Introduction

A great variety of self-inflicted foreign bodies have been removed from the lower urinary tract and male external genitalia. These foreign bodies were inserted or applied for autoerotic, psychiatric, therapeutic, or no definite reasons by the patient. Most patients were too ashamed to admit they had inserted or applied any object and usually presented when a complication had occurred from the foreign body such as difficulty in voiding, hematuria, pain or swelling, extravasations or abscess formation. Our case is a peculiar one. No such foreign body in urinary bladder has been reported so far in the literature.

Case History

14 year old boy came to us with complaints of pain, difficulty in voiding with dribbling of urine and subsequently developed acute urinary retention of 24 hours duration. Previously he had no urological symptoms before this episode. After further questioning he gave an interesting history. While he was cleaning the fish tank in his house, he was holding a fish in his hand and went to the toilet for passing urine. When he was passing urine, the fish slipped from his hand and entered his urethra and then he developed all these symptoms.

On clinical examination, his external urethral meatus and external genitalia were normal. He had distended bladder. Mentally he was sound and clinically he was absolutely a normal person with no previous history of any psychiatric illness.

Investigations

Routine blood investigations were normal. Plain X ray KUB was normal. Abdominal Ultrasonogram showed normal kidneys, bladder was full and a 1.5 Cm echogenic object found inside the bladder without any after shadow. With the probable diagnosis of foreign body in urinary bladder, we posted the case for emergency cystoscopy under general anesthesia.

Management

With 19F cystoscopic sheath and 30 degree scope, cystourethroscopy was done. His urethra was normal. There was about 2 cm long dead fish found inside the bladder. We tried to remove with biopsy forceps but unable to hold because of the smooth surface. Then we introduced rigid ureteroscope and with the help of stone grasper the fish was removed in Toto. Removed fish was about 2 cms in length and 1.5 cms in width. Patient was asymptomatic at follow-up and subsequently he was sent for psychiatric counseling.

Discussion

All kinds of foreign bodies from the bladder have been reported which includes such odd cases as the finding of two gold chains and a pearl in an Arab [₁]. But no case of fish as a foreign body in bladder has been reported so far. Only one case of perivesical mass, which was diagnosed as an abscess caused by a fish bone that migrated from the intestinal tract, has been reported [₂].

One of the strangest stories from the Amazon was a fish that was urinophilic and could swim up the urethra or into the vagina who urinated while bathing in the Amazon. It was said that this fish, known as candirú [in Brazil; as carnero in Spanish-speaking countries], was long, thin, and capable of forcing its way into the body's passageways following the trail of urine [₃]. Once inside it would eat away the mucous membranes and tissues until hemorrhage would kill it or the host. It was also said that even if one caught the fish by the tail, once in the urethra it could not be pulled out because it would spread itself like an umbrella.

The Candirú or Canero (Vandellia cirrhosa) is a freshwater fish belonging to the Catfish group. The species grows only to being one to two inches in length and four to six millimeters wide. It is shaped like an eel and is almost completely transparent, making it almost impossible to see in the water. A fast, powerful swimmer, the fish is smooth and slimy, with sharp teeth and backward-pointing spines on its gill.

One way to expel the fish would be to drink the juice of the green fruit of the Jagua tree, Genipa Americana L. The juice of this fruit is brewed into a tea and drunk hot, supposedly causing the skeleton of the fish to dissolve and resulting in its expulsion from the victim within a couple hours. A synthetic version of the brew has been used in the past by urologists to dissolve bladder “incrustations” and kidney stones. The Candiru can also be removed surgically. But both these processes are time consuming.

All sources insist that the incredible story is true, but for evidence they rely mostly on vague second- or thirdhand reports from missionaries, doctors, natives, and the like. Even the doctors' accounts tend to lack persuasive detail, although one article (Lins, Journal of Urology, 1945) claims a U.S. navy surgeon named Charles Ammerman operated on three candirú victims, in one case slicing into the bladder to extract the fish [₄]. One catfish researcher believes that the root of these tales is the need to keep village streams, the only source of drinking water, unpolluted. This frightening story would stop anyone from urinating in the water, which may be the whole point. His investigations found no proof that this fish has ever entered a human being. We assume that our case may be the first evidence of fish traveling upstream in the urethra crossing the external sphincter and entering the bladder.

Conclusion

Introduction of foreign bodies into the bladder may be through self-insertion, iatrogenic means or migration from adjacent organs. Extraction should be tailored according to the nature of the foreign body and should minimise bladder and urethral trauma. Complete extraction should also be confirmed by panendoscopy at the end of the extraction procedure. The possibility of an intravesical foreign body should be considered in any patient with chronic unexplained lower urinary tract symptoms.

Correspondence to

Prof.R.Jeyaraman.Consultant Urologist,Chennai. 4,Police quarters road, T.Nagar,Chennai- 600 017. Tamil nadu, India. Phone: 9841020556. E mail:www.drrjeyaraman@eth.net