First Successful Endoscopic Removal of a Pen from the Male Urinary Bladder

Somanatha Sharma¹, Javangula Venkata Surya Prakash¹, Vetrivel Natarajan¹

¹Department of Urology, Government Stanley Medical College, The Tamil Nadu Dr. M.G.R. Medical University, Chennai, India

DOI : 10.5505/GJU.2024.39200

Pages : 059-062

Abstract

Self-inflicted foreign bodies in the urinary bladder are very rarely reported. Insertion of a wide variety of objects into bladder due to autoerotic stimulation, psychiatric disturbances, and senility etc. have been reported in the medical literature. This case report discusses an exceptional incident where a young male patient self-inserted a ball-point pen into his urinary bladder via the urethra. Notably, the pen negotiated the curvatures of the urethra without causing significant lower urinary tract injury. The report underscores the challenges and successful endoscopic removal of the pen, marking the first documented instance of such an extraction in a male patient.

Introduction

The presence of self-inflicted foreign bodies in the urinary bladder is an uncommon phenomenon, with objects typically small in size and associated with factors like sexual gratification, psychiatric disorders, or advanced age [1]. In literature, there have been reports of long foreign bodies such as pens, pencils, telephone cable, beading awl and thermometer that have been found in the bladder [2-7]. This case presents the unique instance of a self-inserted ball-point pen in a male patient"s bladder, successfully removed through endoscopic methods using a nephroscope cystoscopy.

Case Presentation

A 34-year-old migrant laborer experienced dysuria, terminal hematuria, and suprapubic pain following self-insertion of a ball-point pen into the urinary bladder during masturbation. Radiological examinations confirmed the intravesical location of the pen [Figure 1,2]. Under regional anesthesia, we performed cystoscopy with a 20 F 30-degree telescope which revealed intact anterior and posterior urethra, with minor mucosal injuries in the posterior urethra. The freely moving pen in the bladder and its impingement on the bladder wall were noted [Figure 3]. Initial cystoscopic extraction attempts to grab its freely dangling distal end with a conventional cold-cup grasper failed due to the wide diameter of the pen. A three- prong grasper was delivered through the work channel of a 22 F rigid nephroscope introduced through urethra and the pen was extracted successfully highlighting the need for adaptive techniques in endoscopic procedures [Figure 4,5]. Despite the challenges such as the sharp tip, wide diameter and slippery surface of the pen, the three-prong grasper enabled successful extraction without significant mucosal injuries. The procedure was completed in less than 40 minutes, emphasizing the importance of precise maneuvering in overcoming such challenges.

Figure 1. X-ray of the pelvis depicting the metal portion of a linear foreign body within the bladder region

Figure 2. CT-KUB confirming the presence of the foreign body in the bladder without any signs of bladder perforation

Figure 3. Cystoscopic observation displaying both ends of the foreign body within the bladder (A, B); Successful extraction of the pen through endoscopy using a nephroscope and triprongs grasper (C, D)

Figure 4. Armamentarium used for the extraction; 22 F rigid nephroscope and tri-prongs grasper, alongside the successfully removed foreign body

Figure 5. Extracted pen from the bladder measuring 13 cm in length

Discussion

The insertion of foreign bodies into the urinary bladder, termed as "self-inflicted urethral foreign body insertion," is a rare but documented phenomenon. While successful extraction of foreign bodies from the female urinary bladder has been documented [6], extracting them from the male urinary bladder presents distinct anatomical and technical challenges [4,5]. Previous reports have described cases of bladder perforation, migration of foreign bodies into the abdominal cavity, and the need for open surgical interventions in these patients [7-10]. Therefore, the successful endoscopic extraction presented in this case adds valuable insights to the existing body of literature and reinforces the feasibility of minimally invasive approaches in managing such cases. The successful transurethral removal of a pen from inside the male urinary bladder using endoscopic methods marks a significant milestone in urological practice. This case underscores the importance of employing adaptive techniques and specialized equipment, such as rigid nephroscopes and three-prong graspers, in addressing unique challenges posed by long and rigid foreign bodies. The ability to negotiate through the urethral curvatures and extract the pen without causing significant mucosal injuries highlights the expertise and skill required in endourological procedures. Nevertheless, urologists should be prepared to switch to open surgical procedures if endoscopic extraction is unsuccessful, in the absence of appropriate endoscopic equipment or they have insufficient surgical expertise in endoscopic techniques [11,12].

Conclusion

In conclusion, the successful endoscopic extraction of a ball-point pen from inside the male urinary bladder highlights the efficacy of minimally invasive approaches in managing complex cases of self-inflicted foreign bodies. This case demonstrates that long foreign objects can be effectively removed endoscopically, provided that appropriate endoscopic instruments, and equipment are readily available.

Ethics Committee Approval: N / A.

Informed Consent: An informed consent was obtained from the patient.

Publication: The results of the study were not published in full or in part in form of abstracts.

Peer-review: Externally peer-reviewed.

Authorship Contributions: Any contribution was not made by any individual not listed as an author. Concept – S.S., J.V.S P., V. N.; Design – S.S., J.V.S P., V. N.; Supervision – S.S., J.V.S P., V. N.; Resources – S. S., J.V.S P., V. N.; Materials – S. S., J.V.S P., V. N.; Data Collection and/or Processing – S. S., J.V.S P., V. N.; Analysis and/or Interpretation – S. S., J.V.S P., V. N.; Literature Search – S.S., J.V.S P., V. N.; Writing Manuscript – S. S., J.V.S P., V. N.; Critical Review – S. S., J.V.S P., V. N.

Conflict of Interest: The author declares that there was no conflict of interest.

Financial Disclosure: The author declares that this study received no financial support.