ISSN: 2469-6706 Vol. 6 2019 Boondoggled: A Case Report of Arts and Crafts Gone Wrong David Fumo a, 1 Damian Garcher a Alice Bonnell a , b and Puneet Sindhwani a aDepartment of Urology, The University of Toledo, Health Science Campus, Toledo, USA, and bMercy Health Saint Vincent Medical Center, Toledo, OH, USA Self-insertion of foreign bodies into the urinary tract is a not- uncommon urological problem with significant psychosocial im- plications. A 12-year-old male presented to the ED when his fa- ther noted blood in the patient’s urine. During evaluation, the pa- tient admitted to inserting Boondoggle, a plastic arts and crafts string, into his urethra 1 week prior. He admitted to performing this activity on multiple prior occasions. He subsequently de- veloped worsening frequency, urgency, dysuria, hematuria, and suprapubic pain. Bladder ultrasound and abdominal x-ray were obtained which demonstrated a large amount of hyperdense ma- terial coiled in the bladder. He was brought to the operating room the following day for removal of the foreign body. After failed attempts at endoscopic retrieval, 34 feet of plastic string was removed via an open approach. The bladder was closed and a Foley catheter was left in place. He was discharged on post- operative day 2 on culture specific antibiotics after a successful void trial. Urethral masturbation has been associated with psy- chiatric disorders, fetishism, and sadomasochistic tendencies. For the urologist, it is critical to recognize the mental health is- sues portended by urethral foreign body insertion, and take the appropriate steps to address the underlying problem. genitourinary foreign body | bladder | urethra urinary injury | polyem- bolokoilamania endoscopy | Reports of genitourinary foreign bodies (GUFB) are abundantin the literature. The etiology of GUFB can range from ia- trogenic, the result of penetrating trauma, migration from adjacent organs, or self-insertion (1-8). Self-insertion, by far the most com- monly reported etiology in the literature, has been implicated in a number of underlying psychosocial, developmental, and masochis- tic disorders. The need for psychiatric referral is commonly dis- cussed, even when no known psychiatric diagnosis exists (9-11). The range of objects reportedly found in the genitourinary tract is truly astounding, and appears to be limited only by the caliber of the urethra and the creativity of the patient (12). Symptoms of GUFB are typically those of the lower urinary tract, including dysuria, hematuria, suprapubic tenderness, or reten- tion (13,14). Diagnosis is often made via patient history and symp- tomatology. However, this can be difficult as shame and humiliation often deters patients from being completely forthright about the pre- ceding event. Imaging modalities including ultrasound, plain x-ray, and computed tomography (CT) have been used to aid in or confirm diagnosis, as well as to plan removal strategies. Surgical interven- tion is typically required, and should proceed stepwise from least to most invasive modality necessary (12,15). While removal of GUFB may require a degree of creativity on the part of the physician, the instruments and surgical techniques re- ported are generally not outside the skillset of the average urologist. However, the overall management of these patients is not as straight- forward. The focus should be on preventing recurrence, as GUFB self-insertion is usually not an isolated event (16-18). Particular at- tention should be paid to addressing the underlying motivations for this erratic behavior. At the very least this should include extensive education regarding the dangers of such activities. Psychiatric refer- ral should almost always be considered to address the psychosocial disturbances that lead to this behavior. Case report Patient information. Age: 12 years, gender: male, ethnicity: caucasian. Related medical problems: urinary tract infection, hema- turia, genitourinary foreign body. Objective. To discuss psychosocial implications of genitouri- nary foreign body self-insert. Case. A 12-year-old male presented to the ED when his father noted blood in the patient’s urine. When confronted, the patient ad- mitted to inserting Boondoggle, a plastic arts and crafts string, into his urethra 1 week prior. He admitted to performing this activity on multiple prior occasions because "it feels like sex". On this occa- sion the string was unable to be retrieved despite multiple extraction attempts with a Q-tip. He subsequently developed worsening fre- quency, urgency, dysuria, hematuria, and suprapubic pain. Bladder ultrasound and abdominal x-ray were obtained which demonstrated a large amount of hyperdense material coiled in the bladder (Fig. 1). Past medical history was significant for depression and attention deficit disorder. There was also a question of autism spectrum dis- order. Two months prior he had been in a motor vehicle collision resulting in multiple facial lacerations