Delayed Diagnosis of an Intraurethral Foreign Body Causing Urosepsis and Penile Necrosis

Abstract

Cases of self-inserted foreign bodies in the male urethra and urinary bladder are unusual. In most cases, the type of foreign body can be identified by taking a history or from radiological findings; sometimes, however, it is difficult to identify the foreign body because of decreased mental capacity of the patient or unknown radiological characteristics of the foreign body. We experienced a chronic alcoholic patient with septicemia and penile necrosis in whom a fragment of mirror glass had passed through the urethra into the bladder. The glass, 2 cm in length and 0.7 cm in diameter, was detected by cystoscopy and was removed by using a resectosope.

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Korean Journal of Urology
ⒸThe Korean Urological Association, 2010 149 Korean J Urol 2010;51:149-151
www.kjurology. org
DOI:10.4111/kju.2010.51.2.149
Case Report
Delayed Diagnosis of an Intraurethral Foreign Body Causing
Urosepsis and Penile Necrosis
Eu Chang Hwang, Jun Seok Kim, Seung Il Jung, Chang Min Im, Bu Hyeon Yun, Dong Deuk Kwon,
Kwangsung Park, Soo Bang Ryu, Jun Eul Hwang1
Departments of Urology and 1Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
Cases of self-inserted foreign bodies in the male urethra and urinary bladder are
unusual. In most cases, the type of foreign body can be identified by taking a history
or from radiological findings; sometimes, however, it is difficult to identify the foreign
body because of decreased mental capacity of the patient or unknown radiological char-
acteristics of the foreign body. We experienced a chronic alcoholic patient with septice-
mia and penile necrosis in whom a fragment of mirror glass had passed through the
urethra into the bladder. The glass, 2 cm in length and 0.7 cm in diameter, was detected
by cystoscopy and was removed by using a resectosope.
Key Words: Foreign bodies; Urinary bladder; Urethra; Sepsis
Article History:
received
14 October, 2009
accepted
30 December, 2009
Corresponding Author:
Chang Min Im
Department of Urology, Chonnam
National University Medica l School,
8, Hak-dong, Dong-gu, Gwangju
501-757, Korea
TEL: +82-62-220-6700
FAX: +82-62-227-1643
E-mail: ganglion7 2@hanmail.net
FIG. 1. Abdominal computerized to-
mography (CT). (A) CT was suggestive
of a right retroperitoneal abscess, and
(B) a needle-like radiopaque lesion
between the rectum and bladder.
We report a case of urosepsis due to a glass particle that
had passed into the bladder after being self-inserted into
the urethra. We present the evaluation, imaging, and man-
agement of the condition and the unique complications sub-
sequent to the self-insertion of an intraurethral foreign
body. Our case was unique in that this is the first reported
case of urosepsis induced by an intraurethral foreign body
that resulted in a retroperitoneal abscess and penile glans
necrosis.
CASE REPORT
A 57-year-old male visited the emergency room because of
worsening fever, right flank pain, and gross hematuria
lasting 3 days. A review of his medical history determined
that he underwent an operation 7 years previously because
of an abdominal stab wound. He was a chronic alcoholic and
was mentally challenged. Before visiting our hospital, he
had been admitted to another hospital for complaints of
voiding difficulty and abdominal discomfort; he was exam-

