Self introduction of foreign body into the urethra has been reported in the literature(1-6). Majority of such cases belonged to older age groups and are often associated with mental illness, senility or sexual perversions(2,3). The diagnosis and management of these cases require expertise(2,3,7).

An 11-year-old boy presented to the emergency with oliguria and dysuria of 2 days duration. There was no history of hematuria, headache or past history of urinary complaints. Examination revealed a normally built, afebrile child with normal blood pressure. Abdominal examination revealed no organomegaly or bladder distension. There was suprapubic tenderness. Radiography and ultrasound examination of the abdomen did not reveal any abnormality. The blood urea and creatinine levels were normal. Urology consultation was sought. They catheterized the bladder, removed 50 ml of clear urine and suggested medical cause for the symptoms. Child was given a fluid challenge. Examination of the external genitalia at this stage, revealed a thread like object protruding through the external meatus. It was removed carefully and found to be a 10 cm long thick thread. The child could void freely after that without any dysuria. He initially maintained ignorance about the foreign body, but on repeated questioning, admitted that he inserted the foreign body through the meatus out of curiosity, but could not remove it. He was the first born of parents without any marital discord. His detailed pscyhological evaluation did not reveal any abnormality and the urine culture was sterile.

The lower urinary tract is the recipient of a variety of foreign bodies which almost defies imagination(7,8). Most of them are due to self instrumentation. The reasons for introduction of objects into the urinary tract could be psychiatric, accidental, sexual stimulation, curiosity especially among adolescents, therapeutic in cases of stricture urethra, relieve tension, administering illicit drugs or commit suicide(1,2). The types of foreign body, include plastic caps, hooked wire, paper clips, metal objects, glass rods, shells, light bulbs, etc.(1-3,5,7,8). Multiple urethral foreign bodies also have been described(2,4).

Patients usually present with dysuria, as in our case. Other presenting complaints include difficulty in voiding, hematuria, pain and swell-ing of genitalia, extravasation of urine, abscess formation, purulent discharge, etc.(2,3,5). Various organisms like coagulase negative staphylococcus, b-hemolytic streptococcus, E. coli, Staphylococcus aureus, Enterococcus fecalis, Proteus mirabilis and Candida albicans have been isolated from the urine(2,3). The urine culture was sterile in our patient.

Foreign body in the urethra can be above or below the urogenital diaphragm(5). This classification helps in the diagnosis and management of patients. Objects placed below the urogential diaphragm are palpable and can easily be removed endoscopically. Radiography with or without contrast may be required for diagnosis and treatment of objects placed above the urogenital diaphragm(2,5,8,9). Some authors have advised cystourethroscopy after the removal of foreign body in all the cases to assess mucosal tears, bleeding and presence of additional foreign bodies(5,10). In our case, after the bladder catheterization and fluid challenge test, the cotton thread was projecting through the external urinary meatus, which could be removed without any difficulty. Moreover the child became asymptomatic after the removal of the thread.

Psychiatric evaluation is advised in all cases of self introduction of foreign bodies into the urethra(1,2,5,7,10). Some patients have intro-duced objects for sexual stimulation or to maintain erection(2,10). The foreign objects sometimes get slipped into the bladder. Our patient was psychologically normal and there was no stress in the family also. There are only a few case reports of foreign bodies in the urethra among children. Moreover, the insertion of cotton thread is unusual.

Lakshman Rajesh,
Ajmal Kader,
Vishnu Bhat B.,
Department of Pediatrics,
JIPMER,
Pondicherry 605 006, India.

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