1328 | Social Shyness Stands behind a Roll Pen in a Female Bladder: It Mimics Acute Appen- dicitis Ihab A. Hekal Corresponding Author: Ihab Ahmed Hekal, MD, PhD Department of Urology, Dossary Hospital, Alkhobar, Saudi Arabia. Tel: +96 65 6677 2693 E-mail: eahekal@yahoo.com Received December 2011 Accepted February 2012 Department of Urology, Dossary Hospital, Alkhobar, Saudi Arabia. Keywords: abdomen; acute; etiology; foreign bodies; female; urinary bladder; appendicitis. INTRODUCTION Herein, we reported unique case which had been presented to emergency with picture simulating acute appendicitis. The surprising event; when she underwent the routine investigations, an intact roll pen was seen on her pelvic cavity. Later, she claimed self-inflected intravesical trans-urethral roll pen (14 cm) that was inserted for two months prior to her presentation. CASE REPORT A 38 years old Saudi female, married with 4 offspring. She was presented to emergency with right iliac fossa pain and fever of two days duration. She also experienced nausea and vomit- ing twice. On examination she was febrile (38˚C) with tender right iliac region and guarding. Leukocytosis, anemia and high erythrocytes sedimentation rate (ESR) were the remarkable findings in her laboratory workup. Primary diagnosis was acute appendicitis with shifting to surgical ward. Routine preoperative abdominal and pelvic ultrasound revealed minimal right iliac fossa collection (2 × 3 cm) with possible foreign body in the bladder or near the uterus. CASE REPORT Case Report 1329Vol. 11 | No. 01 | Jan-Feb 2014 |U R O LO G Y J O U R N A L A Roll Pen In a Female Bladder, It Mimics Acute Appendicitis | Hekbal Urological consultation was requested. Kidney ureter blad- der (KUB) X-ray was done in which a complete roll pen was obliquely lie inside her pelvic cavity (Figure 1). Urinalysis showed microscopic hematuria and minimal pyuria. Non contrast abdominal and pelvis computerized tomography (CT) was performed; it revealed a roll pen (14 cm) obliquely lie inside the bladder, its tip was piercing the bladder on right side and it has been under the skin (Figure 2). Retrospective through history taking; the patient claimed that she inserted the roll pen for sexual play and she could not retrieve it when it had been slipped inside her bladder. Social shyness prevents her to seek any medical advices and keep silent for 2 months. On next day; cystoscopy was carried out and trial manipulation of the roll pen inside the bladder with a grasping forceps (Figure 3A). With hydro-distension of the bladder, the roll pen was mobilized inside the bladder cavity starting by detachment of the blunt posterior end first, once it became free withdrawal of the other end aiming to be on its longitudinal access. Intact extraction of the roll pen via the urethra has been done (Figure 3B). Re-check cystosco- py for possible perforation was negative. Fixation of large caliber urethral catheter was done with recommendation of one week catheterization. Total procedure time was 30 min- utes. The patient stayed in hospital for couple of days with low grade fever. Ultrasound follow-up showed a small pel- vic free fluid in Douglas pouch. She was responded well on intravenous antibiotic and discharged afebrile with normal ultrasound findings. One week later, passive aseptic cysto- gram was carried out; it showed no leakage with intact blad- der walls. DISCUSSION Although foreign body (FB) inside the adult bladder is not a rare condition, but the aggressiveness of the case by insertion of a complete roll pen as well as the minimal invasive proce- dure with safely extraction of the whole object as one unit are worth to be demonstrated. In English literature many articles discuss the insertion of pen case, cover or even smaller ob- jects were reported. In most of them cystoscopic extraction was the best treatment modality. However, open surgery is still encountered. Most of reported bladder FB cases were presented to the hospital with urinary symptoms. Different objects have been reported, majority of them were iatrogenic in nature, intrau- terine devices (IUD), artificial sphincters, vaginal pessaries, catheter, and beak of resectoscope.(1-9) However, self-inflect- ed objects were encountered aiming for sexual pleasure and gratifications. In Rafique and colleagues study,(10) they traced many cases with different objects (wire, thermometers, hair pen, battery and others), all presented with urological symp- toms. The radiological diagnosis of radiopaque objects is the corner stone before any intervention. The identification of numbers, length, size, and associated injuries are the main goals. In our case, CT was important to identify the extent of associated Figure 1. KUB-X ray from abdomen and pelvis. Figure 2. Serial CT images of the bladder demonstrated the roll pen in bladder; A) the metallic tip of the pen under the skin on right iliac fossa; B) the blunt tip was resting on the bladder wall with thickening of the posterior bladder wall. 1330 | bladder injury. The treatment of choice is surgical extraction. Minimal in- vasive techniques (endoscopic) is the best, however in some complicated cases the open surgical treatment (cystostomy) is warranted. In English literature, we could trace only one case similar to our case (ball pen) in which the open surgery was done(10) and the urinary symptoms were the presentation. In our case, the object is 14 cm long, stiff, rigid and obliquely lies with small perforation. Late presentation due to social shyness prevents early intervention. Non-familiar presenta- tion; right iliac fossa pain and suspicious of acute appendi- citis was the primary diagnosis. All these factors were made difficultly, urological challenge and seldom case presenta- tion. CONCLUSION In community; shyness, social traditions and believes may mask serious surgical conditions. For general surgeons, dif- ferential diagnosis of bladder problems should be excluded before any operative intervention. Routine investigation, at least ultrasound, KUB- X-ray, prior to any lower abdominal surgery is mandatory. For urologists, whenever FB in the bladder, minimal invasive techniques should be exhausted before open surgery is threatened. CONFLICT OF INTEREST None declared. Figure 3. A) Cystoscopic view of the pen inside the bladder; B) extraction of the pen intact through urethra. REFERENCES 1. Bartoletti R, Gacci M, Travaglini F, Sarti E, Selli C. Intravesical mi- gration of AMS 800 artificial urinary sphincter and stone forma- tion in a patient who underwent radical prostatectomy. Urol Int. 2000;64:167-8. 2. Tornero J, Palou J, Prados M, Salvador J, Vicente J. Bladder per- foration caused by foreign body migration. Int Urol Nephrol. 2000;32:241-3. 3. Nouira Y, Rakrouki S, Gargouri M, Fitouri Z, Horchani A. Intravesical migration of an intrauterine contraceptive device complicated by bladder stone: a report of six cases. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:575-8. 4. Chamary VL. An unusual cause of iatrogenic bladder stone. Br J Urol. 1995;76:138. 5. Cardozo L. Recurrent intra-vesical foreign bodies. Br J Urol. 1997;80:687. 6. Grody MH, Nyirjesy P, Chatwani A. Intravesical foreign body and vesicovaginal fistula: a rare complication of a neglected pessary. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10:407-8. 7. Aliabadi H, Cass AS, Gleich P, Johnson CF. Self inflicted foreign bodies involving lower urinary tract and male genitals. Urology. 1985;26:12-6. 8. Ohashi H. A case of bladder calculus due to a ruptured balloon frag- ment of a Foley catheter. Hinyokika Kiyo. 1997;43:227-8. 9. Persad RA, Paisley A, Smith PJ. Retained catheter tip causing re- current urinary tract infection in a 91-yearold man. Br J Urol. 1990;66:664. 10. Rafique M. Intravesical foreign bodies: review and current manage- ment strategies. Urol J. 2008;5:223-31. Case Report