Int J Adolesc Med Health 2015; 27(4): 463–465
Case Report Rajendra Prasad Ray, Bastab Ghosh and Dilip Kumar Pal*
Urethral foreign body in an adolescent boy: report of two rare cases and review of literature Abstract: The presence of a foreign body in the urethra is uncommon. A wide variety of foreign bodies have been described in urethras, but they are often missed in physical examinations as the patient tries to hide the fact. We report two unusual cases of foreign bodies in the urethra in two adolescent boys suffering from psychiatric disorders. In the first case, a 12-year-old boy presented with introduction of sewing needle into the urethra 3 days back. The patient in that case suffered from a delusional disorder. In the second case, a 19 year old man introduced a metallic screw into his urethra for sexual gratification several times in the preceding 4 years. That patient suffered from schizophrenia. Although psychiatric illness is associated with urethral foreign body, such underlying psychiatric disorders are very rare. Keywords: delusional disorder; foreign body; schizo phrenia; urethra; urethroplasy. DOI 10.1515/ijamh-2014-0057 Received October 5, 2014; accepted January 1, 2015; previously published online March 7, 2015
Introduction It is rare for a patient to present with a foreign body (FB) in their urethra. Because of guilt and embarrassment, patients usually do not take medical advice unless a complication arises. Therefore, a foreign body in the urethra may remain undiagnosed unless patients reveal a clue. Psychiatric illness is one of the underlying causes. Herein, we report two rare cases of a FB in th urethra in patients who were suffering from delusional disorder and *Corresponding author: Dilip Kumar Pal, Institute of Post Graduate Medical Education and Research, Department of Urology, Kolkata 700020, India, Phone : +91-94-33132553, E-mail: [email protected] Rajendra Prasad Ray and Bastab Ghosh: Institute of Post Graduate Medical Education and Research, Department of Urology, Kolkata, India
schizophrenia. The salient points in the management of such cases are highlighted, and the relevant literature is discussed in this case report.
Case reports Case 1 A 12-year-old boy presented with hematuria and dysuria for 3 days. On further questioning, he admitted the introduction of a sewing needle to relieve itching within the urethra and that he had been doing so for the previous 2 years. The external genitalia were normal on physical examination. A needle-like structure was palpated in the bulbar urethra. Plain X-ray of the pelvis revealed a linear radio-opaque FB below the symphysis pubis overlying penile soft tissue shadow (Figure 1A). Urethroscopy showed a sharp sewing needle at the bulbar urethra was present along the longitudinal axis (Figure 1B). Urethroscopic removal of the needle was performed. The patient was referred to the psychiatric department and was diagnosed as having a delusional disorder. On follow-up, he is doing well and is now under treatment by the psychiatric department.
Case 2 A 19-year-old male presented with dysuria, obstructive voiding symptoms, and swelling of the external genitalia for 3 months. He had a history of self-introduction of metallic screws into his urethra. There was history of a similar event on multiple occasions in the past 4 years. He also exhibited bizarre behavior like talking to self and some imaginary persons. On examination, penis and scrotum were swollen and tender. A metallic FB was palpated in the penile urethra. He was treated with antibiotics and analgesics. Retrograde urethrography showed a metallic screw in the proximal penile urethra with normal anterior urethra (Figure 2A). On urethroscopy, a metallic screw was Brought to you by | University of Exeter Authenticated Download Date | 10/13/16 5:03 PM
464 Ray et al.: Two rare cases of urethral foreign body
A
A
B
B
Figure 1: (A) A linear radio opaque foreign body below the symphysis pubis overlying penile soft tissue shadow on plain X-ray pelvis. (B) Cystourethroscopy showing a sharp sewing needle at the bulbar urethra along its axis.
seen in the proximal penile urethra, embedded into the epithelium. Urethroscopic removal failed. A urethrotomy was performed, and the FB was removed (Figure 2B). The urethra closed over a Foley catheter. The patient was diagnosed as suffering from schizophrenia by the psychiatric department. He is currently under treatment of psychiatric department. On follow-up, he is doing well, with good urinary flow.
