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\begin{document}

\title{Female intravesical foreign body penetrating the bladder wall: a rare
case of traditional Asian hair stick \emph{kanzashi}}



\author[1]{Masahiro Arai}%
\author[1]{Hideki Takeshita}%
\author[1]{Wataru Hirata}%
\author[1]{Kojiro Tachibana}%
\author[1]{Shoichi Nagamoto}%
\author[1]{Sachi Kitayama}%
\author[1]{Akihiro Yano}%
\author[1]{Yohei Okada}%
\author[1]{Satoru Kawakami}%
\affil[1]{Saitama Medical Center}%


\vspace{-1em}



  
  \date{May 16, 2024}


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\textbf{Female intravesical foreign body penetrating the bladder wall: a
rare case of traditional Asian hair stick \emph{kanzashi}}

Masahiro Arai, MD; Hideki Takeshita, MD, PhD; Wataru Hirata, MD; Kojiro
Tachibana, MD; Shoichi Nagamoto, MD; Sachi Kitayama, MD, PhD; Akihiro
Yano, MD, PhD, Yohei Okada, MD, PhD, Satoru Kawakami, MD, PhD

Department of Urology, Saitama Medical Center, Saitama Medical
University, Kawagoe, Saitama, Japan

\textbf{Corresponding author:}

Hideki Takeshita, M.D., Ph.D., Department of Urology, Saitama Medical
Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama
350-8550, Japan

Email: takeuro@saitama-med.ac.jp

Tel: +81-49-228-3673; Fax: +81-49-226-9944

\textbf{Informed consent}

Written informed consent for publication was obtained from the patient
in accordance with the journal's patient consent policy, provided that
the ptient's photographs were in grayscale.

\textbf{ORCID}

Hideki Takeshita: 0000-0002-1512-6904

Kojiro Tachibana: 0009-0007-2129-297x

Shoichi Nagamoto: 0000-0002-0583-814X

Sachi Kitayama: 0009-0003-1930-1436

Akihiro Yano: 0000-0001-8453-2474

Yohei Okada: 0000-0001-9050-471X

Satoru Kawakami: 0000-0001-6319-3821

\textbf{Keywords}

Foreign Bodies, Urinary Bladder, Female Genitourinary Diseases,
Abdominal Injuries, Sexual Behavior, Beauty Culture

\textbf{Key Clinical Message}

A female in her thirties inserted an Asian traditional hair stick,
kanzashi, into her urinary bladder for sexual gratification. We need to
know that everyday objects can become bladder foreign bodies and how to
manage them properly.



\textbf{Introduction}

Foreign bodies (FBs) of the urinary bladder are common in urological
clinical practice.\textsuperscript{1,2} Most FBs in the bladder are
inserted through the urethra for sexual gratification and psychological
condition.\textsuperscript{1,2} FBs vary, including plastic forks,
spoons, metal screws and pieces of aluminum, pieces of cardboard and
paper, staplers, writing instruments, such as pens and pencils, coaxial
cables, etc.\textsuperscript{1,3} This unusual sexual act of FB
insertion into the urethra is known as ``urethral
sounding.''\textsuperscript{4,5} It is generally rarer in females than
in males\textsuperscript{2} and even rarer to be inserted so deep enough
into the urethra to damage the bladder.\textsuperscript{6} Herein, we
report a rare case of a female who forcefully used a sharp hair stick
for urethral sounding until it penetrated the bladder wall.



\textbf{Case presentation}

A woman in her thirties was referred to our center with a complaint of
difficulty in removing an FB inserted into her urinary bladder through
the urethra. She also complained of lower abdominal pain and admitted
that she inserted the FB by herself through her urethra for sexual
gratification. She had no history of illness, including a psychiatric
one. Her blood sample test revealed an almost normal but slightly
elevated C-reactive protein of 0.21 mg/dl. Cystoscopy was immediately
performed in the outpatient care unit, which revealed a rod-shaped FB
stuck into her left bladder wall (Figure 1a). Pelvic computed tomography
(CT) revealed that FB had completely penetrated the left bladder wall,
but its tip did not appear intraperitoneally (Figure 1b-d). She was
diagnosed with bladder FB complicated by bladder perforation. She
underwent a surgical exploration instead of transurethral FB excision
because the presence of peritoneal injury was not excluded. The Retzius
cavity was expanded and a cystostomy was made through a lower abdominal
Pfannenstiel incision. The FB turned out to be a 9.5-cm long plastic
Asian traditional hair stick called \emph{kanzashi in Japanese} (Figure
2a). The peritoneum was confirmed to be intact, consistent with the CT
diagnosis, although the hair stick penetrated the bladder wall (Figure
2b). The bladder wall was fixed by suturing in two layers. Her
postoperative course was uneventful, and the urethral catheter was
removed 6 days postoperatively after a cystography confirmed no leakage.
She was recommended to stop the urethral sounding after her discharge.
We also suggested that she use medical intermittent catheters instead of
kanzashi as a tool for sounding If she could not stop it. However, she
denied our suggestion, and our postoperative followup was terminated.



