Review Reports - Self-Inflicted Foreign Bodies in the Lower Urinary Tract Associated with Sexual Activities—A Case Series

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a very interesting study on a rare topic. The authors have provided a very large case-series for such a rare entity. The cases are celarly presented and the images are explanatory. The conclusions are well-supoorted by the results. Comments for the authors:

1) The abstract must be rewritten. Most of the current abstract is accupied by the introduction and the results and the conclusions, which are the most significant sections for the readers are summarized in two rows. Please include homogenous number of lines for all the sections (introduction, methods, results, conclusions).

2) The authors have provided in their discussion section, some important information regarding sexual patterns. However, they have not performed a litarature review on the topic. It would be very interesting for readers to have a literarure review on the topic. Moreover, the management of these very rara cases could vary among different Centers. In these settings, a presentation of the different available treatlemt modalitied would be interesting.

Author Response

Thank you for your comments. We fully agree and we corrected the manuscript as follows:

Comments 1: The abstract must be rewritten. Most of the current abstract is accupied by the introduction and the results and the conclusions, which are the most significant sections for the readers are summarized in two rows. Please include homogenous number of lines for all the sections (introduction, methods, results, conclusions).

Response 1: The abstract has been rewritten according to the suggestions, as follows:

“Foreign bodies in urological patients are commonly found in the lower urinary tract, especially in the bladder and urethra. Items such as pens, pencils, wires, and cables are often inserted for erotic stimulation, typically associated with alcohol intoxication or psychiatric disorders. The aim of this study is to present the adverse events of non-conventional sexual manipulation and the harmful effects of using atypical objects for masturbation purposes. The study presents a series of case reports describing patients with self-inflicted foreign bodies in the lower urinary tract, collected over 20 years at a single medical center. Most patients were admitted to the hospital with lower urinary tract symptoms (LUTS) and signs of infection, such as abdominal pain and fever. Only 6 out of 12 patients revealed their intention regarding foreign body insertion. Additionally, 9 out of 12 patients did not attend the follow-up visit. Self-inflicted foreign bodies in the lower urinary tract vary in type and motive. Patients may be reluctant to disclose these circumstances, complicating diagnosis and treatment, which can lead to serious health risks and a reduced quality of life.”

Comments 2: The authors have provided in their discussion section, some important information regarding sexual patterns. However, they have not performed a litarature review on the topic. It would be very interesting for readers to have a literarure review on the topic. Moreover, the management of these very rara cases could vary among different Centers. In these settings, a presentation of the different available treatlemt modalitied would be interesting.

Response 2: We added the new part of discussion section with the comparison of the latest literature with our material. We also added a sentence about different treatment modalities mentioned in the literature.

“In comparison to our data, Palmer et al. have described the presentation symptoms as dysuria, gross hematuria, urinary retention, urinary tract infection, and penile discharge. [6] Other authors agreed that foreign bodies in the lower urinary tract present with lower abdominal pain, penile and urethral pain, and various lower urinary tract symptoms. [3,9,14,15,21,22] Another symptom mentioned in the literature is the perineal swelling and painful protrusion from the perineum. [8,10,23]

Most common imaging test used to confirm the diagnosis was plain KUB x-ray, which was usually sufficient. [2,4,6] In some recent cases, CT scan and ultrasonography also play an important role in confirming the diagnosis. [13,24]

The literature divided the treatment into two main procedures: endoscopic removal and open surgery. In our results, 58% of cases were handled endoscopically and the reset by cystotomy. Oh et al. reported that in 27 cases, 74.1% used an endoscopic approach while 25.9% involved open surgery, including suprapubic cystostomy and perineal extraction. [5] Porav-Hodade et al. published the minimally invasive method of endoscopic and laparoscopic removal of wire from the bladder by inserting a trocar to the bladder, cutting the foreign body into pieces with laparoscopic scissors, and removing it through the urethra [24] Sometimes endoscopic removal was combined with extrinsic pressure on the bladder. In some cases, authors have created novel devices, like the magnetic sheath developed by Zeng et al. [22]

Severe complications like Fournier’s gangrene, fistula, urethral stricture, urinary retention, urosepsis were pointed out in a few reports. They were usually associated with foreign bodies remaining in the urinary tract for a long period. [5,6,8]

Our study found that self-infliction was mainly due to sexual stimulation and alcohol abuse. In some patients, the cause was unknown. Unfortunately, none of the cases received psychiatric evaluation during hospitalization. Other Authors reported different psychiatric disorders in their study groups: schizophrenia, post-traumatic stress disorder (PTSD), borderline or antisocial personality disorder, illicit substance abuse, polyembolokoilamania. [4,5,21,24,25]

As mentioned before, foreign bodies self-inflicted into the urinary tract in adults are rare. In the past 15 years, only 3 studies had a larger sample size than ours. [2,5,6] ”

Reviewer 2 Report

Comments and Suggestions for Authors

The article about self-inflicted foreign bodies in the lower urinary tract,is a clinical presentation of a series of 12 cases,during 20 years.I have the following comments:

-in the Introduction part,please state more clear what is the aim of the study,what do you think this presentation can add something new to the existing literature.

