sexual gratification usually for psychiatric patients and mentally retarded cases especially during masturbation. In this report, we represented a male case who is inserted a 195 cm cannula by himself into the bladder through the urethra because of his psychiatric disorder.

Introduction

Detection of a foreign body in the genitourinary system is a rarely encountered phenomenon in adults. Mostly it occurs after iatrogenic manipulations, migration from adjacent organs, and tissues or self-insertion of the patient. In the etiology of self-insertion, serious psychiatric problems, mental retardation, and erratic sexual drives take place.^[1] In men foreign substance generally remains within the urethra, while in women, it can migrate inside the bladder.^[2]

Herein, we report on a 21-year-old male patient who had self-inserted a liquid cannula into his urethra, and bladder which we extracted succesfully.

Case presentation

A 21-year-old male patient was brought to the emergency service of our hospital by his relatives with complaints of urinary incontinence, and penile pain. His first examination was performed by emergency medicine specialists, and he consulted to us with the diagnosis of an intraurethral foreign substance. From information gathered from patient’s relatives, and talks with the patient, we learnt that he was receiving psychiatric treatment, and had borderline personality disorder On physical examination, a knotted thin liquid cannula protruding from his urethral meatus was observed (Figure 1). Besides, suprapubic tenderness was detected on palpation. His personal history was unremarkable as for any disease or previous surgery. The patient rejected his condition, and his family played the ignorant, so a correct anamnesis could not be retrieved. We obtained non-contrasted lower abdominal computed-tomograms (CT) to acquire more information. CT demonstrated an intraurethrally inserted foreign substance longer than we estimated, with multiple knots within the bladder (Figure 2).

Figure 1.

A long, and thin cannula with a knot protruding from the urethral meatus

Figure 2.

Intravesical cannula with multiple knots as seen on CT

Enlightened consent was obtained from the patient, and his first degree relative for surgery. After consultation with anesthesia, under general anesthesia, following appropriate cleansing of the surgical field, while the patient in the lithotomy position, priorly the external part of the foreign substance protruding from the urethra was cut from its proximal part. The remaining intraurethral segment was pushed under direct vision with the aid of 21 Ch cystoscope into the bladder. During cystoscopy, cannula knotted on itself three times. Using cystoscopic scissors, and holmium laser, knotted parts of the cannula were untied, and with foreign substance forceps they were extracted from the bladder. Before termination of the operation, debris, and small particles of coagulum were irrigated, and eliminated. Postoperatively examined foreign substance was a soft cannula 195 cm in length, and 0.5 cm in diameter (Figure 3). Postoperatively the patient was started on weekly antimicrobial, and antiinflammatory therapy. On the first postoperative day, before his discharge, psychiatric follow-up was requested.

Figure 3.

Extracted foreign substance; A 195 cm-long soft plastic cannula with a diameter of 0.5 cm

Discussion

Insertion of foreign substance into genitourinary system is usually practiced by psychiatric patients, and mentally retarded cases, with the assumption of increasing sexual desire especially during masturbation.^[3] However in the literature, patients who inserted foreign substances through their urethras to relieve urinary retention, and urethral itching have been also reported.^[4] As cited in the literature cell batteries, pencils, phone cables, keys, needles, serum sets, thermometers, electrical cables, hairpins, pushpins, and paperclips are among some of the extracted foreign substances.^[5,6] The presenting symptoms of these patients include urinary retention, dysuria, painful erection, microscopic or even macroscopic hematuria, and as is in our case, it can be incontinence secondary to incomplete closure of urethral sphincter.^[7]

In their series of 17 cases, Rahman et al.^[8] indicated psychiatric disorders, and auto-erotic drives as causes of self-insertion of foreign substances. In addition, Trehan et al.^[9] reported a patient without any psychiatric disorder, but experienced post-MI erectile dysfunction, and inserted telephone cables for erection, and sexual satisfaction.^[9] Besides, Kılıç et al.^[10] reported a case of extraurethral self-insertion where a prisoner cut his penis to place a piece of mica inside his penis.

Especially, thin, and flexible foreign substances, and catheters can be tangled within the bladder.^[11] If foreign substances, and catheters are forced into the bladder, then they form spirals inside the bladder. Under the impact of bladder wall compression, and contractions, they intertwine and with time form knots.^[12] Manual extraction of intraurethral foreign bodies might cause serious bladder neck, and urethral injury. In such cases the most important steps leading to diagnosis are detailed anamnesis, physical examination, and imaging. In the detection of foreign substances, direct urinary system radiography (KUB), ultrasound, and CT have important roles.^[13]

Intraurethral, and intravesical foreign substances should be taken out during the postoperative early phase. If treatment is delayed, then urethritis, chronic cystitis, rectal, and periurethral abscesses, urethral fistulas, lacerations, stenosis, urethral, and vesical diverticulas, calcifications, and stone formation on foreign substances can be seen.^[14] In the management of intraurethral, and intravesical foreign substances, firstly endoscopic methods should be taken into consideration. If endoscopic procedures fail, then open surgery should be contemplated. In order to prevent postoperative recurrence of such erratic behaviours, the most important issue is close monitorization, and treatment of the psychiatric disorder which is the most frequently seen underlying cause. Awareness should be raised in the patient, and his/her relatives, and intimates about this issue, and necessary guidance should be provided.

In conclusion, when social pressure, psychological status, and psychiatric problems are taken into consideration, genitourinary system complaints of the patients who consult to the outpatient clinics should be dealt with seriously, and a detailed anamnesis should be taken, meticulous physical, and if possible radiological examinations should be performed. Without delay first of all, foreign substance should be extracted endoscopically, and psychiatric evaluation should be absolutely recommended with an anticipated possibility of recurrence.