Unusual Foreign Bodies in the Lower Genitourinary Tract

Foreign body in the lower genitourinary tract is a relatively rare occurrence. A variety of foreign bodies have been reported in the literature. Commonly reported condition under which foreign bodies are introduced into genitourinary tract is autoeroticism. The highest incidence occurs in homosexuals, lesbians and masochism. But self-introduction of foreign body in the vagina in a 5-year-old girl is an extremely rare occurrence. Here we report two cases of self-inserted lower genitourinary foreign body in two different ages.


Introduction
Foreign body insertion in the lower genitourinary tract is unusual.But several cases have been reported and possible causes are as a result of curiosity, autoerotic stimulation, psychosexual disorder, drug intoxication and various medical procedures. 1 The inserted foreign bodies varied from very smooth and slippery substances to even rough and sharp objects like wire, screw, snake, mobile charging pin, head phone jack etc. 2 Patients with self-introduced foreign body seek medical attention quickly after failure of retrieval.Diagnosis of these foreign bodies can be made by clinical history, physical examination and imaging studies.

Case 1
A 5-year-old girl brought to the emergency department by her parents with complaints of pain and itching in the external genitalia for four hours.They also brought an eyeliner with a missing cap which the baby was used to play with.Their suspicion was during playing the baby might have inserted it through the vagina.After arrival the baby was quiet and no active bleeding was noted.Radiography of pelvis showed a radioopaque elongated shadow in the pelvic cavity (Fig 1).
Ultrasound of abdomen revealed no abnormality.After proper exposure with general anaesthesia a metallic hollow foreign body was noted inside the vagina which was removed with a small artery forceps and after retrieval it revealed an eyeliner cap (Fig 2).After removal of foreign body there was no bleeding and the baby was observed for 4-6 hours and was discharged.A 35-year-old man presented with the history of electric wire passing through his urethra by himself six hours back.He stated that he inserted this wire due to urethral irritation and after insertion he could not retrieve it.He did not develop urinary retention and could pass urine with the wire in situ.On inquiry he mentioned that the wire was a mobile phone audio cable.Examination revealed a black wire passing through the urethra.With minimal traction it caused pain and failed to retrieve.Plain radiograph revealed a coiled radio-opaque substance in the pelvis which was knotted inside and that caused failure of retrieval.Abdominal sonography showed no abnormality (Fig 3).Urethrocystoscopy was performed and knotted wire was retrieved.No bladder injury was found and only small urethral erosion was noted.

Discussion
Foreign body in the genitourinary tract is a relatively uncommon condition.Irrespective of sex, the spectrum of foreign bodies varies from sharp objects (pin, needles, ballpoint pen, pencil lead, safety pin) to wire-like objects (telephone cables, rubber tube, feeding tubes, straws), tooth brushes, household batteries, thermometer, vegetables (cucumber, beans, leaves), animal parts (leaches, fish bones), powder (cocaine) and fluid (glue and hot wax). 2,3Self-infliction is more common in men than the women with a ratio of 7:1. 4 Motivation for self-infliction is mostly auto-erotic.Other reasons are psychiatric disorders, mental confusion, narcotic drug intoxication etc. 2,5 In children it is out of inherent curiosity.Few theories are postulated for motivation of self-infliction.The theories are Kenny's and Wise's theories.
Kenny's theory postulates that after an initiating event of accidentally discovered pleasurable stimulation of urethra, it will be followed by repetition of same actions using different objects.Wise considered urethral manipulation as a paraphilia combining sadomasochistic and fetishist elements, where the orgasm of a particular individual depends on the presence of a fetish. 6r first case was a 5-year-old girl who inserted an eyeliner cap into her vagina while playing with it was quite unnatural as the girl was not supposed to be aware of vaginal orifice and not self-motivated to insert such foreign body.Her parents told us the history and details of the foreign body and showed an eyeliner with missing cap.However, we confirmed it by radiograph.
In our second case, as the foreign body was coiled inside the bladder the patient could not retrieve it by himself and he sought medical attention.A rough metallic end of an audio jack is extremely uncommon to use in urethra for sexual desire.The management depends on nature of foreign body, its position, availability of imaging facilities and expertise.Immediate management consists of firm assurance, adequate analgesic, broad-spectrum antibiotic and proper localization by imaging studies.Usually plain X-ray can locate the position.Sometimes USG is necessary if the foreign body is thought to be radiolucent. 6The main goal is to complete removal of the foreign body with minimal trauma to the genitourinary tract.
If such foreign body remains for a long time, it may cause complications such as infection, stones or fistulae formation.Delayed complications such as vaginal stricture, urethral stricture, fistula with adjacent organs can occur. 7So close follow-up is recommended.

Conclusion
Many techniques may be applicable for extraction of lower genitourinary foreign body.Such cases should be treated with minimally invasive techniques if possible.A regular follow-up with psychiatric consultation is necessary to prevent recurrent occurrence and early detection of late complications.

Fig 1 .
Fig 1. Radiograph shows a radio-opaque shadow in pelvis

Fig 3 .
Coiled electronic wire inside the bladder