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Introduction
A great variety of self-inserted foreign bodies in the bladder have been described. The reason is usually eroticism or curiosity. Self-inserted foreign bodies cases in the bladder are infrequent in adolescents. Depending on the nature of the foreign body, the diagnosis and management might be challenging. Diagnosis is always difficult because the insertion is hidden. Our presentation aims to report a case of an unusual self-inserted intravesical foreign body with calcification as a first-reported complication and briefly discuss the diagnostic and therapeutic implications in this challenging situation.
Case presentation
A 15-year-old healthy male adolescent applied to a urologist immediately after seeing blood in his urine. He has also confessed to groin pain, dysuria, and foul-smelling urine for 6 months. Vital signs and physical examination were insignificant other than a mild suprapubic tenderness to palpation. Laboratory blood test results were normal. The urinary sediment showed > 80 white blood cells/μL and > 5 red blood cells/μL. X-ray, ultrasonography (USG), and computed tomography (CT) were performed, respectively (Figs. 1-3) (supplementary material 1). Cystoscopy was planned for the optimal diagnosis and treatment. Under general anesthesia, a cystoscope with a 20 Fr sheath was introduced into the urethra, and a bladder stone was identified in the bladder trigone. After the holmium laser process was started, as the superficial stone layer was removed, a deeply colored core consisting of spheres appeared (Fig. 4) (supplementary material 2).. The superficial stone layer was easily fragmented, but the colorful inner layer was resistant, even though fragmented, the pieces were being reunited. The fragments of the outer stone layer were cleared through the cystoscope, but since the beads and metallic fragments were not split due to the magnetic attraction, withdrawal through the cystoscope or using forceps was impossible. Hence, a small cystotomy was performed through a Pfannenstiel incision, and all the 64 magnetic spheres were removed, some of which were partially fragmented by holmium laser, and the bladder was cleared completely (Fig. 5). The patient´s course in the post-operative period was stable. A preliminary psychological evaluation was administered on the 1st post-operative day. The patient volunteered his story about the magnetic spheres; 9 months ago, out of curiosity, he had sent one sphere through the urethra and used the second one to pick the first one up, thus inserting all 64 beads into the urethra. On the 3rd postoperative day, the drain was removed, and the patient was discharged with a urethral catheter. The catheter was removed on the 1-week follow-up after a cystogram was performed which revealed neither leakage nor any residual contrast (supplementary material 3). The patient recovered without complications.
Figure 2 Ultrasonography reporting a stone of 35 mm × 39 mm and emphasizing a strong acoustic shadow.
Figure 3 Coronal and sagittal computed tomography sections revealing a 31 mm diameter globe-shaped hyperdense image in the bladder with a marked metallic artifact.
Discussion
Intravesical foreign bodies are not rare cases1. Ingress of foreign bodies into the bladder may be by self-insertion, migration from neighbor organs, traumatic, and iatrogenic2. A variety of intravesical foreign bodies has been documented, including thermometers, electrical wires, needles, batteries, and so on3. Foreign bodies also vary according to changing eras. Neodymium spheres with high magnetic power, with the smallest diameter of three millimeters, which are marketed as toys, have also recently started to appear as a foreign body in the bladder (Fig. 6)4. The cases documented in the available literature regarding self-inserted neodymium magnetic spheres are compiled in table 1. Self-insertion of foreign bodies is rarely seen in the childhood age5. Usually, they are initially sighted at the beginning of puberty6. The reasons for the insertion of foreign bodies into the genitourinary tract could be sexual gratification, psychiatric, accidental, curiosity, especially among children, or therapeutic7. Most patients delay referring to a health professional due to embarrassment causing serious short and/or long-term complications8. In this article, calcified magnetic spheres were highlighted for the 1st time in the literature, due to delayed presentation. The consequences usually include symptoms such as frequency, dysuria, nocturia, hematuria, urethrorrhagia, obstruction, or retention9. Physical examination may reveal suprapubic tenderness and external genital organ swelling. Urinalysis may represent erythrocyturia or leukocyturia. After taking a detailed history, ideal imaging (X-ray-USG-CT) is essential in diagnosis10. X-ray is useful for radiopaque foreign bodies only, as the USG is helpful for both radiopaque and radiolucent foreign bodies. In our case, the uniform clustering of magnetic spheres led to the diagnosis of bladder stones with the help of stone formation in the outer layer making them appear blurred in the X-ray. Cystoscopic visualization is a precise method to verify the presence of intravesical foreign bodies11. In the majority of cases, cystoscopic removal is presumed optimal, usually working with balloon-wire snares, endoscopic forceps, and stone-retrieving baskets12. The studies that subject self-inserted and iatrogenic foreign bodies claim that cystoscopic retrieval is possible in approximately half of the cases13. Objects introduced through the urethra have a higher cystoscopic retrieval rate since their sizes are limited by urethral diameter14. Suprapubic cystostomy or open surgery may be performed unless cystoscopic intervention is successful in removing foreign bodies15. The up-to-date reports suggest prioritizing the open method in magnetic spheres16. An immediate proper treatment option is recommended to reduce complications. One of the most common complications in delayed presented cases is stone formation since all the foreign bodies when left for long behave as a nidus for stone formation. It is suggested that a psychiatric evaluation should be recommended to discover any underlying mental health disorders, thus reducing the risk of recurrence17.
