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

Abstract

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 (LUTSs) 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.

1. Introduction

Foreign bodies found in the urinary tract are usually localized in the urethra or urinary bladder. There is a high diversity of foreign bodies that are self-inflicted by both men and women. These often include pens, pencils, wires, phone cables, hairpins, or other stiff objects. In most cases, foreign bodies are inserted for erotic stimulation during sexual activities. This practice is often associated with underlying psychiatric disorders or intoxication [1,2,3,4,5,6].

The following clinical manifestations result from the irritating influence of foreign bodies: symptoms include pollakisuria, hematuria, vesical tenesmus, dysuria, and urgency. The intensity of the symptoms depends on the duration of the presence of the foreign bodies in the urinary tract; a longer duration may cause pyuria and, in some cases, even urine retention.

Diagnosis is usually based on various imaging methods, as patients often do not admit to inserting foreign bodies into the urinary tract. Severe damage to the urinary tract is rare; however, a case of urinary bladder rupture has been described in the literature [7,8]. The treatment of choice is the removal of the foreign body via a transurethral approach or by open surgery [4,5,6,9,10].

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.

2. Materials and Methods

Twelve patients diagnosed with foreign bodies inserted into the lower urinary tract were selected from all patients presenting with LUTSs and treated in the Department of Urology and Urological Oncology from 2000 to 2020. The medical history records were analyzed retrospectively to gather the demographic data (age, gender, medical interview, comorbidities) and a series of case reports were prepared, along with photo documentation. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Ethics Committee of Komisja Bioetyczna przy Uniwersytecie Medycznym w Lublinie (protocol no. KE-0254/119/2023) for studies involving humans.

3. Results

3.1. Case Overview

Case no. 1

On 15 May 2005, a 34-year-old male patient was admitted to the Department of Urology due to hematuria. During the medical examination, a cord was observed protruding from the external opening of the urethra. The patient did not disclose the events leading to the presence of the cord in the urethra. A plain X-ray of the pelvis revealed a coil of wire within the urinary bladder, which precluded removal through the transurethral approach [Figure 1]. The patient subsequently underwent cystotomy with removal of the foreign body. The postoperative period was uncomplicated. However, the patient did not attend the follow-up visit [Figure 2].

Case no. 2

On 8 April 2007, a 25-year-old female patient was admitted to the Department of Urology due to recurring urinary tract infections accompanied by urination difficulties. During the gathering of her medical history, she revealed that about five weeks earlier, while she had been masturbating with a pencil, the pencil had accidentally displaced into her urinary bladder. A cystoscopy was performed, and the foreign body was removed via a transurethral approach [Figure 3]. The postoperative period was uncomplicated, and the follow-up was without complications.

Case no. 3

On 21 November 2008, a 32-year-old male patient was admitted to the Department of Urology due to severe hematuria. He had been treated for recurrent lower urinary tract infections for three years. The patient reported having inserted a nylon string into the urethra while under the influence of alcohol a few years prior to his current hospitalization. A cystoscopy was performed, during which a calculus on the coils of the string. The patient underwent cystolithotomy, and the stone was successfully removed [Figure 4]. The postoperative period was uncomplicated; however, the patient did not attend the follow-up visit.

Case no. 4

On 23 December 2010, a 63-year-old male patient was admitted to the Department of Urology due to a hairpin lodged in his urethra. The patient had inserted it to achieve penile rigidity. The KUB (kidney, ureter, bladder) X-ray revealed the hairpin located in the pelvic region [Figure 5]. An attempt to remove the hairpin using a transurethral procedure failed, as it was situated beneath the prostate gland. The patient subsequently underwent open surgery, during which the foreign body was removed. The postoperative follow-up was without complications.

