Transperineal approach for penetrating injury of corpus spongiosum and bulbous urethra caused by vesicourethral foreign body: a case report

Introduction

Foreign bodies in the bladder and urethra are frequently encountered in urological practice. Such cases often involve self-insertion for sexual gratification or psychiatric disorders, although iatrogenic causes, such as retained surgical materials migrating through the bladder wall, have also been reported.1 Presenting symptoms vary and may include frequency, dysuria, hematuria, decreased urinary stream, and fever. Reported foreign bodies encompass a wide variety of objects, including thermometers, pens, cotton swabs, tampons, clips, straws, and batteries.2,3 While endoscopic removal is typically attempted initially, open surgical intervention is often required in cases involving large objects or bladder perforation. In rare instances, when foreign bodies penetrate the urethra, open surgery is frequently necessary.

We present a case in which a bamboo skewer was self-inserted into the urethra for sexual gratification, resulting in penetration of the bulbar urethral corpus spongiosum. This report describes the clinical presentation, surgical management, and relevant considerations for this rare entity.

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Koto Hospital (IRB No. 202302). Written informed consent was obtained from the patient in this study. The CARE checklist was also performed for reporting this case (Supplementary Material S1).

Case presentation

Patient information

A 64-year-old man presented to our urology department the day after he was unable to remove a bamboo skewer he had self-inserted into the external urethral meatus for masturbation. He had no prior medical history and was not taking any medications. The patient retained the ability to void spontaneously after the procedure. No external injuries, bleeding, abdominal tenderness, or guarding were observed.

Clinical findings and diagnostic assessment

Laboratory findings included, WBC (white blood cell count): 11,640/μL, RBC (red blood cell count): 5,090,000/μL, Hb (Hemoglobin): 16.8 g/dL, PLT (platelet count): 172,000/μL, ALT (alanine aminotransferase): 30 IU/L, AST (aspartate aminotransferase): 32 IU/L, CRP (C-reactive protein): 0.42 mg/dL, Na (Sodium): 140 mEq/L, K (Potassium): 4.1 mEq/L. Tests for Hepatitis B Virus (HBV), HCV (Hepatitis C Virus), HIV (Human Immunodeficiency Virus), and syphilis were all negative.

Abdominal computed tomography (CT) revealed a rod-like foreign object extending from the bulbar urethra into the bladder (Figure 1). Cystoscopy confirmed a bamboo skewer extending through the urethra into the bladder, penetrating the bulbar urethral corpus spongiosum (Figure 2A). Endoscopic removal using grasping forceps was unsuccessful. The patient was admitted, and a suprapubic cystostomy was performed. Empirical antibiotic therapy with cefazolin was initiated in this patient. Surgical removal was scheduled for day 2 of hospitalization. 6 months after the injury, the urethra had healed, and there was no urethral stricture (Figure 2B).

FIGURE 1. Computed tomography (CT) images of the patient. (A) CT scan showing a foreign body extending from the urethra into the bladder. (B) 3D composite CT image. A rod-shaped foreign object protruding from the pelvic cavity was observed. The image was reconstructed using volume rendering technique on a SYNAPSE Vincent workstation (FUJIFILM, Tokyo, Japan)

FIGURE 2. Cystoscopy images of the patient. (A) Immediately after injury, A bamboo skewer was lodged in the bulbar urethral corpus spongiosum. (B) 6 months after the injury, the urethra had healed, and there was no urethral stricture

Surgical procedure

Anesthesia and Positioning: Under general anesthesia, the patient was placed in the lithotomy position. Standard sterilization was performed, and the perineal region was draped using sterile drapes.

Urethral Exposure and Foreign Body Removal: A midline perineal incision was made to expose the bulbar corpus spongiosum. The tip of the skewer was manually palpated. The urethra was opened via a 4 mm incision at the palpable site (Figure 3A), and a 13 cm bamboo skewer with an attached elastic cord was removed (Figure 3B).

FIGURE 3. (A) The urethra was opened at the bulbar urethra through a perineal midline incision. (B) A bamboo skewer approximately 13 cm long and an attached elastic band

Urethral repair

The tunica albuginea of the corpus spongiosum was closed with absorbable sutures. The corpus spongiosum and skin were subsequently closed, and a compression dressing was applied. Cystoscopy confirmed the absence of residual intravesical foreign body.

On postoperative day 2, the suprapubic catheter was clamped, and spontaneous voiding was confirmed, allowing for its removal. Uroflowmetry on postoperative day 3 showed a voided volume of 176 mL, Qmax 21.2 mL/s, voiding time 13 s, and postvoid residual of 11 mL. On postoperative day 7, antibiotics were de-escalated to cefcapene pivoxil based on urine culture sensitivity, and the patient was discharged the same day.

At 6 months postoperatively, retrograde urethrography, voiding cystourethrography (Figure 4) and cystoscopy (Figure 2B) showed no evidence of urethral stricture or fistula. No complications, such as dysuria, incontinence, or erectile dysfunction, were observed during the follow-up period.

