Beans in the wrong stalk: A case of urethral foreign bodies.

Placement of foreign bodies within the urethra has intrigued urologists for years. We present the case of a 30-year-old man who had self-inserted 6 kidney beans into his urethra for sexual pleasure. Conservative attempts at removal with bedside interventions were unsuccessful. The patient required operative intervention with cystoscopy and urethral foreign body retrieval. No additional trauma was appreciated and all beans were extracted. Management of patients with a urethral foreign body can be attempted with bedside extraction, however proximal or challenging objects may require surgical extraction via either endoscopic or open approaches.

Introduction

Placement of foreign bodies within the urethra has intrigued urologists for years. Reasons for placement include sexual stimulation, psychiatric illness, sexual assault, or even attempts to relieve urinary obstruction.1, 2, 3, 4, 5 Additionally, considering the taboo nature of the topic, it is often challenging to ascertain the underlying reason for placement. Cases can frequently be managed endoscopically, but may require more invasive modalities including meatotomy, urethrotomy, or cystotomy. We present the case of a 30-year-old man who had self-inserted 6 kidney beans into his urethra.

Case presentation

A 30-year-old male presented to the emergency department complaining of difficulty urinating. Upon further evaluation, it was revealed that earlier in the day he had inserted six kidney beans into his urethra for sexual pleasure with the intent of expressing the beans during ejaculation. He further explained that this was not his first time participating in this practice, although he never attempted to utilize this many beans. Prior to presenting to the emergency department, the patient made attempts to remove the beans through natural emission as well as with tweezers. The emergency department staff also made an effort to extract the more distal beans without success. He was comfortable and voiding around the beans with a post-void residual of 35 cc. A CT scan demonstrated six foreign bodies spanning from the bulbar urethra to the distal penile urethra, each measuring approximately 15 mm × 7 mm (Fig. 1). The patient was seen by urology in the emergency department and wished to attempt bedside extraction. Utilizing a combination of lidocaine jelly, manual compression of the urethra, and hemostats the most distal bean was extracted piecemeal. Due to the difficulty in extracting this bean, it was recommended that the patient be taken to the operating room to remove the more proximal specimens. The next day, he underwent urethral dilation, cystoscopy and urethral foreign body extraction. Four of the remaining five beans were noted in a grouping at the bulbar urethra (Fig. 2). Using a combination of graspers and basketing, each bean was removed separately. The final bean was encountered within the bladder. This was also basketed and removed (Fig. 3). No additional abnormalities or foreign bodies were seen and the urethra had minimal resulting trauma. He was discharged home the same day with information on safe urethral sounding behavior.

Fig. 1

CT demonstrating three of the beans in the distal penile urethra.

Fig. 2

Introperative image revealing the foreign bodies.

Fig. 3

Five beans after extraction from the patient.

Discussion

In the general population, the incidence of urethral foreign body insertions is rare. Although more cases have been reported where the patient has existing psychiatric comorbidities, another common motivation for insertion is autoerotic stimulation as part of a sexual practice known as “sounding”., It is important to try and obtain the reason behind the insertion, as repeat instances put the patient at higher risk for infection, severe injury, permanent disfigurement, among other complications related to the genitourinary tract. Lack of access to healthcare may additionally place patients at risk; in one report, a patient inserted a 40 cm long household pipe in an attempt to relieve his urinary retention because he did not have access to health insurance or sufficient finances.

A thorough history and physical exam with penile palpation should be performed. Symptoms of foreign body can range from entirely asymptomatic to urinary frequency, retention, dysuria, hematuria, abdominal or pelvic pain. Patients can be hesitant to discuss this issue, thus making a high index of suspicion and physical exam paramount during evaluation., A pelvic x-ray and/or computed tomography may be helpful to determine the foreign body's orientation, location, and proximity to the surrounding viscera. Deciding on method of removal is based on the entire clinical picture. When feasible, a manual extraction should be attempted first, so long as the foreign body is small (<1 cm), palpable, located in the distal urethra, and the patient can tolerate the procedure. Should manual extraction fail, the next step in management is endoscopic removal aided by baskets or graspers. Additionally, objects not retrievable through endoscopic practice may require urethrotomy, meatotomy, or cystotomy., One similar case of urethral kidney beans ended in a cystotomy after the beans had swollen over several days which made endoscopic retrieval impossible. While typically endoscopic management has a high success rate, some risks include pushing foreign bodies further retrograde or damaging the urethral mucosa. Open surgery may be required in cases involving intravesicular foreign bodies, larger objects, or irregularly shaped small objects.,3, 4, 5 Post-operative care may include a course of antibiotics and catherterization.

Conclusion

Management of patients with a urethral foreign body can be attempted with bedside extraction while more proximal or challenging objects may require surgical extraction via either endoscopic or open approaches. In this case, one bean was able to be removed at the bedside but the others ultimately required surgical intervention with cystoscopic extraction. In addition to removing the object in question, it's imperative that patients receive additional psychiatric referral or counseling on safe sexual practices and sounding behavior to prevent repeat occurrences.

Fundings

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.