Unusual intravesical foreign body management: the Casablanca experience Case report

Self-insertion of foreign bodies in the urethra is most commonly associated with sexual or erotic arousal of adolescents with mental health disorders. It may rarely be practiced by healthy adults for masturbation. A diagnosis is usually made radiologically. Iatrogenic foreign bodies were found to be the most frequent type of insertion encountered. Endoscopic retrieval is usually successful, with minimal morbidity. The aim of this paper was to expose our experience about intravesical foreign bodies. The management of 4 cases with intravesical foreign body is exposed and analyzed.


Introduction
The variety of foreign bodies inserted into, or externally attached, to the genitourinary tract defies imagination and includes all types of objects, the usual causes for insertion of foreign bodies in genitourinary system include sexual curiosity, autoerotic stimulation, or during invasive procedures [1,2].
Obtaining an accurate history from patients with this condition may be difficult, especially for patients who insert objects for sexual pleasure. Foreign bodies used for the above mentioned purpose may include flexible or rigid and fragile or strong materials such as needles, bullets and pens, as well as candles, gauzes, etc. The presenting features usually include urinary tract infection, pain and hematuria. The physical examination is almost always unremarkable and urine microscopy usually reveals pus cells and red blood cells. Radiopaque objects can easily be seen on radiographs, while others are identified by the ultrasonography. Cystoscopy is rarely required for diagnosis. Most of the inserted objects can be retrieved endoscopically using the latest available equipment and open surgery is usually not required [3]. In this paper, we reported the successful management of 4 interesting cases of different bodies inserted in the urethra for erotic arousal purposes and migrated to the bladder.

Case 1
A 26-year-old man came to the emergency department for hematuria and dysuria during the two previous weeks. The patient reported a sabliuria without mictional burns or antecedent of urethritis. The clinical examination revealed a weak urinary stream with hematuria. Palpation of the penile urethra exposed a hard and motionless hard formation inside the penile urethra at 1 cm from the meatus. A radiological assessment by renal and bladder ultrasound, urinary shaft without preparation, pelvic radio and radio centered on the penis was performed. Ultrasound, Appareil urinaire sans préparation (AUSP) and pelvic radio were without abnormality.
The radio centered on the penis revealed a roughly triangular formation ( Figure 1). The most likely diagnosis was lithiasis enclosed in the urethra. L'Examen cytobactériologique des urines (ECBU) was sterile. Endoscopic extraction was decided.
Intraoperative exploration found a piece of pen enclosed in the urethra (Figure 2). The endoscopic extraction was unsuccessful, a surgical extraction allowed to discover the tip of a pen. Postoperatively, the patient admitted that he was using this method for auto-erogenous purposes.
Postoperative suites were simple.

Case 2
A 24-year-old patient with no particular medical history who was presented to the emergency department for dysuria and hematuria. The physical examination revealed a palpable mass along the anterior side of the penis, the rest of the somatic examination was without particularities. A pelvic x-ray objectified the presence of a linear opacity projecting in the penis ( Figure 3). The retrospective interrogation found the notion of self-introduction of the foreign body for an autoerogenous purpose 6 hours before admission. ECBU was sterile. Endoscopic extraction was impossible because of the size of the foreign body (pen) which was enclosed, it showed traumatic lesions of the urethral mucosa, a cystotomy was proposed allowing the extraction of a pen measuring 12 cm in length ( Figure 4). The postoperative suites were simple.

Case 3
A 80-year-old female patient who is known to be diabetic and hyper-tense, and followed-up for dementia, has presented with intermittent terminal hematuria and urinary burns evolving during a year according to the family. The patient was

Discussion
Insertion of a foreign object in the urethra and bladder is a pathological situation that occurs due to sexual disorders.  [7,8]. Radiologic evaluation helps in determining the exact size, location and number of the foreign bodies [9].
Confirmation can easily be done in cases of radiopaque foreign bodies with plain kidney urinary bladder (KUB) Page number not for citation purposes 4 radiograph and for radiolucent foreign bodies with ultrasound and computed tomography (CT) [4]. However, urethrocystoscopy remains the most accurate method for diagnosis of intravesical foreign bodies [10].
The treatment should be aimed to remove the foreign object, avoiding complications, without compromising erectile function for male patients. The method of removing the foreign body should be selected based on the size, nature and mobility of the object [11]. Removal can be attempted under either regional or general anaesthesia to minimize patient discomfort and movement during the manipulation and retrieval process. If the surgeon thinks that the object can be removed without urethral damage, endoscopic methods should be attempted first [12]. This can be either involve

Conclusion
The presence of a foreign body in the genitourinary tract

Competing interests
The authors declare no competing interests.