Self-insertion of urethral foreign body: A simple endoscopic technique for removal of a metal forceps from male urethra

Abstract

22 year old male presented with self insertion of a foreign body in his urethra 4 years ago. The metal forceps was successfully extracted endoscopically with the aid of the external pressure technique. This is the second time in literature where an open thumb metal forceps is diagnosed. The metal forceps poses additional difficulties during its extraction owing to its sharp open distal ends, which necessitates the use of external pressure technique and expert endoscopic skills. In the case of open metal forceps, we recommend the use of external pressure technique to aid extraction without injuring the urethra any further.

Introduction

Foreign bodies of the urethra and bladder are seldom seen in clinical urologic practice with iatrogenic injury, self-insertion, and rarely migration from adjacent sites.¹ Foreign bodies are most commonly inserted into the urinary tract by psychiatric, intoxicated, confused, or sexually curious patients. Treatment is focused on foreign body extraction, diagnosing complications, and avoiding compromise of erectile function. With advances in endourology, the majority of cases can now be managed endoscopically.² In this case we present our endoscopic technique for removal of a metal forceps from male urethra.

Case report

A 22-year-old male presented to our clinic with history of inserting a metal foreign body into his urethra 4 years ago. Patient denied any urological symptoms, fevers or chills. He was able to pass urine normally. His physical examination showed a non-distended bladder, normal external urethral meatus, and a palpable long foreign body from the mid-shaft of the penis to beyond the penoscrotal junction. X-rays of the pelvis and ascending urethrogram (Image 1) showed a metal forceps approximately 8 cm length in the anterior urethra.

Image 1.

Ascending urethrogram showing an open forceps in the anterior urethra.

The patient was taken to the operating room after receiving pre-operative intravenous antibiotics. Under general anesthesia, cystoscopic examination was performed which demonstrated the metallic hair removal forceps with its closed end embedded in a false passage at the proximal end of the bulbous urethra, and its open end is about 7 cm proximal to the external urethral meatus. Our simple endoscopic technique for removing the metal hair removal forceps was accomplished by asking the surgeon assistant to close the open end of the forceps by external pressure on the palpable sides of the forceps through the penile shaft (image 2), then an endoscopic foreign body forceps was introduced through the cystoscope, and the distal closed end of the metal forceps was held under vision and pulled out the urethra (Image 3).

Image 2.

Closed ends of the forceps after applying external pressure technique.

Image 3.

Endoscopic forceps holding the closed end of the metal forceps.

At the end of the procedure, no urethral catheter was inserted, the patient voided well and went home post procedure. The patient was recommended to undergo a psychiatric evaluation but he refused. The patient did not follow up with the outpatient department.

Discussion

Self-insertion of foreign bodies in a male urethra is a rare issue but still can be seen. The most common reason for self-insertion of a foreign body into the male urethra is for autoerotic and sexual gratification, especially during masturbation.³ In the vast majority of cases, the patients feel guilty and humiliated and, therefore, often delay asking for medical help.⁴ Our case is very interesting as the patient presented after 4 years of insertion and denied any inflammatory symptoms during this period.

Diagnosis is most often confirmed on physical examination. Foreign bodies distal to the urogenital diaphragm are readily palpable. A pelvic X-ray and computerized tomography of the abdomen and/or pelvis can be useful in defining a foreign body's position, orientation, relationship and its ramification to surrounding viscera.² In our case, diagnosis was made by physical examination, pelvic x-ray and ascending urethrogram which showed the open thumb forceps.

Different types of foreign bodies have been reported in literature over the years. Variety of foreign bodies that are inserted to the genitourinary tract defies imagination. These include objects such as fish hooks, metal roads, hairpins, screws, pellets, wires, wooden sticks, piece of fish, and telephone cables.³

This case is interesting, as the insertion of an open thumb metal forceps in male urethra hasn't been mentioned in literature except only once.⁵ The open thumb metal forceps poses more technical difficulties during endoscopic extraction, and this is because of its sharp open distal ends, which can injure the urethra during removal. This was avoided by using the external pressure technique and skillful endoscopic manipulation to grasp the forceps with its ends closed. This technique warrants safe endoscopic removal of metal forceps and avoids open surgery.

Conclusion

Urethral Foreign body extraction is guided by its morphology and position, and can often be successfully achieved endoscopically. However, a more holistic approach to management is crucial, which includes, prevention of complications or further urethral injury. In the case of open metal forceps, we recommend the use of external pressure technique to aid extraction without injuring the urethra any further. Psychiatric consultation is recommended to prevent further attempts at insertion of other foreign bodies in the urinary tract.