Discussion The insertion of foreign bodies into the urethra is rare, and a wide variety of objects have been implicated (1, 2). Common motives are sexual or erotic in nature, including masturbation or other forms of sexual variation or gratification. Other psychiatric illness have also been reported (3, 4). Delusional disorder and schizophrenia,
Figure 2: (A) A radio opaque foreign body (metallic screw) in proximal penile urethra with normal anterior urethra on retrograde urethrography. (B) A metallic screw was removed through urethrotomy.
as in our cases, are extremely rare. Alibadi et al. studied reasons for FB self-insertion in 18 patients and reported autoeroticism in 33% and obvious psychiatric causes in 11%. In three patients (17%), no definite reason could be determined, and, interestingly, 39% of patents reported assistance of voiding as a reason for insertion of a FB (5). Men are 1.7 times more likely to self-insert foreign bodies into their lower genitourinary tract than women (6). A variety of foreign bodies such as pencils, electric cables, thermometers, glass rods, toothbrushes, candles, serum sets, balloons, hairpins, wires, ampoules, broken keys, plastic spoon handles, and pocket batteries have been reported in literature (7, 8). Patients may present with lower abdominal pain, dysuria, urethral discomfort, pollakiuria, nocturia, hematuria, gross bleeding from the urethra, painful erection, difficulty in voiding, and urinary retention (8). If left untreated, FB can cause Brought to you by | University of Exeter Authenticated Download Date | 10/13/16 5:03 PM
Ray et al.: Two rare cases of urethral foreign body 465
repeated infections, urinary retention, squamous cell carcinoma, urethral stenosis, rectal abscess, periurethral abscess, and/or fistula, calcification of foreign bodies, and stone formation. Although a straightforward history, clinical examination, and radiography confirm the diagnosis, many patients hide their history due to embarrassment or mental illness, and nonspecific symptoms make difficult to diagnose until imaging. A high index of suspicion is necessary for diagnosis and management of these challenging cases. Radiological evaluation is necessary to determine the exact size, location, and number of foreign bodies, and, in most cases, a plain radiograph is sufficient (3). Early and immediate removal of the urethral FB is recommended. Methods described in literature are meatotomy, cystoscopy, urethrotomy, and suprapubic cystotomy. Endoscopic removal of foreign bodies is often considered the first treatment choice (7). In the first case, the patient was diagnosed as having delusional disorder. The underlying psychiatric illness of self-insertion of a urethral FB reported in literature is extremely rare. In our case, the patient was thinking of insects crawling into the urethra, and he used the sewing needle to get rid of sensation. One such case has been reported by Walter (9). In the second case, the patient was suffering from schizophrenia, and under the command of an imaginary person, he would put objects into his urethra. A screw slipped, and he wasn’t able to remove it. Such schizophrenic patients usually insert an object in the mouth or rectum, but insertion of FB in urethra is reported, although rarely (10).
Psychiatric illness is commonly associated with FB insertion. To avoid repeat insertion, a psychiatric evaluation should be considered in all cases (11).
References 1. Wenderoth U, Jonas U. Curiosity in urology? Masturbation injuries. Eur Urol 1980;6:312–3. 2. Granados EA, Riley G, Rios GJ, Vicente J. Self introduction of urethrovesical foreign bodies. Eur Urol 1991;19:259–61. 3. Rahman NU, Elliott SP, McAninch JW. Self-inflicted male urethral foreign body insertion: endoscopic management and complications. BJU Int 2004;94:1051–3. 4. van Ophoven A, deKernion JB: Clinical management of foreign bodies of the genitourinary tract. J Urol 2000;164:274–87. 5. Aliabadi H, Cass AS, Gleich P, Johnson CF. Self-inflicted foreign bodies involving lower urinary tract and male genitals. Urol 1985;26:12–16. 6. Nakatani T, Senju M, Iseki T, Sugimoto T, Nishio S, et al. Statistic study of 1,272 cases of foreign bodies in the bladder or urethra. Acta Urol Jap 1983;29:1363–8. 7. Trehan RK, Haroon A, Memon S, Turner D. Successful removal of a telephone cable, a foreign body through the urethra into the bladder: a case report. J Med Case Reports 2007;1:153. 8. Ayyildiz A, Gürdal M, Nuhoğlu B, Ersoy E, Huri E, et al. A foreign body self-inserted via the urethra into the bladder: pocket battery. Int Urol Nephrol 2003;35:251–2. 9. Walter G. An unusual monosymptomatic hypochondriacal delusion presenting as self-insertion of a foreign body into the urethra. Br J Psychiatry 1991;159:283–4. 10. Gonzalgo ML, Chan DY. Endoscopic basket extraction of a urethral foreign body. Urol 2003;62:352. 11. Kenney RD. Adolescent males who insert genitourinary foreign bodies: is psychiatric referral required? Urology 1988;32:127–9.
