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.