Table 1 Self-inserted magnetic spheres cases in the available literature are listed in the table. Cases are always male, usually without psychiatric disorders, on their first attempt, confessing the self-insertion and used spheres 5-mm in diameter. Exceptional information is given in the symptoms column
| Author | Age | Symptoms (additional information, if any) | # | Retrieval method |
|---|---|---|---|---|
| Gurpriya et al.3 | 19 | Dysuria, inability to pass urine | 51 | Extraperitoneal laparoscopy after a cystoscopic failure |
| Alyami et al.7 | 19 | Dysuria, voiding difficulty (with documented psychiatric illness) | Cystotomy after a cystoscopic failure | |
| Brooks et al.11 | 26 | Dysuria, decreased urinary output for three days, | 42 | Cystoscopy using basket and three-pronged grasper |
| Ellimoottil et al.5 | 11 | Acute onset of gross hematuria and difficulty voiding | 24 | Cystoscopy using basket and grasper |
| Graziottin et al.14 | 22 | Urethral bleeding and dysuria (with panic disorder) | 29 | Cystoscopy using forceps |
| Hedgepeth15 | 23 | Urgency, frequency, hematuria | 62 | Cystotomy after a cystoscopic failure |
| Levine and Evans16 | 42 | Applied with confessing the insertion | 18 | Cystotomy after a cystoscopic failure |
| 43 | Applied with confessing the insertion | 55 | Cystotomy after a cystoscopic failure | |
| 30 | Urinary retention (has previous insertion history) | 50 | First-line cystotomy | |
| Song et al.9 | 41 | Hematuria, urinary retention, dysuria | 82 | Cystoscopy using grasper |
| Pieretti4 | 16 | Mild hematuria | 25 | Cystotomy after a cystoscopic failure |
| Robey et al.17 | 12 | Applied with confessing the insertion | 30 | Percutaneous cystostomy due to cystoscopy is time-demanding |
| Zeng et al.10 | 21 | Gross hematuria, frequency, acute lower abdominal pain (has previous insertion history) (3-mm diameter spheres) | 125 | Cystoscopy using a self-invented magnetic sheath |
| Li et al.2 | 50 | Lower abdominal pain dysuria | 57 | Cystoscopy |
| Gibson et al.6 | 11 | New onset hematuria (with attention hyperactivity disorder) | 16 | Cystotomy after a cystoscopic failure |
| 18 | Dysuria, gross hematuria (with autism spectrum disorder) | 52 | Cystotomy after a cystoscopic failure | |
| Lindsay12 | 18 | Applied with confessing the insertion | 60 | Cystoscopy using grasper |
| Liu et al.13 | 28 | Applied with confessing the insertion | 159 | Nephroscope and its forceps through the cystoscope |
| Tang and Tsai8 | 17 | Gross hematuria, frequency, dysuria (never confessed the insertion) | 74 | Cystoscopy using grasper |
| Zhang et al.1 | 11 | Lower abdominal pain, urethral bleeding, dysuria | 38 | Pneumovesicoscopy after a cystoscopic failure |
#number of the magnetic spheres.
Conclusion
The physician should keep the presence of foreign bodies in mind in patients presenting with frequency, dysuria, nocturia, and hematuria. The presentation of these cases is usually delayed due to the fear of embarrassment. Imaging techniques are crucial to identify the number, exact size, and nature of the foreign bodies. The best approach for the removal of the foreign bodies depends directly on foreign bodies´ location, nature, and size and patients´ age, as well as surgical expertise and accessible equipment. However, most foreign bodies can be retrieved utilizing cystoscopic techniques, according to the literature. Open surgical removal is usually reserved for those in whom cystoscopic techniques are unsuitable or have failed.