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Case Report Rajendra Prasad Ray, Bastab Ghosh and Dilip Kumar Pal*
Urethral foreign body in an adolescent boy: report of two rare cases and review of literature Abstract: The presence of a foreign body in the urethra is uncommon. A wide variety of foreign bodies have been described in urethras, but they are often missed in physical examinations as the patient tries to hide the fact. We report two unusual cases of foreign bodies in the urethra in two adolescent boys suffering from psychiatric disorders. In the first case, a 12-year-old boy presented with introduction of sewing needle into the urethra 3 days back. The patient in that case suffered from a delusional disorder. In the second case, a 19 year old man introduced a metallic screw into his urethra for sexual gratification several times in the preceding 4 years. That patient suffered from schizophrenia. Although psychiatric illness is associated with urethral foreign body, such underlying psychiatric disorders are very rare. Keywords: delusional disorder; foreign body; schizo phrenia; urethra; urethroplasy. DOI 10.1515/ijamh-2014-0057 Received October 5, 2014; accepted January 1, 2015; previously published online March 7, 2015
Introduction It is rare for a patient to present with a foreign body (FB) in their urethra. Because of guilt and embarrassment, patients usually do not take medical advice unless a complication arises. Therefore, a foreign body in the urethra may remain undiagnosed unless patients reveal a clue. Psychiatric illness is one of the underlying causes. Herein, we report two rare cases of a FB in th urethra in patients who were suffering from delusional disorder and *Corresponding author: Dilip Kumar Pal, Institute of Post Graduate Medical Education and Research, Department of Urology, Kolkata 700020, India, Phone : +91-94-33132553, E-mail: [email protected] Rajendra Prasad Ray and Bastab Ghosh: Institute of Post Graduate Medical Education and Research, Department of Urology, Kolkata, India
schizophrenia. The salient points in the management of such cases are highlighted, and the relevant literature is discussed in this case report.
Case reports Case 1 A 12-year-old boy presented with hematuria and dysuria for 3 days. On further questioning, he admitted the introduction of a sewing needle to relieve itching within the urethra and that he had been doing so for the previous 2 years. The external genitalia were normal on physical examination. A needle-like structure was palpated in the bulbar urethra. Plain X-ray of the pelvis revealed a linear radio-opaque FB below the symphysis pubis overlying penile soft tissue shadow (Figure 1A). Urethroscopy showed a sharp sewing needle at the bulbar urethra was present along the longitudinal axis (Figure 1B). Urethroscopic removal of the needle was performed. The patient was referred to the psychiatric department and was diagnosed as having a delusional disorder. On follow-up, he is doing well and is now under treatment by the psychiatric department.
Case 2 A 19-year-old male presented with dysuria, obstructive voiding symptoms, and swelling of the external genitalia for 3 months. He had a history of self-introduction of metallic screws into his urethra. There was history of a similar event on multiple occasions in the past 4 years. He also exhibited bizarre behavior like talking to self and some imaginary persons. On examination, penis and scrotum were swollen and tender. A metallic FB was palpated in the penile urethra. He was treated with antibiotics and analgesics. Retrograde urethrography showed a metallic screw in the proximal penile urethra with normal anterior urethra (Figure 2A). On urethroscopy, a metallic screw was Brought to you by | University of Exeter Authenticated Download Date | 10/13/16 5:03 PM
464 Ray et al.: Two rare cases of urethral foreign body
A
A
B
B
Figure 1: (A) A linear radio opaque foreign body below the symphysis pubis overlying penile soft tissue shadow on plain X-ray pelvis. (B) Cystourethroscopy showing a sharp sewing needle at the bulbar urethra along its axis.
seen in the proximal penile urethra, embedded into the epithelium. Urethroscopic removal failed. A urethrotomy was performed, and the FB was removed (Figure 2B). The urethra closed over a Foley catheter. The patient was diagnosed as suffering from schizophrenia by the psychiatric department. He is currently under treatment of psychiatric department. On follow-up, he is doing well, with good urinary flow.
