Key Messages

Interdepartmental coordination is essential to achieve optimum health care delivery, failing which may exhaust the resources available in preventable issues.

Introduction

Self introduction of foreign bodies introduced per urethra is not an unknown entity₁. Self-insertion of foreign bodies into the urethra is usually associated with sexual motive. However, foreign bodies can be inserted by children due to curiosity and by mentally retarded people as well as patients with psychiatric disorders₂ Usually, the patients seek medical help only when they are symptomatic. Detection might be either by self reporting or plain abdominal films when the foreign bodies are radiopaque or by the use of contrast media. The majority of the cases, it is a one off episode which usually never committed again by the patient as the urethral passage is very narrow and the whole episode is very traumatic₃, ₄ We present a case where an unfortunate patient with personality disorder was self reported with various type of foreign bodies 13 times in less than one year period.

Case Presentation

A 30 year old single mother with known personality disorder lives in a care home for mentally challenged persons and having 24hrs carer support. This pleasant friendly lady visited accident and emergency with complaints of lower abdominal pain and dysuria

An erect x ray abdomen showed a circular shadow in lower pelvis. The gynaecological examination was normal. Cystoscopy was performed and a two pence coin was subsequently removed from bladder. She was counselled prior to discharge to care home. Within a month she came back with similar complaints and admitted that she has introduced a porcelain piece into her bladder which was eventually removed under general anaesthetic. Since then she has been admitted 13 times with different foreign bodies in her bladder and once with an electric plug in her vagina.

Some of the foreign bodies which were removed include pieces of glass, porcelain which were sharp edged, but she was fortunate to escape potentially dangerous bladder rupture and subsequent damage adjacent structures. The largest foreign body removed was a porcelain piece measuring about 5 cm x 7cm. The patient had intravenous antibiotics prior to the procedure and followed by a course of oral antibiotic on every admission. We noticed she has a patulous urethra which bleeds when attempts made to remove the foreign bodies. Surprisingly she has no incontinence.

Each episode was promptly communicated to the carers and the psychiatrist treating the patient. Written communication emphasizing the importance of preventing further episodes were sent. Counselling and drug treatment were successful for short period of time. Intense suggestion from auditory hallucinations were found to be the reason for this act. Therapeutic changes and increasing carer support were proposed. Five months ago patient was transferred to more secure care home with 24 hours two carers support. After the change of environment and high carer support there was no recurrence reported.

Figure 1

Figure 1: Foreign bodies retrived from urinary bladder on various occasions from the same patient

Discussion

The introduction of foreign body in bladder is not a frequent incident The literature search revealed that it is more common in patients with psychiatric background₁, ₅, ₆. There is no report on recurrent episodes in a same patient. We have not come across any case with 13 instances of self introduction of foreign body.

Although there was effective communication between both specialities, the ultimate goal was not achieved initially due to the complex nature of the problem. The psychiatrist played major role in treating this challenging task. The multi-modal approach using counselling, increasing carer support and change of place found to be successful. It is essential to have a multidisciplinary approach to this kind of problems which will eventually give opportunity to exchange the concern of each doctor involved in the care of patient.

Conclusion

Foreign bodies introduced per urethra is not an unknown entity amongst the psychiatric patients but we could not find any case report with an overwhelming 13 instances which needless to say involved cystoscopy at each time under general anaesthetic. Interdepartmental coordination with more intense care at the home could save the potential complications.