Removing chewing gum from the urinary bladder of a 32-year-old male patient.

We report a 32-year-old male patient who was admitted to our emergency department with history of insertion of chewing gum into his urethra. The patient was extremely worried and panicky at the time of admission. On enquiry, the patient had a past history of passing a urinary stone. On advice of a friend he had chewed a gum, thinned it, and inserted it through his urethra to clean it. Subsequently, he was unable to remove the chewing gum. He was not under the influence of alcohol or any other psychotropic substances, which was confirmed by blood analysis. No psychiatric history or any chronic medication usage was found. The patient had no lower urinary tract or voiding symptoms. Urine analysis revealed microscopic hematuria and pyuria. Kidney-ureter-bladder radiograph was normal [Figure 1a]. Lower abdomen computerized tomography (CT) was done which revealed a 38 × 23 mm sized foreign body in the bladder with a mean density of 123 HU (min: 100; max: 156). The urethra was completely open without any obstruction [Figure 1a–c]. The patient was cautioned about possible acute urinary retention and offered catheterization, but he declined consent for the procedure. Considering contamination with oral bacterial flora, empirical intravenous antibiotic therapy was started: ceftriaxone 1g twice a day and metronidazole 500mg thrice a day. The next day, the patient gave consent for catheterization. Urine culture revealed a mixed result of Enterococci, coagulase-negative Staphylococci and Escherichia coli, which were sensitive to the given antibiotics. Urethrocystoscopy was performed with a 21 F rigid cystoscope and foreign body forceps [Figure 2a]. Urethra and prostatic lodge was clear. Bladder wall and ureteral orifices were normal. An attempt was made to extract the gum with a foreign body forceps, but due to its size, softness, and elasticity, it failed. Hence the chewing gum was removed by doing an open cystostomy surgery under general anesthesia [Figure 2b, c]. Suprapubically, a 3 cm transverse incision was done, bladder was opened, and the gum was removed with a Babcock clamp. The bladder wall was repaired with double-layered waterproof suturing. The patient was discharged next day with an indwelling urinary catheter. On 7th postoperative day, urine culture was sterile and the catheter was removed after cystography to ensure that there is no urinary extravasation. On one and six months follow ups the patient was asymptomatic.

Figure 1

(a) normal kidney-ureter-bladder X-ray of patient; (b) and (c) computerised tomography of lower abdomen, coronal and saggital views, showing chewing gum [red box] in urinary bladder

Figure 2

(a) cystoscopic view of the chewing gum; (b) open cystostomy procedure to remove chewing gum; (c) extracted chewing gum 4 cm in length

Our aim here is to present an unusual case of chewing gum in bladder and to suggest a guiding perspective for cases of foreign bodies detected in the urinary bladder. Although rarely encountered in practice, they require urgent diagnosis and treatment. In literature, various foreign objects have been reported to have been inserted into the urinary bladder; such as electrical cable, thermometer, glue, battery, light bulb, carrot, and hair clips, via the urethral route.[1] In addition, iatrogenic materials such as gauze, nonabsorbable suture materials, pieces of DJ stents, intrauterine device, mesh materials, prosthetic devices have been detected via migration.[2] Mostly, non-iatrogenic foreign bodies are the results of extreme sexual satisfaction for autoerotic purposes, psychiatric disorders, or the influence of drugs or intoxicating substances.[3] The present case is an interesting one as he did not have these predisposing factors.

Foreign body in the urinary bladder can have a varied symptomatology; ranging from the patient having a thin stream during micturition, acute retention, polyuria, dysuria, hematuria, and suprapubic pain. However, the patient can even be completely asymptomatic. A thorough clinical history helps in suspecting this condition. Imaging techniques may be useful depending on the properties of the foreign body in the bladder. Kidney-ureter-bladder radiograph, ultrasonography examination of the bladder, and lower abdominal computerized tomography/magnetic resonance imaging aid in diagnosing the condition. Retrograde urethrography may be performed to detect any remnant of the foreign body and/or to detect if any urethral damage has occurred while performing the urethrocystography procedure.

The chosen method for treatment should be based on the natural properties of the object. Hardness, flexibility, elasticity, size, solubility in water, and density are the features that a surgeon should consider while deciding the operative procedure. The gum, which is solid at room temperature, appears in a more elastic and soft form at body temperature, which complicates endoscopic maneuvers. Even metal objects in the bladder have been removed utilizing a magnetic sheath.[4]

Complications have been previously reported such as chronic, recurrent urinary tract infection, calcification, vesicovaginal/vesicorectal fistula, urethral stricture, obstructive uropathy leading to chronic renal failure, squamous cell cancer of the bladder, Fournier's gangrene, and death due to septicemia.[5] In addition, after treatment, the patient should be aware of all obstructive and irritative lower urinary tract symptoms and should be monitored for urethral strictures or neurourological disorders.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

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Nil.

Conflicts of interest

There are no conflicts of interest.