Discussion The insertion of foreign bodies into the urethra is rare, and a wide variety of objects have been implicated (1, 2). Common motives are sexual or erotic in nature, including masturbation or other forms of sexual variation or gratification. Other psychiatric illness have also been reported (3, 4). Delusional disorder and schizophrenia,
Figure 2: (A) A radio opaque foreign body (metallic screw) in proximal penile urethra with normal anterior urethra on retrograde urethrography. (B) A metallic screw was removed through urethrotomy.
as in our cases, are extremely rare. Alibadi et al. studied reasons for FB self-insertion in 18 patients and reported autoeroticism in 33% and obvious psychiatric causes in 11%. In three patients (17%), no definite reason could be determined, and, interestingly, 39% of patents reported assistance of voiding as a reason for insertion of a FB (5). Men are 1.7 times more likely to self-insert foreign bodies into their lower genitourinary tract than women (6). A variety of foreign bodies such as pencils, electric cables, thermometers, glass rods, toothbrushes, candles, serum sets, balloons, hairpins, wires, ampoules, broken keys, plastic spoon handles, and pocket batteries have been reported in literature (7, 8). Patients may present with lower abdominal pain, dysuria, urethral discomfort, pollakiuria, nocturia, hematuria, gross bleeding from the urethra, painful erection, difficulty in voiding, and urinary retention (8). If left untreated, FB can cause Brought to you by | University of Exeter Authenticated Download Date | 10/13/16 5:03 PM
Ray et al.: Two rare cases of urethral foreign body 465
repeated infections, urinary retention, squamous cell carcinoma, urethral stenosis, rectal abscess, periurethral abscess, and/or fistula, calcification of foreign bodies, and stone formation. Although a straightforward history, clinical examination, and radiography confirm the diagnosis, many patients hide their history due to embarrassment or mental illness, and nonspecific symptoms make difficult to diagnose until imaging. A high index of suspicion is necessary for diagnosis and management of these challenging cases. Radiological evaluation is necessary to determine the exact size, location, and number of foreign bodies, and, in most cases, a plain radiograph is sufficient (3). Early and immediate removal of the urethral FB is recommended. Methods described in literature are meatotomy, cystoscopy, urethrotomy, and suprapubic cystotomy. Endoscopic removal of foreign bodies is often considered the first treatment choice (7). In the first case, the patient was diagnosed as having delusional disorder. The underlying psychiatric illness of self-insertion of a urethral FB reported in literature is extremely rare. In our case, the patient was thinking of insects crawling into the urethra, and he used the sewing needle to get rid of sensation. One such case has been reported by Walter (9). In the second case, the patient was suffering from schizophrenia, and under the command of an imaginary person, he would put objects into his urethra. A screw slipped, and he wasn’t able to remove it. Such schizophrenic patients usually insert an object in the mouth or rectum, but insertion of FB in urethra is reported, although rarely (10).
Psychiatric illness is commonly associated with FB insertion. To avoid repeat insertion, a psychiatric evaluation should be considered in all cases (11).
References 1. Wenderoth U, Jonas U. Curiosity in urology? Masturbation injuries. Eur Urol 1980;6:312–3. 2. Granados EA, Riley G, Rios GJ, Vicente J. Self introduction of urethrovesical foreign bodies. Eur Urol 1991;19:259–61. 3. Rahman NU, Elliott SP, McAninch JW. Self-inflicted male urethral foreign body insertion: endoscopic management and complications. BJU Int 2004;94:1051–3. 4. van Ophoven A, deKernion JB: Clinical management of foreign bodies of the genitourinary tract. J Urol 2000;164:274–87. 5. Aliabadi H, Cass AS, Gleich P, Johnson CF. Self-inflicted foreign bodies involving lower urinary tract and male genitals. Urol 1985;26:12–16. 6. Nakatani T, Senju M, Iseki T, Sugimoto T, Nishio S, et al. Statistic study of 1,272 cases of foreign bodies in the bladder or urethra. Acta Urol Jap 1983;29:1363–8. 7. Trehan RK, Haroon A, Memon S, Turner D. Successful removal of a telephone cable, a foreign body through the urethra into the bladder: a case report. J Med Case Reports 2007;1:153. 8. Ayyildiz A, Gürdal M, Nuhoğlu B, Ersoy E, Huri E, et al. A foreign body self-inserted via the urethra into the bladder: pocket battery. Int Urol Nephrol 2003;35:251–2. 9. Walter G. An unusual monosymptomatic hypochondriacal delusion presenting as self-insertion of a foreign body into the urethra. Br J Psychiatry 1991;159:283–4. 10. Gonzalgo ML, Chan DY. Endoscopic basket extraction of a urethral foreign body. Urol 2003;62:352. 11. Kenney RD. Adolescent males who insert genitourinary foreign bodies: is psychiatric referral required? Urology 1988;32:127–9.
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