FIGURE 4. (A) Retrograde urethrography six months after injury. (B) Voiding cystourethrography six months after the injury. There was no evidence of urethral stricture or fistula

Discussion

Bladder and urethral foreign bodies are not rare in urological practice, and various objects have been reported. Although more commonly seen in men, these incidents can occur across all age groups.4 Foreign body cases in urology are relatively uncommon. According to van Ophoven et al., they account for approximately 0.7 per 100,000 urological hospital admissions.4 However, due to embarrassment or underlying psychiatric issues, many patients may avoid seeking medical attention, and the true incidence is likely underestimated. Foreign bodies in women are more likely to migrate into the bladder because of the shorter and straighter female urethra.4

The optimal removal approach depends on the size, location, and composition of the object, and the extent of urinary tract injury. If the object is small (<1 cm), mobile, distal, palpable, and the patient is not experiencing gross hematuria, manual extraction by external compression may be attempted initially. Most foreign bodies can be removed manually or endoscopically, with minimal complications and favorable outcomes.3 Holmium laser has also been reported as effective for fragmentation and removal of intravesical foreign bodies.5,6 In contrast, large intravesical objects, those causing bladder perforation, or those embedded in the posterior urethra or associated with severe inflammatory response, often require open surgical removal.4 According to Palmer et al., in a series of 27 patients (35 episodes), the most common removal method was manual extraction with external pressure (54%), followed by endoscopic retrieval (23%), open cystotomy (3%), and spontaneous voiding (20%).7 This indicates that a majority of urethral foreign bodies can be managed with minimally invasive techniques, although a small proportion still require open surgery due to the size, location, or complexity of the foreign object. Penetrating urethral injuries from foreign bodies are rare, but many cases necessitate open surgery.8

Psychiatric disorders are the leading cause of foreign body insertion, followed by intoxication and autoerotic behavior. Although mental health assessments are often overlooked, some authors recommend psychiatric consultation to prevent recurrence.3 In the present case, psychiatric intervention was considered but was declined by the patient. Nevertheless, urologists can still play a proactive role in addressing the psychosocial aspects of such cases, including initiating conversations about mental health, identifying patterns of self-injurious behavior, and facilitating referrals to psychiatric services when necessary. Moreover, establishing rapport with the patient and ensuring a non-judgmental clinical environment may encourage future engagement with mental health support and reduce the risk of recurrence.

Urethral trauma can lead to complications such as urethral stricture, urinary incontinence, erectile dysfunction, and infection, with stricture being the most frequent and serious long-term outcome.9 Open surgical management is preferred for large or sharp objects retained in the urethra, as repeated endoscopic manipulation can exacerbate injury and promote fibrosis. Postoperative surveillance for urethral stricture is essential to prevent delayed complications and reduce the need for long-term intervention.10 Imaging modalities such as urethrography are recommended during the first year after injury when scarring and inflammation are most active. In our case, no urethral stricture or fistula had developed at six months, based on both retrograde urethrography and voiding cystourethrography (Figure 4), suggesting that the transperineal approach may serve as a valuable surgical option in select cases. Given the hypothesis that the development of urethral stricture is partly attributable to ischemic changes following injury to the urethral epithelium and corpus spongiosum,10 it may be possible to preserve urethral blood flow by performing a targeted transperineal closure of the corpus spongiosum in cases involving only localized ventral spongiosal injury caused by sharp foreign bodies. Specifically, this approach could be considered by urologists as a successful alternative in cases involving transperineal penetrating injury to the corpus spongiosum caused by sharp foreign bodies, particularly when aiming to minimize urethral trauma and prevent subsequent stricture.

Conclusions

This report presents a case of transperineal surgical removal of a bladder-urethral foreign body that penetrated the bulbar urethra and corpus spongiosum. With an aging population and increasing diversity in sexual practices and preferences, similar cases may become more prevalent. Tailored multidisciplinary approaches are essential for effective management.

Acknowledgement

None.

Funding Statement

The authors received no specific funding for this study.

Author Contributions

The authors confirm contribution to the paper as follows: Conceptualization, Kazuki Yanagida and Daisuke Watanabe; methodology, Kazuki Yanagida; software, Hazuki Inoue; validation, Takashi Ujiie; formal analysis, Kazuki Yanagida; investigation, Daisuke Watanabe; resources, Kazuki Yannagida; data curation, Kazuki Yanagida; writing—original draft preparation, Kazuki Yanagida; writing—review and editing, Daisuke Watanabe; visualization, Akio Mizushima; supervision, Akio Mizudhima; project administration, Akio Mizushima. All authors reviewed the results and approved the final version of the manuscript.

Availability of Data and Materials

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

Ethics Approval

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Koto Hospital (IRB No. 202302).

Informed Consent

Written informed consent was obtained from the patient in this study.

Conflicts of Interest

The authors declare no conflicts of interest to report regarding the present study.

Supplementary Materials

The supplementary material is available online at https://www.techscience.com/doi/10.32604/cju.2025.068677/s1.

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