Polyembolokoilamania: Self-insertion of transistor radio antenna in male urethra.

Though self-insertion of a foreign body in the male urethra is an infrequent urologic emergency, a weird variety of self-inserted foreign bodies have been reported. Most of these are attributed to autoerotic stimulation, a consequence of mental illness or the result of drug intoxication. We report an unusual case of a 65-year-old African man who self-inserted a broken transistor radio antenna into his urethra to serve as an improvised 'itchstick' to ease a bothersome itchy urethral condition. The foreign body subsequently migrated proximally out of reach. He presented a week after with urethral bleeding following nocturnal penile erections and we describe his evaluation and the challenge of retrieval. The reasons for self-inserting objects into the urethra may be as varied as the foreign bodies themselves and may include objects being used as an improvised 'itchstick' for itchy urethral conditions. The urologist's creative tendencies will often be required in safely removing these objects.

INTRODUCTION

Self-insertion of foreign bodies in the male urethra is an infrequent urologic emergency. It is part of a broad group of disorders referred to as polyembolokoilamania in which patients’ inserts foreign bodies into body orifices for diverse reasons which may be psychopathological or otherwise. A weird variety of objects self-inserted into the urinary tract have been reported and includes electrical wires, batteries, glass, pencils, chopsticks and telephone cables.123456 The more common reasons for self-insertion of these foreign bodies into the urethra are autoerotic stimulation, a consequence of mental illness or a result of drug intoxication.234 An unusual case of a transistor radio antenna self-inserted into the male urethra for the purpose of serving as an improvised ‘itchstick’ to relieve an itchy urethral condition is presented and discussed.

CASE REPORT

A 65-year-old African man presented to our surgical emergency with a week history of bleeding per urethra following nocturnal penile erections. He admitted to have introduced a broken transistor radio antenna into his urethra a week before to serve as an improvised ‘itchstick’ to ease a bothersome itchy urethral condition. The object subsequently migrated proximally out of reach. He made several unsuccessful attempts at self-retrieval prior to presentation and remarkably reported no difficulty with voiding. He had no history of psychiatric disorder, alcoholic or drug intoxication and had no prior history of similar or other self-injurious behaviour. He, however, had a bothersome perineal and itchy urethral condition which was worse at nights.

Physical examination revealed a hard rod-like mass in the proximal part of the penis extending to the perineum; the mass had only minimal mobility. A pelvic X-ray done showed a rod-like radio-opaque foreign body in the region of the penile and bulbar urethra [Figure 1]. A diagnosis of foreign body in the male urethra was made. After obtaining informed consent, removal of the foreign body was planned. Under caudal regional block with 2% Xylocaine gel instilled into the urethra, an attempt at ‘milking out’ the foreign body was made but failed. Endoscopic removal was considered but deemed inappropriate as the distal end of the object was jagged (irregular) and appeared impacted in sub-urethral tissue. External urethrotomy of the anterior urethra was performed with the incision made into the proximal penile urethra at the distal tip of the foreign body which was then easily extracted [Figure 2]. The extracted foreign body, an aluminium tube transistor radio antenna measured 13 cm in length [Figure 3], urethral swab for microscopy and culture was taken and urethrotomy closed over a 16 Fr Foley's catheter. The patient was discharged after 48 hours and the catheter removed after a week at the clinic. The urethral swab grew Klebsiella pneumoniae and he was treated with sensitive antibiotics, tabs Augmentin for 2 weeks. At 1 month follow-up, he complained of a decreased but persistent urethral itch. Four-bottle urine microscopy revealed numerous pus cells, few epithelial cells and spermatozoa and only scanty growth of K. pneumoniae. No worm or ova was found. Antibiotics (Augmentin) were continued for a further 2 weeks and empirical treatment for pin worm infestation was given (Albendazole) resulting in resolution of symptoms. A psychiatric evaluation revealed him psychologically normal. At 9 month follow-up, he had no recurrent itch and normal voiding with good uroflow.

Figure 1

Oblique pelvic X-ray showing foreign body in the region of penile and bulbar urethra

Figure 2

Intra-operative photograph of the foreign body being removed via external urethrotomy of the anterior urethra

Figure 3

Post-operative photograph of the foreign body - a transistor radio antenna. The antenna is an aluminium tube and measured 13 cm in length

DISCUSSION

Polyembolokoilamania represents a broad group of disorders characterised by self-insertion of objects into body orifices. Self-inserted foreign bodies in the urinary tract are the purview of the urologist and a variety of objects have been reported to be self-introduced presenting a challenge of retrieval and management.123456 Often the patient presents late due to embarrassment and often will have made several efforts at self-removal.1578 This may complicate the picture further with introduction of more objects or development of urosepsis.35 Embarrassment, efforts at self-removal and late presentation have also been reported in polyembolokoilamania patients who had self-inserted objects in other body orifices.9 Our patient presented a week following the introduction of the radio antenna and after he had made several unsuccessful attempts at removal himself.

Several reports have attributed autoerotic stimulation, mental illness, drug or alcoholic intoxication as the more common reasons for self-insertion of a foreign body into the urethra.123456 This is to our knowledge probably the first reported case of foreign body in the male urethra resulting from the very unusual practice of using a foreign body as an improvised ‘itchstick’ in the urethra for an itchy urethral condition. There is, however, a report of a young female with urethral itch who used knitting needle to scratch around the urethral with subsequent loss into the bladder.10 There is no consensus presently on the role of psychiatric consultation in these patients; some have advocated that for optimal management psychiatric evaluation is required for all while others insist there is only a need in patients with prior or documented psychiatric problems.91112

An itchy urethral condition resulting from Enterobius vermicularis (pin worm) infestation of the lower urinary tract has been reported and this resolved with use of antihelminths.13 We did not find microbiological evidence of pin worm in our patient; however, due to the suggestive clinical history, we empirically treated him with Albendazole. The urethral swab we obtained grew K. pneumoniae which may have been the cause of the itchy urethral condition as there was resolution of symptoms following treatment with sensitive antibiotics.

Various methods of retrieval of the foreign bodies in the lower urinary tract have been described and endoscopic removal is often favoured.12345678911 A recent report, however, advocated the use of open removal for similar self-inserted foreign bodies in the lower urinary tract as they noted endoscopic removal often fails and there are risks of additional iatrogenic trauma during retrieval.14 We decided against endoscopic removal in our patient as the distal end of the foreign body was irregular (jagged edges) and impacted with risks of further injury to the urethra during endoscopic retrieval. External urethrotomy, though more invasive, was the safer and easier option in this case and did not result in any significant morbidity.

CONCLUSION

Self-inserted foreign body in male urethra is infrequently seen. The reasons for inserting these objects may be as varied as the foreign bodies themselves and may include objects being used as an improvised ‘itchstick’ for itchy urethral conditions. The urologist's creative tendencies will often be required for safe retrievals due to the wide array of introduced objects that are seen.