\textbf{Discussion}

Several previous reports presented FBs in the genitourinary
tract.\textsuperscript{1,2} Opthven and Kernion collected approximately
800 cases in English literature from 1755 to
1999.\textsuperscript{1}Miura et al. reviewed 1,367 cases in Japan from
1917 to 1994.\textsuperscript{2} Teens and twenties account for
approximately half of the patients (49.2\%),\textsuperscript{2} with
self-insertion as the most cause of FBs mostly due to psychiatric
illness or sexual gratification.\textsuperscript{1,2} This act of
inserting an object into the urethra for erotic purposes is called
``urethral sounding.''\textsuperscript{4,5} Recent
Google\textsuperscript{TM}search 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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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\%,\textsuperscript{2} and the percentage of females
among people with bladder FBs complicating perforation was
41\%.\textsuperscript{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.\textsuperscript{3} Cotton balls,
pens, thermometers, and hairpins were the most common types of FBs among
females.\textsuperscript{2, 3} Among them, thermometers were the most
common bladder FB in females with bladder
injuries.\textsuperscript{7}However, most previous reports are
considered slim cylindrical mercury-in-glass
thermometers,\textbackslash{}sout\textsuperscript{11} 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.\textsuperscript{7,8} The current
case inserted a traditional Asian hair stick called \emph{Kanzashi} in
Japanese. Several reports presented hairpins as bladder
FBs,\textsuperscript{1, 2} but this is the first report
of\emph{kanzashi} , to our best knowledge. \emph{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 areas\textsuperscript{9} and \emph{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.\textsuperscript{3} The act of inserting FBs into the urethra is
psychiatrically defined as
polyembolokoilamania.\textsuperscript{10}These 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.\textsuperscript{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.



\textbf{Conclusion}

The sexual preference for inserting an FB through the urethra for sexual
gratification is not uncommon, but FB with bladder perforation in a
female is uncommon. We should be aware that anything that is used daily
can become bladder FB, and efforts must be made for safe removal.
Postoperative patient mental care would be mandatory to prevent
recurrences.

\textbf{Funding}

This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.

\textbf{Conflicts of interest}

The authors declare no conflicts of interest.

\textbf{Approval of the research protocol by an Institutional Reviewer
Board}

N/A.

\textbf{Registry and the Registration No. of the study/trial}

N/A.

\textbf{Author agreement}

All authors have approved the final version of the manuscript.

\textbf{Acknowledgments}

We would like to thank enago (https://www.enago.jp) for the English
editing.

\textbf{Author contributions}

Masahiro Arai: Conceptualization, Data curation, Resources,
Visualization, Writing--original draft. Hideki Takeshita:
Conceptualization, Project administration, Resources, Supervision,
Visualization, Writing--original draft, Writing--review \& editing.
Wataru Hirata: Data curation. Kojiro Tachibana: Data curation. Shoichi
Nagamoto: Writing--review \& editing. Sachi Kitayama: Writing--review \&
editing. Akihiro Yano: Writing--review \& editing. Yohei Okada: Data
curation, Writing--review \& editing. Satoru Kawakami: Supervision;
writing--review \& editing.



\textbf{References}

1. Van Ophoven A, deKernion JB. Clinical management of foreign bodies of
the genitourinary sector. J. Urol. 2000; 164: 274--87.

2. Miura T, Taniguchi T, Lkeda I, Kondo I. {[}Case report: a foreign
body (cloth chip) in the bladder by trauma{]}. Jpn. J. Urol. Surg. 1996;
9:585--8. (Japanese)

3. Palmer CJ, Houlihan M, Psutka SP, Ellis KA, Vidal P, Hollowell CM.
Urethral foreign bodies: clinical presentation and management. Urology.
2016; 97: 257--60.

4. Breyer BN, Shindel AW. Recreational urethral sounding is associated
with high-risk sexual behavior and sexually transmitted infections. BJU
Int. 2012; 110: 720--5.

5. Rinard K, Nelius T, Hogan L, Young C, Roberts AE, Armstrong ML.
Cross-sectional study examining four types of male penile and urethral
``play''. Urology. 2010; 76: 1326--33.

6. Kinjo T, Oka T, Imanaka T, Yamanaka Y, Nomura H, Yoshioka I et al.
{[}Vesical perforation caused by a foreign body: a case report --a
clinical review of 41 cases in Japan-{]}. Hinyokika Kiyo. 2018;
64:169--73. (Japanese)

7. Reztsova M, Chien KS, Post KT, Canales A, Yokota S. Bladder
perforation as a rare complication of urethra sounding with a
blunt-marking pen. J. Surg. Case Rep. 2023; 2023: rjad032.

8. Aljarbou A, Abdo AJ, Almosa MA, Hariri A. The extraction of foreign
bodies from the urinary bladder using a nephroscope: a case report of
endoscopy treatment. Urol. Ann. 2023; 15: 95--7.

9. Nishibori T. Stay cool in Little Edo this summer with free parasols.
Asahi Shimbun {[}cited May 4 2023{]}. Available from:
https://www.asahi.com/ajw/articles/13061436

10. Unruh BT, Nejad SH, Stern TW, Stern TA. Insertion of foreign bodies
(polyembolokoilamania): underpinnings and management strategies. Prim.
Care Companion CNS Disord. 2012; 14.

\textbf{Figure legends}

Figure 1. (a) Cystoscopic image. A foreign body was stuck into the left
bladder wall. It is displayed in grayscale at the patient's request. (b)
A coronal section image of computed tomography (CT). A foreign body
penetrates the bladder wall. Soft tissues are colored vermilion and
foreign body in blue for easy identification. (c,d) Front and left
oblique view of pelvic three-dimensional reconstruction CT, with a
foreign body colored blue for easy identification. A foreign body is
colored blue for easy identification.

Figure 2. (a) A foreign body. A 9.5-cm long plastic Asian hair stick. It
is called \emph{kanzashi} in Japan. (b) Surgical exploration results.
The tip of the foreign body remained in the retroperitoneal space while
penetrating the bladder wall, (a) and (b) are displayed in grayscale at
the patient's request. (c) A woman wearing a kimono with
multiple\emph{kanzashi} . Kisegawa of the Matsubaya. A work by Kitagawa
Utamaro (Japanese, early 1750s--1806). Photograph \selectlanguage{ngerman}© {[}date of
publication{]} Museum of Fine Arts, Boston.

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