Korean J Urol 2010;51:149-151
150 Hwang et al
FIG. 2. A necrotic lesion of the penile glans.
FIG. 3. (A) Follow-up CT shows a newl
y
detected hyperdense lesion inside the
bladder. (B) Cystoscopy shows an in-
travesical 2x0.7 cm glass particle.
ined by computerized tomography (CT) and received a ure-
thral catheterization. The CT demonstrated a distended
bladder, suggestive of a right retroperitoneal abscess, and
a needle-like radiopaque lesion between the rectum and
the bladder (Fig. 1). A physical examination revealed right
costovertebral angle tenderness and gross hematuria
through the urethral catheter. His vital signs were as fol-
lows: blood pressure, 90/60 mmHg; heart rate, 102 bpm;
body temperature, 38.2oC; and respiratory rate, 22/min.
Laboratory tests gave the following results: white blood cell
(WBC) count, 9,500; hemoglobin, 13.0 mg/dl; platelet
count, 29,000/μl; blood urea nitrogen, 122.7 mg/dl; crea-
tinine, 7.9 mg/dl; aspartate aminotransferase, 181 U/l; ala-
nine aminotransferase, 47 U/l; C-reactive protein, 35.7
mg/dl; and urinalysis, WBC 5-9/HPF and RBC 100/HPF.
Early urine and blood cultures showed methicillin-sensi-
tive Staphylococcus aureus (MSSA). Ceftriaxone (2 g/day)
was initiated for the sepsis, and hemodialysis was started
for the acute renal failure.
On day 5, he had not improved and had developed respira-
tory failure, so he was intubated for mechanical venti-
lation. On day 6, a cystostomy was made because of an ul-
cerative skin lesion on the penile glans (Fig. 2). Follow-up
cultures taken from the lesion and from the blood were pos-
itive for methicillin-resistant Staphylococcus aureus
(MRSA). Treatment was administered with meropenem (2
g/day) and teicoplanin (400 mg/day). A follow-up CT
showed a retroperitoneal abscess extending to the pelvic
cavity and a newly detected hyperdense lesion inside the
bladder. The foreign body in the urethra was probably pro-
pelled into the bladder during the urethral catheterization
(Fig. 3A). On day 14, the patient’s vital signs normalized,
and he underwent a cystoscopy. The cystoscopy revealed
a bladder wall injury and a 2x0.7 cm mirror-glass particle
that was removed by using a resectoscope with a cutting
loop by vertically repositioning the foreign body (Fig. 3B).
After removal of the foreign body, the gross hematuria
gradually improved. On day 24, hemodialysis was stopped
because the serum creatinine had normalized. On day 30,
the penile glans lesion was necrotized and then dropped out
spontaneously. The patient stabilized after drainage of the
percutaneous retroperitoneal abscess, and he was dis-
charged. After 9 months, the patient is being treated for pe-
riodic urethral dilation because a urethral stricture devel-
oped in the penile urethra.
DISCUSSION
Most foreign bodies in the urethra are self-inserted for mas-
turbation, but a mental illness, impulsive self-assaultive
acts, or drug intoxication may also be the cause [1,2].
Patients are often embarrassed to seek medical care and
may make several attempts to remove the object, resulting
in further migration of the object into the bladder and
injury. Symptoms induced by urethral foreign bodies are
varied. In an acute situation, pain with urination, gross
hematuria, and urgency may develop; in a chronic sit-
uation, there may be a recurrent urinary tract infection and
dysuria [3]. Antibiotic therapy has no effect on the in-
fection, because the underlying factor has not been re-
moved. A diagnosis is most easily made by clinical history,
physical examinations, and plain x-rays; if the object is ra-
diolucent, ultrasonography or CT is useful.

Korean J Urol 2010;51:149-151
Foreign Body in the Urethra Causing Urosepsis 151
Sometimes it is difficult to differentially diagnose a for-
eign body from other lower urinary tract diseases when pa-
tients do not admit that a foreign body was self-inserted,
when patients with diminished mental capacity forget that
they inserted a foreign body, or when patients are ignored
because there has been no preceding incident [3]. In our
case, because the patient was mentally challenged and in-
toxicated with alcohol, an accurate diagnosis was delayed,
and we did not identify the needle-like object between the
rectum and the bladder.
Extraction of the foreign object should minimize bladder
and urethral injury. Most objects are removed by endo-
scopic or minimally invasive techniques; however, manip-
ulation of the foreign body and urethral catheterization
should be avoided until the exact type, shape, size, mobi-
lity, and location of the object are determined.
Longstanding foreign bodies may cause urinary re-
tention, ascendant urinary tract infection, sepsis, and ure-
mia [3,4], but penile necrosis is a rare complication asso-
ciated with long-term hemodialysis in patients with dia-
betic renal failure [5,6]. It is also associated with pseudo-
monas sepsis [7]. In our case, urethral catheterization was
performed based on the initial diagnosis of acute renal fail-
ure secondary to alcohol-induced urinary retention, which
might have caused a delay in the removal of the foreign body
and more aggravated sepsis. We presumed that the vas-
cular insufficiency was attributable to sepsis, and the
short-term hemodialysis might have led to the penile
necrosis.
In conclusion, although the current case is an extremely
rare example, in this situation, history taking and patient
conditions are most important for early diagnosis and prop-
er management.
Conflicts of Interest
The authors have nothing to disclose.
REFEREN CES
1. Rahman NU, Elliott SP, McAninch JW. Self-inflicted male ure-
thral foreign body insertion: endoscopic management and compli-
cations. BJU Int 2004;94:1051-3.
2. Walter G. An unusual monosymptomatic hypochondriacal delu-
sion presenting as self-insertion of a foreign body into the urethra.
Br J Psychiatry 1991;159:283-4.
3. van Ophoven A, deKernion JB. Clinical management of foreign
bodies of the genitourinary tract. J Urol 2000;164:274-87.
4. Sunwoo HS, Kwon CH, Kim YS, Chung KS, Kim JC. Five cases of
foreign bodies in the bladder. Korean J Urol 1980;21:82-5.
5. Guvel S, Yaycioglu O, Kilinc F, Torun D, Kayaselcuk F, Ozkardes
H. Penile necrosis in end-stage renal disease. J Androl 2004;25:
25-9.
6. Jacobsohn HA, Jenkins PG, Jacobsohn KM. Penile calciphylaxis.
Urology 2002;60:344.
7. Rabinowitz R, Lewin EB. Gangrene of the genitalia in children with
pseudomonas sepsis. J Urol 1980;124:431-2.