-row 46 please specify what department and from when till when,not only the totel period of time.

-row 47 please insert here what variables from medical history records did you utilised.

-row 63 instead "open operation",please name the operation,for example cystotomy with removal of foreign body.

-row 193 replace the word "excised" with removed.

-row 293 Research indicates" Please provide citation.

- In the Discussion part you should discuss about your cases and results,and not only providing generalities about this thema.Also,what is specific to your case comparing to other cases presented in the literature?

Author Response

Thank you for your comments. We fully agree and we corrected the manuscript as follows:

Comment 1: n the Introduction part,please state more clear what is the aim of the study,what do you think this presentation can add something new to the existing literature.

Response 1: The aim of the study was stated in the introduction.

“The aim of this study is to investigate the potential hazards linked to the use of atypical objects for masturbation and the negative outcomes associated with unconventional sexual practices.”

Comment 2: row 46 please specify what department and from when till when,not only the totel period of time.

Response 2: The department and exact years were stated.

Comment 3: row 47 please insert here what variables from medical history records did you utilised.

Response 3: The specific medical history variables were bulleted in the text.

Comment 4: row 63 instead "open operation",please name the operation,for example cystotomy with removal of foreign body.

Response 4: Corrected.

Comment 5: row 193 replace the word "excised" with removed.

Response 5: Corrected.

Comment 6: row 293 Research indicates" Please provide citation.

Response 6: Corrected.

Comment 7: In the Discussion part you should discuss about your cases and results,and not only providing generalities about this thema.Also,what is specific to your case comparing to other cases presented in the literature?

Response 7: We added the new part of discussion section with the comparison of the latest literature with our material. We also added a sentence about different treatment modalities mentioned in the literature.

“ In comparison to our data, Palmer et al. have described the presentation symptoms as dysuria, gross hematuria, urinary retention, urinary tract infection, and penile discharge. [6] Other authors agreed that foreign bodies in the lower urinary tract present with lower abdominal pain, penile and urethral pain, and various lower urinary tract symptoms. [3,9,14,15,21,22] Another symptom mentioned in the literature is the perineal swelling and painful protrusion from the perineum. [8,10,23]

As mentioned before, foreign bodies self-inflicted into the urinary tract in adults are rare. In the past 15 years, only 3 studies had a larger sample size than ours. [2,5,6] ”

Reviewer 3 Report

Comments and Suggestions for Authors

The presented case series contains really interesting cases. I think it will contribute to the literature.

1. The dates of the cases should also be written.

2. The references should be replaced with the most up-to-date ones as much as possible.

Comments on the Quality of English Language

....

Author Response

Thank you for your comments. We fully agree and we corrected the manuscript as follows:

Comments 1: The dates of the cases should also be written.

Response 1: We added the missing dates of the cases. Starting every case report with the date of admission to the hospital.

Comments 2: The references should be replaced with the most up-to-date ones as much as possible.

Response 2: We made another literature search, replaced the older, less significant references with the most up-to-date ones. What is more, we added some new literature.

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[2] Zhang Z, Zhu X, Wang Y, Chen D, Fan J, Deng C, et al. Sexual dysfunction associated with chronic retention of foreign bodies in the low urinary tract. Andrologia 2021;54. https://doi.org/10.1111/and.14346.

[3] Tuncer H, Karacam H, Cam B. A Self-Inserted Foreign Body in the Urinary Bladder and Urethra. Cureus 2021. https://doi.org/10.7759/cureus.16322.

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[9] Fatahajjad HH, Ompusunggu RA, Laksita TB, Soebadi MA. Multiple lower urinary tract calculi induced by foreign bodies inserti on: A case report. Radiol Case Rep 2024;19:2443–7. https://doi.org/10.1016/j.radcr.2024.02.100.

[10] Ahmed MM, Ahmed NA, Sharma V. A Self Inserted Unusual Foreign Body “An Entire Pencil” in a Male Uret hra and Bladder: A Case Report. Cureus 2022. https://doi.org/10.7759/cureus.25198.

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[18] Montorsi F, Adaikan G, Becher E, Giuliano F, Khoury S, Lue TF, et al. Summary of the recommendations on sexual dysfunctions in men. J Sex Med 2010;7:3572–88. https://doi.org/10.1111/J.1743-6109.2010.02062.X.

[19] McCabe MP, Sharlip ID, Atalla E, Balon R, Fisher AD, Laumann E, et al. Definitions of Sexual Dysfunctions in Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015. J Sex Med 2016;13:135–43. https://doi.org/10.1016/J.JSXM.2015.12.019.

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[22] Zeng S-X, Li H-Z, Zhang Z-S, Lu X, Yu X-W, Yang Q-S, et al. Removal of Numerous Vesical Magnetic Beads with a Self-Made Magnetic S heath. J Sex Med 2015;12:567–71. https://doi.org/10.1111/jsm.12762.

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Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

No additional comments.