An unusual case of polyembolokoilamania: Urethral avulsion from foreign object use during sexual gratification

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We read with interest the recent unusual case of genitourinary trauma reported by Chan et al.¹ A very rare case of urethral avulsion resulting from auto-insertion of a plastic tube for sexual gratification (polyembolokoilamania) is presented and the subsequent surgical management — an emergency urethroplasty — is described. The authors are to be commended for avoiding a perineal urethrostomy and for performing a urethral realignment in an emergency situation. Although the followup reported is limited to eight weeks post-injury, it is reassuring to see that erectile activity has been preserved without significant chordee. It is stated that no voiding complaints have been reported by the patient, but it is not mentioned if the patient has resumed intercourse postoperatively or if ejaculation is affected in any way.

The authors allude to the many etiologies of self-embedding behaviour, with particular reference to the genitourinary tract, and highlight polyembolokoilamania as a predominant one. Specific to certain patient groups, it should be acknowledged that repeated urethral foreign body insertion can be a form of manipulative behaviour, as it requires transfer to an acute healthcare provider.² It has also been reported in the psychiatric literature that the practice can be mimicked by other patients in institutions.³ In 2013, we reported an emergency surgical intervention rate of 9% in the acutely hospitalized, incarcerated patients and demonstrated higher rates of urethral foreign body insertion;⁴ however, all cases were managed with endoscopic retrieval.

The authors discuss that the exact prevalence of self-inflicted injuries following foreign body insertion is unknown and mention that delayed presentation is common and further discuss the symptoms and complications. It should be mentioned that self-embedding behaviour may also cause injury to the patient’s partner. The well-documented practice of “genital beading,” performed in order to enhance the sexual response of partners,⁵ may cause inadvertent vaginal lacerations, as well as acute and delayed problems in the male.^6,7

Finally, the authors emphasize the importance of a candid history being offered by the patient, as well as appropriate radiology and cystoscopic evaluation. This is an important point. Eke has demonstrated that cultural attitudes may hinder patients from divulging the exact nature of a sexual related injury and, consequently, treatment may not be sought until the complications become intolerable.⁸ Although expertise in such cases is limited to a few, it is important to note that injudicious attempts at removing genitourethral foreign bodies can potentially compound the initial injuries. The role of the radiologist should not be underestimated, as prompt and appropriate radiological investigations aid in determining the exact location, orientation, and radiolucency of the foreign body⁹ and, in select cases, may also assist in foreign body removal.¹⁰