Valentine's day misadventure: Missing vagina for urethra.

Case report

A 48 year old female self presented accompanied by her husband to our Urology service on Valentine's day with a history of accidental insertion of foreign body in the urethra instead of vagina as part of consensual sexual act. She complained of dysuria and suprapubic fullness. There was accompanying single episode of haematuria.

Her past medical history included overactive bladder for which she was on antimuscarinics.

On initial examination vital signs were within normal range. Examination of the cardiovascular and respiratory systems was unremarkable. Examination of the abdomen revealed suprapubic tenderness. Pelvic examination was unremarkable.

Baseline blood investigations included a full blood count, renal profile, coagulation screen, urine analysis and Xray pelvis. All bloods were with in normal range. Her urine analysis showed microscopic haematuria without any evidence of active infection. Xray pelvis revealed a large foreign body in the bladder Fig. 1.

Fig. 1

Xray Pelvis showing foreign body (radio antenna).

Diagnosis was made with clinical history, examination and X-ray findings and she was planned for transurethral extraction of foreign body under general anaesthetic.

She underwent rigid cystoscopy with a 23F rigid cystoscope under antibiotic cover. A radio antenna was identified. Bladder was distended to manipulate the foreign body prior to extraction and careful bladder inspection. A grasper was introduced via cystoscope and foreign body was carefully extracted via transurethral approach Fig. 2, Fig. 3. There were no immediate complications. Post-operative recovery was uneventful and she was discharged home 24 hours later following successful trial without catheter and counselling. Outpatients follow up was arranged in 8 weeks time.

Fig. 2

Cystoscopic view of foreign body (radio antenna) being extracted.

Fig. 3

Extracted foreign body (radio antenna).

Discussion

The reasons for insertion of foreign bodies in lower urinary tract include psychological disorders, trauma and migration from other organs. Sexual gratification is an important and common reason of such an act. A variety of foreign bodies have been reported such as ballpoint pens, razor blades, pencils and a dead snake. They can result in urethral and bladder trauma, encrustation, stone formation, urinary tract infection and bladder perforation.

Contrary to our case, diagnosis can sometimes be daunting because patients may feel embarrassed to accurately report the problem. In psychiatric patients claiming to have inserted a foreign body, care givers may deem it incredulous leading to delay in diagnosis therefore high index of suspicion is necessary. Initial management should include control of pain and urinary drainage. In most cases diagnosis can be made with X-ray pelvis. A CT scan may not be necessary unless diagnosis is unclear or extra information is required regarding the involved organ. The approach to extract foreign body depends on size, type and mobility of the object inserted. Smaller caliber, smooth objects can be removed carefully by a grasper introduced via a cystoscope permitting transurethral approach in line with the long axis of urethra. Foreign bodies with jagged or sharp edges, or which are larger should not be removed endoscopically as there is a risk of iatrogenic injury.