239Archivio Italiano di Urologia e Andrologia 2016; 88, 3 CASE REPORT A rubber tube in the bladder as a complication of autoerotic stimulation of the urethra Konstantinos Stamatiou, Hippocrates Moschouris Tzaneio Hospital, Pireas, Greece. Self-insertion of foreign bodies in the ure- thra is most commonly associated with sexual or erotic arousal of adolescents with mental health disorders. Rarely it may practiced by healthy adults for mas- turbation. Migration of foreign bodies used for the above- mentioned purpose from the urethra to adjacent organs is a relatively uncommon urologic problem that may cause seri- ous complications which arose tardive. Presentation includes a variety of acute or chronic symptoms that depend of the underlying complications. The method of extraction depends on the shape, size and nature of the object and should be tailored according to the condition of the patient. In the present article we present a case of a rubber tube inserted to the urethra for erotic arousal purposes which migrated to the bladder during masturbation. KEY WORDS: Foreign bodies; Urinary tract; Fetishism. Submitted 29 February 2016; Accepted 25 April 2016 Summary No conflict of interest declared. of a rubber tube inserted to the urethra for erotic arous- al purposes which was migrated to the bladder during masturbation and its successful management. CASE REPORT A 65-year-old man presented in the emergency depart- ment reporting a rubber tube placement in the urethra for sexual pleasure, for more than 36 hours. He reported no dysuria or pain after insertion. Physical examination showed no evidence of foreign body in the urethra. Laboratory findings revealed microscopic hematuria and mild pyuria in routine urine analysis, but the results of the complete blood count and electrolyte profile were normal. X-ray of the pelvis showed a coiled-up radio-opaque shad- ow in the bladder (Figure 1). Cystoscopy confirmed the presence of a red coloured plastic tube in the bladder lumen (Figure 2). With the use of a crocodile type endo- scopic grasper, rearrangement of the tube in order to facil- itate its removal due to inconvenient positioning of the tube inside the bladder was successfully done under local anaesthesia and the tube was finally removed. Length of tube was 23 cm (Figure 3). No urethral and/or bladder trauma occurred. The complete extraction of the object was confirmed by both endoscopy and radiology at the end of the extraction procedure. Postoperative period was uneventful. DOI: 10.4081/aiua.2016.3.239 INTRODUCTION Insertion of foreign bodies in the urinary tract is a rela- tively common condition and is due to different aetiolo- gies. It is usually iatrogenic in the upper urinary tract, however in the bladder and urethra it may equally be iatrogenic or due to self-insertion, and rarely due to migration from adjacent organs (1). Self-insertion of for- eign bodies in the urethra is an unusual condition and the reasons for it are difficult to comprehend. It is most commonly associated with sexual or erotic arousal of adolescents with psychiatric disorders. Other reasons for urethral manipulation include, drug intoxication, mental confusion, sexual curiosity, sexual arousal and/or a desire to get relief from urinary symptoms. Foreign bodies used for the above mentioned purpose may include flexible or rigid and fragile or strong materials such as needles, bul- lets and pens, as well as candles, gauzes, etc. Migration from the urethra to adjacent organs is a relatively uncom- mon urologic problem. The foreign body can remain there for a long time with no or minimal discomfort. In most cases, however, the foreign body causes severe pain, hematuria, and urinary tract infection which rise tardive (2). Treatment approach should also minimize urethral and/or bladder trauma and must ensure the complete extraction of the object. The last must be con- firmed by radiology or endoscopy at the end of the extraction procedure. Here, we report an interesting case Figure 1. X-ray of the pelvis shows a coiled-up radio-opaque shadow in the bladder. Stamatiou_Stesura Seveso 21/09/16 09:10 Pagina 239 Archivio Italiano di Urologia e Andrologia 2016; 88, 3 K. Stamatiou, H. Moschouris 240 DISCUSSION Healthy adult individuals rarely practice insertion of for- eign bodies in the urethra. This practice in a sexual context concerns men with urethral manipulation fetishes which are commonly referred with the terms urethral sounding and urethral play. Both can involve the introduction of either soft or rigid items into the meatus of the penis and farther in the urethra and the prostate. Rigid objects such as sounds are usually only inserted about halfway into the glans and can usually be easily retrieved. In contrast, soft objects such as tubes and catheters may be introduced deeper. Some items may even be allowed to curl several times or expand within the bladder. This action in the male may be directly or indirectly associated with stimulation of the prostate gland which produce erotic satisfaction (3). Urethral manipulation may occur both actively or passive- ly associated with fetishism or masochism respectively. Persons who get sexually aroused from the self-insertion of objects into their urethra for autoerotic stimulation pur- poses falls to the first category and consist the majority of the cases. The second category concerns insertion of for- eign bodies in the urethra via medical procedures request- ed by the person. Although this behaviour shares features with masochism since very few of those who engage in such practices report pain, the association does not seem justified based on the clinical evidence reported (4). In our case, despite careful and discrete history taking it wasn’t possible to determine whether the rubber tube was insert- ed to the urethra by the patient or his sexual companion. According to the literature, a multitude of objects have been found in the urinary bladder. Among others, tubes made of rubber are the most commonly used (5). In con- trast to our case, most of the reported cases of foreign body insertion to the urinary tract are characterized by severe symptoms such as pain, hematuria, and urinary tract infec- tion (6). In all cases however, careful history taking, phys- ical examination and imaging evaluation are necessary in order to determine the size and location of the foreign body. This is of outmost importance for the selection of the appropriate method to remove the foreign bodies com- pletely with the minimal damage to the bladder and ure- thra. Similarly to our case, endoscopic management is reported to be successful however in a few cases open pro- cedures such as suprapubic cystostomy, external urethro- tomy or meatotomy are required (7). Our patient refused psychiatric evaluation however it seems that motivation and associated psychosocial issues requires investigation since they are both important in order to prevent future episodes. ETHICAL APPROVAL Written informed consent was obtained from the patient for publication of this case report and its accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. REFERENCES 1. Rieder J, Brusky J, Tran V, et al. Review of intentionally self- inflicted, accidental and iatrogenic foreign objects in the genitouri- nary tract. Urol Int. 2010; 84:471-475. 2. van Ophoven A, deKernion JB. Clinical management of foreign bodies of the genitourinary tract. J Urol. 2000; 164:274-87. 3. http://en.wikipedia.org/wiki/Urethral_sounding. Accessed on 05/03/2015 4. https://drmarkgriffiths.wordpress.com/tag/urethral-foreign-bod- ies/. Accessed on 05/03/2015 5. Cho DS, Kim SJ, Choi JB. Foreign bodies in urethra and bladder by implements used during sex behavior. Korean J Urol. 2003; 44:1131-1134. 6. Moon SJ, Kim DH, Chung JH. Unusual foreign bodies in the uri- nary bladder and urethra due to autoerotism. Int Neurourol J. 2010; 14:186-189. 7. Mitterberger M, Peschel R, Frauscher F, Pinggera GM. Allen key completely in male urethra: a case report. Cases J. 2009; 2:7408. Figure 3. The length of the red coloured rubber tube is 23 cm. Correspondence Konstantinos Stamatiou, MD stamatiouk@gmail.com Tzaneio Hospital 2 Salepoula str. 18536 Piraeus, Greece Hippocrates Moschouris, MD Tzaneio Hospital, Pireas, Greece Figure 2. Cystoscopy image of a red coloured rubber tube in the bladder lumen. Stamatiou_Stesura Seveso 21/09/16 09:10 Pagina 240