Dear Editor,

Urethral foreign body insertions are rare emergencies.Multiple objects are known to be implicated.They have a low incidence,with males 1.7 times more likely to commit the act than females.Dysuria,haematuria,strangury,urinary frequency and urinary retention are common presenting features.Many such patients do not provide the history of selfinsertion due to embarrassment and can hence present late.Neglected cases can lead on to sepsis and death[1-4].Multiple objects have been implicated in foreign body insertion into the urethra.However,insertion of ear phones is a rarity.We report one such unusual case here.

A 26-year-old man presented to the Emergency Department with dysuria and urinary retention.There were no other urinary symptoms.History revealed he had self-inserted the jack of an ear phone into his penis 2 h prior,for autoerotic stimulation.There were three prior instances of such insertions after which he would remove the ear phones himself.He had also tried to catheterize himselfin the past,for sexual gratification.There was no history of underlying psychiatric illness.On examination,the ear phones and the cable were dangling from the external urethral meatus and the cable was palpable within the penile urethra(Fig.1).Pelvic radiography showed a variable length of the cable within the bladder that appeared to be coiled and the ear phone jack,intact(Fig.2).

The foreign body was retrieved through an open suprapubic cystostomy under spinal anesthesia after the wire was cut at the external urethral meatus(Fig.3 and Fig.4:The extracted foreign body).A urethral catheter was placed.The patient voided well and wenthome post-procedure aftercatheterremovalon postoperative day 3.Psychiatric opinion wassoughtin the postoperative period and he was diagnosed to have disorder of sexual preference and appropriate counseling was given.Six months postprocedure,the patient wasdoing wellwith no urologicalproblems,had attended counseling sessions and was planned for regular follow-up.

On review of literature,the array of self-inserted foreign bodies include needles,pencils,ball point pens,pen lids,garden wire,copperwire,safety pins,wire-like objects(telephone cables,rubber tubes,feeding tubes,straws,string),toothbrushes,household batteries,light bulbs,marbles,cotton tip swabs,plastic cups,thermometers,plants and vegetables(carrot,cucumber,beans,hay,bamboo sticks,grassleaves),parts ofanimals(leeches,squirreltail,snakes,bones),toys,pieces of latex gloves,blue tack,intrauterine contraceptivedevices(IUCD),tampons,pessaries,powders(cocaine),fluids(glue,hot wax)[1,2].

Diagnosis is mostly confirmed on physical examination.Radiological examination such as pelvic X-ray and computerized tomography of the abdomen and/or pelvis help delineate the foreign body’s position,orientation and decide on the approach for management[2].Neglected intravesical foreign body can lead to secondary stone formation,chronic cystitis,hydronephrosis and renal failure[5].Multiple removalattemptsrisk urethralinjury and foreign body migration.

The aim of treatment is to minimize urothelial trauma and preserve erectile function.Small foreign bodies distal to the urogenital diaphragm can be extracted by endoscopic methods with the aid of forceps,snares or baskets and have become the standard of care[1,2].When the object is visible through the external urethral meatus,gentle traction may be applied to try and deliverthe object.However,forcefulextraction could lead to damaging consequences.Following removal,cystourethroscopy helps diagnose urothelial injuries and ensure complete removal.Peri-operative antibiotics prevent septic complications.

Sometimes,more invasive foreign body extraction proceduresexternal urethrotomy,suprapubic cystotomy or meatotomy may be necessary[1,6].Infection,urethral stricture,diverticulum,fistula formation and incontinence are the complications[1,2,4].Urethral strictures(5%)are the most common delayed complication[1].Hence,appropriatefollow-upis essential todetect such complications.

Underlying psychologic reasons for such behavior need to be explored and treated appropriately to ensure such instances are not repeated and prevent further damage to the urinary tract.The help of a psychiatrist is invaluable in such cases.Kenney’s theory or Wise explanations have tried to offer explanation for such events[7].They may be seen in cases of pathological masturbation,intoxication,substanceabuseordueto psychological disorders.Accidental,iatrogenic foreign bodies,migration from surrounding organs and penetrating injuries can occur very rarely[3,4].

Itisimportantnotto manipulate such foreign bodiesexcessively when they are seen through the external meatus.An attempt may be made to deliver the object by gentle traction.However,extraction is guided by its morphology and position.Laparoscopic,cystoscopic and open methods are commonly used approaches.A holistic approach to management is crucial with evaluation of the underlying cause for such behavior.

Figure 1　Preoperative photograph of urethral foreign body.

Figure 2　Pelvic X-ray depicting radio-opaque foreign body within bladder.

Figure　3　Intraoperative　photograph　showing extraction through an open suprapubic cystostomy.

Figure 4　The extracted foreign body.

Conflicts ofinterest

The authors declare no conflict ofinterest.

[1]Mannan A,Anwar S,Qayyum A,Tasneem RA.Foreign bodies in the urinary bladder and their management:a Pakistani experience.Singap Med J 2011;52:24-8.

[2]Bedi N,El-Husseiny T,Buchholz N,Masood J.‘Putting lead in your pencil’:self-insertion of an unusual urethral foreign body for sexual gratification.JRSM Short Rep 2010;1:18.

[3]Rieder J,Brusky J,Tran V,Stern K,Aboseif S.Review ofintentionally self-inflicted,accidental and iatrogenic foreign objects in the genitourinary tract.Urol Int 2010;84:471-5.

[4]Moon SJ,Kim DH,Chung JH.Unusual foreign bodies in the urinary bladder and urethra due to autoerotism.Int Neurourol J 2010;14:186-9.

[5]Rahmani MM,Shakiba B,Ameli M.Management of an extremely long foreign body in the urethra and bladder of a 13-year-old boy:a case report.Thrita J Med Sci 2013;2:35-7.

[6]Stravodimos KG,Koritsiadis G,Koutalellis G.Electrical wire as a foreign body in the male urethra:a case report.J Med Case Rep 2009;3:49.

[7]Naidu K,Chung A,Mulcahy M.An unusual urethral foreign body.Int J Surg Case Rep 2013;4:1052-4.

Abheesh Varma Hegde＊

Suryakanth Choubey

Revanna Siddappa Kanagali

Gotam Pipara

A.Nagaraja Rao

A.Mohan

Department of Urology,St.Johns Medical College Hospital,

Bangalore,India