A Cotton Swab in Male Urethra: A Case Report of an Unusual Urethral Foreign Body

Urethral foreign bodies are rare urological emergencies and early management is vital. Mostly, the patient with a psychiatric disorder inserts the foreign body himself for erotic satisfaction. In this paper, we reported a case of a 22-year-old male patient who inserted a cotton swab into his urethra.


INTRODUCTION
A urethral foreign body is a rare reason for adults to apply medical assistance. The presence of a foreign body in the genitourinary tract is mainly related to psyhiatric or sexual behavioural and mental disorders (1). Mostly, the patient with a psychiatric disorder inserts the foreign body himself for erotic satisfaction (2). This situation is generally limited to the urethra in men because of its length whereas it may be found in the urinary bladder in women because of female urethral shortness (3).
In this paper, we present a 22-year-old male patient who implanted a cotton swab into his urethra.

CASE REPORT
A 22-year-old male patient admitted to the emergency service with pain in the genitourinary tract after he had implanted a cotton swab into his urethra on July 2017. The patient stated that he had implanted the foreign body into his urethra with help of his partner's encouragement in his anamnesis. The physical examination of urethra was normal and a foreign body was not palpated. Pelvic X-ray and pelvic computed tomography (CT) were performed respectively. The foreign body could not be detected on pelvic X-ray (Fig.1). Pelvic CT examination revealed some non-spesific findings. (Fig.2). Afterwards, the patient was consulted to urology . 261 Case Report / Olgu Sunumu 2 Urethroscopy was performed and the foreign body was seen in the posterior urethra (Fig.3). The foreign body was taken out in one piece using a forceps (Fig.4).
Subsequently, cytoscopy was performed and no other foreign bodies or serious injuries except from local erythematous appearence was seen. The procedure was finished by placing 18 Fr urethral catheter. The patient was discharged from the hospital after removing urethral catheter next day. Antibiotic and antiinflamatory therapy was given. Psychiatric consultation was recommended but was refused by the patient and his partner.

DISCUSSION
There are many cases in the literature on urethral foreign bodies including hair clip, tweezer, fastener, paperclip, straw, small balls, pin, cable or cotton swab (4,5) Patients usually admit to the hospital with complaints of urinary retantion, dysuria, pollakuria, hematuria, painful erection and genital pain (3,6). A detailed anamnesis is very important and helpful for diagnosis but it is sometimes hard to get true information because of cultural and social structures. Physical examination should be performed on every patient as palpation of the foreign body in the anterior urethra is an important sign.
Pelvic X-ray, ultrasonography or CT can be performed to identify foreign bodies in the genitourinary tract (1,5,7). Radiographic examination should begin with a pelvic X-ray which is a quick and easy method to apply. However, radiolucent foreign bodies are not able to be seen in pelvic X-ray like in our case. Computed tomography may be used to identify a foreign body with gap inside because it can be seen in air density at the CT examination like in our case. It was possible to view the foreign body, a pen, in the anterior urethra because of the air gap inside in a similar case reported by Sahin et al. (8).
Urethral foreign bodies which are smaller than 1 cm, mobile, distally located, and causing no hematuria may be manually extracted. For the foreign bodies bigger than 1 centimeter and If the foreign body is bigger than 1cm or there is some kind of relationship with urinary bladder, the extraction may be performed by open cystotomy. Cystouretroscopy and extraction with forceps endoscopically, like in our case, may be useful for the foreign bodies which are mobile, bigger than 1 cm and totally located in the urethra . However, endoscopic extraction of urethral foreign bodies may not always be possible open urethrotomy may be needed (9).
If the foreign body was implanted by the patient or his/her sexual partner, psychiatric consultation should be performed for both. Almost every couple, like in our case, refuses the psyhiatric examination and treatment (10).
Urethral foreign bodies are rare urological emergencies and early management is vital. Another important aspect of this situation is that recurrence is possible because of psyhiatric disorders. Psychiatric consultation must be performed in these patients.