Case no. 5

On June 30, 2012, a 46-year-old female patient was admitted to the Department of Urology under the influence of alcohol. She claimed that she had attempted to measure her body temperature inside the vagina but was unable to explain how the thermometer ended up in the urinary bladder. A KUB X-ray image revealed the thermometer in the projection of the urinary bladder [Figure 6]. Under spinal anesthesia, the thermometer was removed using Randall’s forceps, which were coaxially inserted with a cystoscope via the urethra [Figure 7]. The postoperative period was uncomplicated; however, the patient did not attend the follow-up visit.

Case no. 6

On 4 October 2012, a 43-year-old female patient was admitted to the Department of Urology due to the accidental insertion of a plastic object into her urinary bladder. She claimed that she used the object to enhance her sexual experience during intercourse. During the endoscopic procedure, the object was removed using Randall’s forceps, which were coaxially inserted with a cystoscope via the urethra, in the same manner as in the previous case [Figure 8]. The patient attended the follow-up visit, and there were no postoperative complications.

Case no. 7

On 5 May 2013, a 16-year-old female patient was admitted to the Department of Urology due to abdominal pain and pyuria. A KUB X-ray revealed a calculus associated with an oblong object [Figure 9]. The patient reported that it was a fragment of a pen that she had inserted into her urinary bladder while masturbating one year prior to her hospital visit. Under spinal anesthesia, the calculus and the fragment of the pen were removed during cystoscopy using lithotripsy [Figure 10]. The postoperative period was uncomplicated. The patient did not attend the follow-up visit.

Case no. 8

On 1 February 2014, a 61-year-old male patient was admitted to the Department of Urology due to difficulty with micturition and a burning sensation in the urethra. Diagnostic investigations revealed a plastic pen cartridge inserted into the urethra [Figure 11]. The patient refused to disclose how the object had entered the urethra. It was removed via a transurethral approach. The postoperative period was uncomplicated, but the patient did not attend the follow-up visit.

Case no. 9

On 3 March 2015, a 24-year-old female patient was admitted to the Urology Department presenting with pyuria following a cesarean delivery, as indicated by subsequent urinalysis. Imaging studies identified a calculus associated with a pencil located within the urinary bladder. The patient was unable to provide a clear account of how the pencil entered the bladder. She subsequently underwent cystolithotomy, during which both the pencil and the calculus were removed [Figure 12]. The postoperative course was uneventful; however, the patient failed to attend her scheduled follow-up appointment.

Case no. 10

On 18 July 2017, a 35-year-old female patient was admitted to the Urology Department presenting with severe abdominal pain, fever, and pyuria. Imaging studies demonstrated a 5 cm calculus associated with a foreign body, identified as a pen, located within the urinary bladder. The patient was unable to provide a history regarding the mechanism by which the pen entered the bladder. She was subsequently indicated for a cystolithotomy, during which the calculus was successfully extracted from the bladder [Figure 13]. Upon wound healing, the patient expressed a desire for discharge to her home. The postoperative course was uneventful. Notably, the patient failed to attend her scheduled follow-up appointment.

Case no. 11

On 11 September 2018, a 26-year-old male patient was admitted to the Urology Department presenting with micturition difficulties and pronounced dysuria. The patient was intoxicated with alcohol and reported that he had humorously injected silicone into his urethra. He had attempted self-removal of the substance for one week prior to admission. Upon evaluation, he exhibited severe abdominal pain, pyuria, and dysuria, necessitating his visit to the emergency department. A transurethral procedure was performed to remove the silicone in fragments [Figure 14]. The postoperative course was uneventful. The patient failed to attend the scheduled follow-up appointment.

Case no. 12

On 15 October 2020, a 51-year-old male patient was admitted to the Department of Urology presenting with urinary retention. An attempt to insert a Foley catheter was unsuccessful due to urethral obstruction. The patient reported that he had been assaulted by three individuals who inserted an unidentified foreign object into his urethra. The patient was urgently evaluated for urethrocystoscopy, during which a silicone cast was successfully extracted from the urethra [Figure 15]. The postoperative course was uneventful. Subsequent psychiatric evaluation and diagnostic assessments were planned following his hospitalization, but the patient did not attend the scheduled follow-up appointment.

