Introduction
Polyembolokoilomania (PEKamania) refers to the act of self-inserting objects into anal, urethral, and vaginal openings [1]. The most common locations for finding such foreign bodies are the urethra and bladder [2]. Potential reasons for the presence of a foreign body within the bladder encompass self-insertion, migration from neighbouring organs, and iatrogenic factors. The most frequently cited cause is self-insertion for sexual gratification [3]. PEKamania has been documented in individuals across various age groups, including adults and adolescents. It can potentially signify underlying psychiatric conditions like paraphilic disorder, eating disorder, substance use disorder, psychosis, factitious disorder, or dementia [4]. The act of inserting a foreign object for sexual pleasure, accompanied by distress, indicates a potential paraphilic disorder. Those engaging in such behaviour might attempt self-removal of these objects. Reluctance to seek medical help due to embarrassment can lead to delayed presentation, often to emergency departments, where symptoms may be unusual and complications affecting both the genital and urinary systems, as well as systemic health, can arise [5]. Here we present a unique care report of urethral PEKamania in an otherwise normal individual with no paraphilic disorder.
Case Report
A 30-year-old male with history of deliberate self-insertion of six green peas per-urethrally presented with complaints of difficulty in passing urine and pain over the undersurface of penis since one day. There was no history of previous similar attempts any psychiatric illness in the past. On examination his bladder was palpable with six discrete rounded foreign bodies palpable along the ventral surface of the penis. Per urethral catheterization was attempted but failed. Emergency cystoscopy was done, green peas, crushed using tri-prong forceps and fragments were retrieved. Psychiatric evaluation in the post-operative period was found to be normal.
In view of acute retention of urine, per urethral catheterization with 8 French infant feeding tube was tried to relieve the retention in the emergency room to empty the bladder but the attempt was unsuccessful as the tube could not be negotiated beyond two cm from the meatus due to the impacted peas. Due to the severe intensity of pain and acute urinary retention, it was decided to subject the patient to emergency cystoscopy and retrieval of the green peas under spinal anaesthesia after initial evaluation with X-ray KUB, ultrasound (USG) abdomen pelvis and routine blood investigations. X-ray was normal, USG showed a distended bladder and routine blood investigations were normal.
On urethrocystoscopy with 22 French cystoscope, impacted green peas were visualized in the mid and proximal penile urethra and they were pushed into the bladder under vision as there was no adequate space to retrieve them from the urethra [Fig.1]. All of the six peas were fragmented individually using forceps and retrieved after giving a thorough lavage with normal saline [Fig.2]. Repeat cystoscopy was done to look for any hidden green pea. A 14 French Foley’s catheter was inserted per urethra. Patient withstood the procedure well. Patient underwent a psychiatric evaluation in the postoperative period which was found to be normal and hence the patient was psychoeducated regarding safe sexual practices and the patient’s family was psychoeduated regarding possible sexual disorders.
Discussion
Urethral PEKamania, involving the insertion of foreign objects into the urethra, is a rare occurrence in urological practice. Nonetheless, there have been numerous documented cases of foreign bodies of diverse shapes and sizes found within the bladder [6]. Various instances of PEKamania have been documented in published literature. Reported objects inserted into the male urethra encompass items such as pencils, thermometers, electric cables, and wires [7]. Social and cultural stigmas play a role in the delayed presentation of individuals with PEKamania [8]. Inserting foreign objects into the male urethra can lead to various complications, some of which can be severe. For instance, there have been reports of serious complications, such as bladder tissue necrosis, arising from the insertion of corrosive substances like batteries [9]. A significant number of the documented cases revolve around patients seeking medical attention because of pain stemming from urinary retention or tissue necrosis. The cause of PEKamania could be attributed from psychiatric, medical, or behavioral factors, affecting individuals who may otherwise appear normal. Various psychological conditions can drive the insertion of foreign objects into bodily orifices. Key psychological and psychiatric contributors include seeking sexual gratification, paraphilic disorders, non-pathological sexual preferences, engaging in non-suicidal self-harm, and having borderline personality disorder. Behavioural patterns observed in mentally sound individuals partaking in such activities encompass self-stimulation, seeking erectile enhancement, craving attention, and malingering [6].
Our patient inserted six green peas into his urethra for erotic stimulation, emulating pornographic content he had viewed on his smartphone. Individuals have described feeling sexual satisfaction through the insertion of foreign objects into both the urethra, vagina and rectum targeting erogenous zones. Most commonly, literatures have reported PEKamania in patients with underlying psychiatric disorders but our patient was otherwise normal and his psychiatric evaluation revealed no obvious abnormality thus telling us that PEKamania can occur in normal individuals as well in rare instances.
Tailoring the approach to urethral foreign bodies is essential, with a focus on individualized care for each patient. Swift assessment, supported by thorough history-taking and examination, forms the cornerstone of initial management. Delving into the reasons behind the insertion of foreign objects via detailed history-taking is crucial for comprehensive care. Building a robust therapeutic alliance and fostering trust between clinicians and patients facilitates the disclosure of the precise nature of their PEKamania.
Conclusion
Urethral polyembolokoilomania, though uncommon, can present as acute urinary obstruction and requires prompt urological intervention. This case highlights that such behaviour may occur even in individuals without psychiatric illness. A combined approach - timely endoscopic removal, psychiatric evaluation, and targeted counselling is essential to ensure safe recovery and prevent recurrence.
Contributors: VK: manuscript writing, patient management; DHM, SiP: manuscript editing, patient management; SaP: critical inputs into the manuscript. DHM will act as a study guarantor. All authors approved the final version of this manuscript and are responsible for all aspects of this study.
Funding: None; Competing interests: None stated.
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