Sexual curiosity
“What teenager has never measured the size of his penis?”
A 15-year-old male patient was transferred from his local hospital to our department after self-insertion of a knotted USB cord into his urethra in the context of sexual experimentation.
His repeated failed attempts to remove the cord soon after its insertion resulted in gross haematuria and he presented to the Emergency Department of his local hospital. Following urological evaluation, he underwent rigid cystoscopy and optical urethrotomy. This was unsuccessful due to the proximal knot of the cord. A suprapubic catheter was inserted under ultrasound guidance, draining approximately 700mls of haematuric urine. This was done to prevent any episodes of clot or foreign body induced retention. The patient was subsequently referred urgently and transferred to our department for tertiary assessment and management.
On admission, he was hemodynamically stable. The two distal ports of the USB wire were found protruding from the external urethral meatus, while the middle part of the knotted wire remained within the urethra. The patient was a healthy and fit adolescent with no history of mental disorders.
After his request to be examined without his mother, he confessed that he inserted the cable into his urethra to measure the length of his penis out of sexual curiosity.
A longitudinal penoscrotal incision was made over the palpable foreign body and careful dissection of the deeper tissues was performed, unfolding the bulbospongiosus muscle. The knotted cord was exposed at the proximal aspect of the penile urethra and cut from the remainder of the cord. Both ends of the cord were successfully pulled through the external urethral meatus.
The urethra was closed with interrupted sutures and a urethral catheter was inserted. His recovery was uneventful and he was discharged the following day with simple analgesia, oral antibiotics and suprapubic and urethral catheters in situ.
A fluoroscopic urethrogram was arranged 2 weeks after the procedure to assess urethral healing before removal of the catheters. No evidence of urine leakage or urethral stricture was noted except for a slight change in caliber in the distal bulbar and proximal penile urethra at the position of the recent urethrostomy.
The catheter was successfully removed and continued follow-up is required to monitor for any long-term damage.
Discussion
Although retained urethral foreign bodies represent a clinical rarity in daily urological practice, several different cases have been described. The insertion of a wide variety of objects has been documented (needles, pins, iron wires, pistachio shells).
The most common causes of foreign body insertion into the lower genitourinary tract include sexual curiosity, sexual activity after intoxication, and mental disorders such as borderline, schizoaffective, and bipolar personality disorders. More rarely, it may be secondary to the migration of medical devices deliberately placed in adjacent organs, such as ureteral stents and intrauterine devices.
In a minority of cases, foreign bodies may be completely asymptomatic. However, in most cases, they present with lower urinary tract symptoms (LUTS), including dysuria, gross hematuria, painful erection, and even acute urinary retention. Furthermore, depending on the mechanism of insertion and the size and shape of the object, they can cause late complications, mainly recurrent urinary tract infections, urethral strictures or false passages, and bladder perforation, which may require major reconstructive procedures to restore the anatomy.
A detailed history, including information about the nature of the foreign body and the mechanism of insertion, is essential to guide further investigations and should be obtained in a supportive and non-judgmental manner, as patients may feel uncomfortable disclosing all relevant information. Therefore, careful physical examination, radiological evaluation and direct visualization with cystoscopy can aid in diagnosis and management. Abdominal and pelvic CT scan or ultrasound may provide more detailed information in challenging cases.
Management of a urethral foreign body can be particularly challenging and depends primarily on the number, nature, and location of the retained objects, as well as the presence of significant urethral injury. Simple manual extraction may be effective for smooth, mobile objects protruding from the external urethral meatus.
In more complex cases, endoscopic retrieval is always preferable to open approaches, as it is minimally invasive and associated with less disruption of the urethral anatomy and shorter hospital stay. 1
Open approaches, including urethrotomy or cystotomy, depending on the location of the object, are reserved for complex cases of abnormally shaped and proximally located foreign bodies. In our case, urethrotomy was elected because of the shape of the foreign body and previous unsuccessful attempts at cystoscopy. The location of the foreign body (proximal penile urethra) has a rich blood supply and is a relatively favorable site for urethrotomy. All treatment techniques should be covered with preoperative and postoperative antibiotics for a minimum of seven days. According to Palmer et al., an empiric seven-day course of antibiotics in patients with negative urine cultures can decrease the rate of postoperative urinary tract infection by 20%.
In our case, the patient was an adolescent accompanied by his mother and therefore initially reluctant to provide clear information about the circumstances of the insertion. There was no evidence of psychiatric disorder and “experimentation” in the context of autoeroticism was indicated as the cause of the insertion. This constituted another case of sexual curiosity, resulting in a challenging urological emergency, which was effectively treated with open surgery and without any short-term complications.
“Situations like the one reported are becoming increasingly common due to social media, which allows the spread of misinformation. When parents fail to talk about sex education with their sons and daughters, curiosity is at the very least aroused, things of this nature.”