3.2. Results Summary

The study cohort comprised 12 patients with a mean age of 38 years, ranging from 16 to 63 years. The gender distribution revealed that 50% of the participants were female. Among the patients, six (50%) explicitly acknowledged their intention to insert a foreign body. Furthermore, three patients (25%) were found to be under the influence of alcohol at the time of presentation. Notably, four patients (33.3%) reported that the insertion was for sexual purposes. Importantly, none of the patients had a prior diagnosis of psychiatric illness before hospitalization, although one patient (8.3%) was referred for further psychiatric assessment.

Follow-up data indicated that 9 out of the 12 patients (75%) did not attend their scheduled follow-up appointment. The maximum reported indwelling time of a foreign body was 3 years. The majority of patients (75%) exhibited symptoms, including lower urinary tract symptoms, hematuria, pyuria, acute urinary retention, and abdominal pain. More than half of the patients (58.3%) underwent management via a cystoscopic approach, while the remaining 41.6% required open surgical intervention.

Detailed information regarding patient demographics, type, and location of the foreign body, intent of insertion, clinical presentation, duration of indwelling, and treatment modalities is presented in

Table 1. Patients with self-inflicted foreign bodies in lower urinary tract system (M—male; F—female; UTI—urinary tract infection; LUTSs—lower urinary tract syndromes; AUR—acute urinary retention).

Case No.	Age	Sex	Foreign Body	Localization	Cause	Indwelling Time	Clinical Presentation	Treatment
	(Years)
1	34	M	wire	urinary bladder	unknown	unknown	hematuria	cystotomy
2	25	F	pencil	urinary bladder	sexual stimulation	5 weeks	UTI, LUTS	cystoscopy
3	32	M	string	urinary bladder	alcohol	3 years	hematuria	cystotomy
					intoxication
4	63	M	hairpin	urinary bladder	sexual stimulation	<24 h	none	cystotomy
5	46	F	thermometer	urinary bladder	alcohol	unknown	none	cystoscopy
					intoxication
6	43	F	plastic	urinary bladder	sexual stimulation	<24 h	none	cystoscopy
7	16	F	pen	urinary bladder	sexual stimulation	1 year	abdominal pain, pyuria	cystoscopy
8	61	M	pen cartridge	urethra	unknown	unknown	LUTS	cystoscopy
9	24	F	pencil	urinary bladder	unknown	unknown	pyuria	cystotomy
10	35	F	pen	urinary bladder	unknown	unknow	abdominal pain, pyuria	cystotomy
11	26	M	silicone	urethra	alcohol intoxication	1 week	abdominal pain, dysuria	cystoscopy
12	51	M	silicone	urethra	unknown	<24 h	AUR	cystoscopy

.

4. Discussion

Most foreign objects are found in the urinary bladder due to the ease of access through the urethra and the difficulty of retrieval without medical assistance once they have entered. Patients often insert foreign bodies, either independently or with the assistance of their partners, to enhance erectile function during sexual intercourse or to achieve heightened sensations during masturbation. Other cases may involve patients with psychiatric disorders or those under the influence of alcohol [1,3,4,5,6,9,11,12,13,14].

