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Amulet in penile tract- A case study

We do get strange cases of self insertion of foreign bodies in the penile urethra. It is very difﬁcult to know the reason for inserting variety of objects. Here this case needs discussion due to extreme rarity and strangeness of getting a metal amulet with the attached hanging thread inserted inside the penile urethra.


Introduction
The insertion of extraneous objects into penile tract or lower genital tract looks unusual but has been found well documented practice in medical literature. [1][2][3] It occurs during pathological masturbation, intoxication, or as a result of psychiatric disturbance. The foreign body may disappear into the urethra or remain visible at the meatus. Some times its removal becomes difficult even in those having portion of foreign body visible at the meatus. 4 There is varied clinical presentation of urethral foreign body. If the object has disappeared into the urethra then increased urinary frequency, dysuria, poor stream, haematuria, and urinary retention are the usual symptoms. 5 The possibility of a retained urethral foreign body can be answered by getting plain radiography of the genitourinary tract done. 6 I present a rare case of a metal amulet which is worn on the waist by thread was self inserted in penile urethra

Case Study
A forty-years-old man presented with haematuria, dysuria and now with retention with full urinary bladder and pain.
Because of his habit of attaining autoerotic stimulation, he had self inserted into his penile urethra about 3 cm size metal amulet with hanging long thread which is used for wearing on the waist. There no history of psychiatric disorders. However the metal amulet was not visible but could be palpated within the penile urethra and hanging thread attached to amulet was seen hanging outside the meatus of glans penis. Under local anaesthesia traction was tried but hinderance was there. So meatotomy was done and more xylocaine jelly was infused and with minimum effort the foreign body was extracted. Foley's catheter was passed for few days and meatotomy site was repaired with 4/0 vicryl. Since the patient was in agony we avoided x-ray and did the case in emergency couch as OPD procedure under local anaesthesia and later other routine tests were done. There was no need for cystourethroscopy as patient was alright after the foley's catheter removal and never reported back for any problems or symptoms of stricture occurrence. However patient supported by his attendants refused to go for psychiatric evaluation for fear of social stigma.

Discussion
Insertions of foreign bodies in lower genital tract is very unusual and different types of foreign materials have https://doi.org/10.18231/j.pjms.2020.036 2249-8176/© 2020 Innovative Publication, All rights reserved. 171  been detected. It has been seen that these patients run under psychological disturbances and develop habit of pathological masturbation and are often involved in drug abuse and intoxication for having erotic spell even by inserting foreign body inside the lower genital tract. 7 Selferotic stimulation with the help of self-inserted urethral foreign bodies has been there since time immemorial and have presented an unusual but known presentation to emergency surgeons. 7,8 Often the presentation is delayed owing to embarrassment. Of those who seek treatment suffer from haematuria, dysuria, urinary frequency, strangury and urinary retention as common presenting signs and symptoms. It has been seen that even fulminant sepsis and death can occur if treatment is delayed. 7 If the foreign body remains protruding from the urethral meatus then the diagnosis is obvious but the management is less straightforward than it would initially appear. 4 Long, flexible foreign bodies tend to knot in the bladder, and this bar to removal may be visible on plain radiography. It is very tempting to attempt removal by traction in these type of cases but should take care in finding what is concealed to prevent urethral trauma on removal. Although variety of objects, mechanism of insertion, and the time that the object remained in the genitourinary tract affect the presentation. Many objects as electrical wire, AAA battery, bullets, bones, plastic cup, beads and intrauterine devices have been reported as foreign bodies or extraneous bodies in lower genitourinary system in literature. [9][10][11] So varieties of foreign bodies in genitourinary tract has been seen. Urethral self-insertion can be found in both sexes, and variety of objects can be introduced to the bladder through the urethral opening. 9 The major causes of self-insertion of objects are psychiatric disorders and autoerotic stimulation.
Physical examination is of great help in diagnosis. These foreign bodies are readily palpable distal to the urogenital diaphragm and a X-ray of pelvis and computerised tomography of the abdomen and/or pelvis can aid in knowing the foreign body's where abouts in relation to surrounding visceral structures. Self insertion of metal amulet is very rare or not heard of and so there is not much information to compare different modalities of treatment. Its removal depends on its physical dimensions and its nature of hardness. Most important is to prevent urinary tract trauma and not adversely affect the erectile function. It is of no doubt that foreign bodies located distal to the urogenital diaphragm can often be successfully removed by endoscopic methods. 12,13 After removal, cystourethoscopy is very important to see for any urothelial injuries and to be sure of complete removal of foreign bodies. Antibiotic cover is advised. 14 Some times in some cases invasive foreign body removal procedures are required like external urethrotomy (for pendulous urethral foreign bodies), suprapubic cystotomy (for posterior urethral foreign bodies), or meatotomy. 12,15,16 Complications following these procedures are rare but can result in infection, fistula, urethral stricture, diverticulum, and incontinence. 12,13,16,17 However urethral strictures occur in 5% of cases as common delayed complication. 12 Thus, appropriate follow-up is a must.

Conclusion
Here the very rare foreign body metal amulet with hanging thread outside the meatus extraction was done easily by controlled traction guided by its morphology and position by clinical examination. Under local anaesthesia, only a small meatotomy was done to felicitate removal of the amulet. We need a comprehensive management of patient for preventing lower genital tract injury while removing the foreign body and preventing infection and following the patient for monitoring of development of any late complications like strictures. Thorough evaluation of cause of unnatural motivation and if there is any psychosocial issues it should be properly addressed with help of psychiatrists to prevent future episodes.

Source of Funding
None.