with significant scarring. His parents were also recently divorced resulting in a complicated and fluctuating home environment. Afebrile with no evidence of systemic infection, he was ad- mitted, started on antibiotics, and brought to the operating room the following day for removal of the foreign body. On cystoscopy the bladder was severely inflamed and filled with neon green string (Fig. 1B). Attempts at transurethral removal were quickly aban- doned as the string became knotted. The bladder was accessed via a pfannenstiel incision. The knotted ball of boondoggle was carefully extracted which, when unraveled, consisted of a single strand 34 feet in length (Fig. 1 C-D). The bladder was irrigated thoroughly, closed, and a Foley catheter was left in place. He was discharged on postoperative day two on culture specific antibiotics after a success- All authors contributed to this paper. 1To whom correspondence should be sent: David.Fumo@utoledo.edu The authors declare no conflict of interest. Submitted: May/07/2019, published: July/19/2019. Freely available online through the UTJMS open access option 8–10 UTJMS 2019 Vol. 6 utdc.utoledo.edu/Translation ful void trial. The patient was lost to follow up despite psychiatric referral and social services involvement. Discussion The etiology of GUFB is varied. Iatrogenic foreign bodies are a particularly sensitive issue with both medical and legal ramifica- tions. Rafique et al. reported 16 cases of GUFB, of which 7 were iatrogenic. Foreign bodies included gauze sponges, a piece of fo- ley balloon, and the Teflon beak of a resectoscope (14). Multiple other reports of iatrogenic GUFB include sutures, mesh, migrated slings and sphincters, and silastic stents (1, 3, 19-22). In females, objects such as tampons, thermometers, and incontinence plugs can inadvertently be lost in the bladder following incorrect insertion (4, 6, 14). Kamil et al. reported a case of a foreign body found in the bladder of a 48-year-old female, which was accidentally inserted by her partner during a consensual sexual act (5). Polyembolokoilamania, a form of paraphilia, is a drastically more complex problem than the cases of foreign bodies acciden- tally inserted into the GU tract mentioned above. In a review of the psychological profiles of multiple cases, Kenny postulated that a serendipitously discovered pleasurable stimulation of the urethral mucosa can be an inciting event, leading to repetition with various objects of unrecognized danger (16). The prevalence of such be- havior is unknown as patients only come to attention when inserted objects are unable to be retrieved. While these objects are often re- moved without significant incident, serious complications have been reported, including urethral stricture, bladder perforation, and even complete urethral evulsion (2, 7, 8, 15, 23, 24). In 1988 Wyman re- ported the development of squamous cell carcinoma of the bladder associated with an intravesical foreign body (25). While uncom- mon, fatalities have been reported (26). It has been postulated that traumatic events, underlying psychi- atric disorders, or unusually strong libidinal drives could modify normal psychosexual drives leading to a fixation or regression to a urethral stage of eroticism1 (1, 12, 18). The prevailing themes present in the psychiatric evaluation of GUFB self-inserters include chaotic and unstable home lives in childhood, psychosexual devel- opment disorders, sadomasochistic tendencies, and self-injurious behavior (10, 16). In the case presented, the patient displays mul- tiple red flags for underlying psychosexual derangements. With a a history of recent trauma and an unstable home life, regression to urethral libidinal eroticism in a pre-pubertal male should be per- ceived as a sentinel event warranting psychiatric evaluation. Unfortunately, as is commonly the case, patient and family compliance with recommendations was not followed. Social work- ers have subsequently been involved with no resolution. A D C B Figure 1. A - abdominal X-Ray with hyperdense foreign body visible in the bladder; B - endoscopic view of coiled foreign body within the bladder; C - open surgical removal of foreign body, mid-extraction; D - open surgical removal of foreign body, post-extraction. Conclusion. GUFB insertion, particularly in children, is frequently the presenting symptom of an underlying psychoso- cial/psychosexual disorder. It should be viewed as a harbinger of fu- ture antisocial and self-injurious behavior. In children, urethral for- eign body insertion is more commonly associated with mischief or curiosity. This case details an alarming sexual act in a pre-pubescent adolescent, which represents an early deviation in psychosexual de- velopment. For the urologist, it is critical to recognize the mental health issues portended by urethral foreign body insertion, and take the appropriate steps to address the underlying problem. 1. 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