Masturbation is defined as the stimulation of the sexual organs, typically to the point of orgasm, with a significant autoerotic component. This term encompasses stimulation using hands, everyday objects, and accessories such as vibrators or artificial vaginas. Masturbation may occur without the partner’s participation or with only passive involvement. The concept of mutual masturbation applies to cases involving the active participation of a partner. Masturbatory hyperstimulation—also referred to as automasturbation or compulsive masturbation—often coupled with pornography, is one of the most prevalent addictions today. However, not all individuals utilize these terms; other descriptors include stimulus-free paraphilia, hypersexuality, and compulsive sexual behavior. Both forms of addiction may contribute to delayed ejaculation during sexual intercourse. Some patients may experience a greater sense of pleasure from self-masturbation than from sexual intercourse. Furthermore, individuals often develop unique masturbation techniques tailored to achieve their desired orgasmic sensations, which are frequently reinforced by sexual fantasies or pornography. Vaginal, oral, or anal intercourse may fail to replicate the stimulation achieved through specific masturbation practices. Research indicates that individuals with these patterns exhibit a reduced frequency of nocturnal emissions and report lower levels of orgasm and sexual satisfaction during intercourse [15]. Concurrently, these individuals often demonstrate heightened anxiety and increased depressive tendencies. The term “partner anorgasmia” refers to men who are unable to achieve orgasm in the presence of a partner but may ejaculate following prolonged, exhaustive masturbation. The paradox in this situation is that ejaculation can occur outside the vagina, while it happens infrequently or never within it [16]. In treating these patients, it is crucial to first eliminate any contributing factors to the dysfunction, such as medications, infections, or hormonal deficiencies. The most employed psychotherapeutic approach is behavioral training, which focuses on modifying the primary factors contributing to dysfunction in each patient. This may include redirecting their preferred method of masturbation to one that is more conducive to vaginal intercourse and altering sexual fantasies [17].

The issue of excessive masturbation in women is less frequently discussed. The principal side effects of excessive masturbation among women include mental disorders, emotional trauma, and complaints regarding poor sexual experiences [18].

The incidence of foreign body insertion through the urethra, as a manifestation of disturbed masturbation, is relatively rare. There is a significant risk of items becoming lodged in the lower urinary tract. Factors contributing to foreign body insertion include lack of a partner, misconceptions about masturbation, and underlying psychiatric conditions. In addition to the most appropriate surgical removal methods, counseling and psychiatric evaluation are essential to prevent recurrences and facilitate early detection of psychiatric issues. Comorbidities reported in patients presenting with foreign body insertion include exotic impulses, disturbed schizoid personality traits, and borderline personality disorder.

The migration of foreign bodies into the urinary bladder in men may be caused or exacerbated by friction during sexual intercourse, contractions of the muscular layer of the male urethra, and the retraction of the penis following the resolution of an erection. In women, the short length of the urethra facilitates the movement of foreign bodies, which may be further supported by contractions of the urogenital diaphragm muscles during sexual arousal [19].

The presence of foreign bodies in the urinary tract poses a challenging issue for patients, as demonstrated by the previously described cases, which complicate the process of obtaining a medical history. Often, it is challenging to obtain a clear explanation from the patient regarding the type of foreign body inserted and the circumstances surrounding the insertion. Consequently, medical imaging techniques are crucial and should be performed on every patient exhibiting persistent lower urinary tract symptoms. Following diagnosis, it is imperative that every foreign body be removed, either via a transurethral approach or, in certain cases, through surgical intervention.

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 [3,9,13,14,20,21]. Another symptom mentioned in the literature is the perineal swelling and painful protrusion from the perineum [8,10,22].

The most common imaging test used to confirm the diagnosis was a 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 [12,23].

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 [23]. 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. [21].

Severe complications like Fournier’s gangrene, fistula, urethral stricture, urinary retention, and 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, and polyembolokoilamania [4,5,20,23,24].

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

5. Conclusions

There is great diversity in both the types of self-inflicted foreign bodies in the lower urinary tract and the circumstances under which they are inserted. Often, the reason for these actions is a desire for intensified sexual stimulation, as well as underlying psychiatric disorders and addictions. The diagnostic process and subsequent follow-up after treatment can be problematic, as patients often struggle to explain the circumstances surrounding their actions. The reasons for this may include social status, mental health issues, and embarrassment about the situations they find themselves in. Atypical object self-insertion can have severe health implications and lead to unnecessary surgical interventions, ultimately lowering patients’ quality of life. Therefore, it is crucial to increase awareness among both patients and physicians regarding this rare yet serious complication.