Self-insertion of foreign bodies into the urethra is a phenomenon encountered in both general medical and urologic practice. Cases involving urethral foreign bodies occur frequently and have been reported since the earliest days of the medical literature. Diagnosis is based largely on the history and physical examination; however, radiographic or cystoscopic studies may be required to confirm the diagnosis and to determine appropriate treatment. The management of patients with urethral foreign bodies includes extraction of the object and further treatments as needed for the prevention of long-term complications. In addition, assessment of the patient's motivation and possible psychiatric referral may be indicated. Thus, a multidisciplinary approach is required for patients who have urethral foreign bodies.
In this report, we present a typical case involving a urethral foreign body. A review of the relevant medical literature is included so that the clinician can gain a comprehensive understanding of this unique medical condition.
Case report
A 66-year-old white man presented to a local emergency department with fever and severe dysuria. He was admitted for antibiotic treatment of urosepsis. CT was performed and identified a tubular metallic object in the patient's urethra. After discharge from the hospital, the patient was referred for definitive urologic evaluation of this finding.
At his urology consultation, the patient complained of a palpable object protruding from the upper scrotum and base of the penis. He suspected that a surgical instrument had been left in his body accidentally during repair of an inguinal hernia 20 years previously. We had followed him in the past for management of lower urinary tract symptoms attributed to benign prostatic enlargement, erectile dysfunction, and urinary tract infections. Three months ago, he underwent cystoscopy and intravenous pyelography as part of a work-up for these urologic conditions. Results of these studies were within normal limits.
The patient's medical history was significant for hypertension, depression, and a pituitary adenoma. He is a divorced father of two children and denied using alcohol, tobacco, or illicit drugs.
On physical examination, the patient was found to be obese but in no acute distress. All of his vital signs were within normal limits. The only pertinent positive finding was a palpable hard, thin mass that appeared to be protruding from the upper scrotum and base of the penis. There was no associated external swelling or erythema. The findings on a digital rectal examination were normal.
Pelvic radiography identified a radiopaque object in the lower pelvis (see the radiograph). Subsequently, flexible cystoscopy was performed, which demonstrated a gold-colored, metallic tubular object impacted in the urethra. The size and position of the object precluded complete examination of the posterior urethra and bladder. The patient was subsequently taken to the operating room for definitive management. Multiple attempts to remove the object endoscopically were unsuccessful, so surgical exposure of the urethra was performed via a midline penoscrotal incision. The object was removed in two parts through urethrotomy and was identified as a ballpoint pen without an associated ink cartridge (see the Figure). The urethral defect was then closed in multiple layers with absorbable sutures over a 20 French catheter.
The patient tolerated the procedure well, and there were no significant complications. The next day, he was discharged home with an indwelling urethral catheter. The catheter was removed 2 weeks after the surgery, and the patient voided without difficulty. On further questioning, the patient denied inserting this object himself or that it was inserted by another person. A psychiatric referral was offered, but the patient refused.