Discussion
Several previous reports presented FBs in the genitourinary tract.1,2 Opthven and Kernion collected approximately 800 cases in English literature from 1755 to 1999.1Miura et al. reviewed 1,367 cases in Japan from 1917 to 1994.2 Teens and twenties account for approximately half of the patients (49.2%),2 with self-insertion as the most cause of FBs mostly due to psychiatric illness or sexual gratification.1,2 This act of inserting an object into the urethra for erotic purposes is called “urethral sounding.”4,5 Recent GoogleTMsearch accessed on April 27, 2023, using the term “urethral sounding” showed approximately 4,120,000 results giving abundant information about online shops selling many kinds of “sounds,” which are products solely for urethral sounding, or websites explaining how to do “sounding.” It has also increased by 7.5 times compared to the report in the last decade.4 An internet-based cross-sectional study in the United States (US) revealed that 10.7% of males having sex with males had engaged in urethral sounding.4 Similarly, another internet-based cross-sectional study in the US revealed that 24% of males with genital piercings had unusual genitourinary tract activities, including urethral sounding.5 So far, only data for selected male populations have been presented, and data for females remain lacking.
Bladder injuries are rare because of urethral sounding, and even rarer in females.6,7 From an anatomical standpoint, females may be hypothesized to have a relatively higher risk of bladder FBs complicating perforation than males because of the anatomical shortness of the urethra. However, information to support this hypothesis is not currently enough. The percentage of females among people with bladder FBs in Japan was 36%,2 and the percentage of females among people with bladder FBs complicating perforation was 41%.6 These two pieces of information revealed no significant differences.
Almost every household tool or appliance that can be physically inserted into the urethra has been reported.3 Cotton balls, pens, thermometers, and hairpins were the most common types of FBs among females.2, 3 Among them, thermometers were the most common bladder FB in females with bladder injuries.7However, most previous reports are considered slim cylindrical mercury-in-glass thermometers,\sout11 and have not been reported recently. This is probably because the use of flat-shaped electronic thermometers with pointed tips has become mainstream. Therefore, pens seem the latest trends.7,8 The current case inserted a traditional Asian hair stick called Kanzashi in Japanese. Several reports presented hairpins as bladder FBs,1, 2 but this is the first report ofkanzashi , to our best knowledge. Kanzashi was usually used with kimono, which is a traditional Japanese garment (Figure 2c), and they were no longer used in everyday life with the disappearance of kimono culture in Japan. However, kimonos are recently becoming popular again in tourist areas9 and kanzashi may be used on more occasions. Urologists should be aware that anything used daily can become bladder FB.
A problematic mental background is possible in patients who put objects in the urethra. Palmer et al. reported that 86% of the patients with bladder FBs had a previous psychiatric diagnosis, including bipolar disorder, schizoaffective disorder, and antisocial personality trait.3 The act of inserting FBs into the urethra is psychiatrically defined as polyembolokoilamania.10These patients may have recurrent bladder FBs because of this unfavorable psychiatric background. Therefore, appropriate psychiatric followup is needed for these patients.
As for treatment, FBs should be removed from the urethra if possible.8 However, urologists should be prepared to perform open conversion surgery at any time for safe FB removal, as in this case if bladder injury complicates.