Friday, June 2, 2023
Loading...
The word "urology" originates from the Greek words ouron and -logia, meaning "the study of urine." What today's urologist encounters in practice, however—from urologic trauma to sexual practices to body modification—makes that description seem banal. The following cases were submitted by practicing physicians and are excerpted from a larger collection called Extreme Urology: Practice on the Edge, published in May 2015 by the William P. Didusch Center for Urologic History, the American Urological Association's museum. Find out more about the museum on slide 13.
This patient was seen in my office for a routine urologic examination of his prostate. I noticed an unusual tattoo—a ladder starting on his lower abdomen and creeping down to the base of the penis, at which point the ladder became a spiral surrounding the shaft of the penis and terminating on the glans. The glans was a solid color. Some of the spiral fanned out onto the scrotum, where the patient had a web covering the entire scrotal sac.
I asked the patient who had designed the tattoo, and he proudly responded, "I did." When I asked who had performed the tattoo, he said that a tattoo specialist had done it. "It must have hurt," I said. "It did," he answered. "How much did it cost?" I asked. "It was expensive—$1000—but the return has been fantastic! You have no idea."
Rainer M. Engel, MD, Key West, Florida
A 37-year-old footballer was brought in to the hospital in the early hours of the morning after a "Mad Monday gone wrong" after winning the Grand Final. He gave a history of passing an object intraurethrally in a dare but was not sure what the object was. He was fairly intoxicated and stuporous, and informed consent had to be obtained from his wife and caregiver. A flexible cystoscopy was performed, as he had some blood at the meatus and access to radiology was not available.
The unknown object turned out to be a "gherkin" or pickled cucumber. The object was too large to remove transurethrally with a flexible cystoscope. The flexible cystoscopy confirmed urethral patency with some trauma to urethral mucosa. After passing a guidewire under vision into the bladder, an 18Fr catheter was inserted to enable bladder drainage until the patient was medically fit to have a rigid cystoscopy under anaesthesia. The "gherkin" was able to be sliced into smaller pieces with a resectoscope and removed successfully transurethrally.
Sanjeev Bandi, MD, Queensland, Australia
An accountant showed up in our clinic with microhematuria and dysuria. My partner did a urethrogram that showed a metallic foreign body in the bulbous urethra. He scoped the patient and saw what looked like the working end of a pen. My partner scheduled him for an exam with me under anesthesia and cystoscopic extraction. The morning of the surgery, my intern showed me the films and asked about the whiteness above the symphysis pubis. I told him that it was probably just some Wite-Out at the very top of the film but advised him to take a higher KUB to prove that. That film revealed a large bladder stone around a foreign body. I had to actually ratchet the bladder in the midline in order to extract the accounting pen with the stone around it that was firmly wedged against the back wall of the bladder with the other end stuck in the urethra. The point I remember is that the pen still worked, and we called this case "the case of the Bic that could take a lick and keep on coming."
Michael McCarthy, MD, Carlsbad, California
A 32-year-old incarcerated white male recently presented to the emergency room (ER) with his fourth foreign body insertion over the past 6 months. He had no previous psychiatry consultation and no input from prison officials. He was suicidal and, in fact, had attempted suicide many times, with one attempt at self-immolation. He was angry, hostile, and threatening to all around him and admitted to placing a plastic fork up his penis, rendering him unable to void. A CT scan showed a foreign body in his rectum and another within his bladder: a 4-cm screw. He had on all previous presentations caused quite the commotion in the ER, the operating room, and on the floor; in fact, he was somewhat of a celebrity at the hospital. He was moderately isolated at his institution, but since he has been coming to the hospital, two others have presented. This is widely recognized as a socio-inductive behavior that perpetuates this behavior at violent institutions. Complaints to the prison when this patient threatened physical harm to others at the hospital finally involved prison authorities, solving this individual's problems and preventing imitators.
Michael Moran, MD, McComb, Mississippi
I was called for a patient who had placed a belt buckle by "mistake" in the wrong place. He actually missed by a lot! No problem—as long as the ortho instruments are around and we have jelly (as we always do)—there is no buckle we can't handle! The patient did fine.
William Roman-Torreguitart, MD, Mayaguez, Puerto Rico
I was at the emergency department and in came a medical chopper with a urologic emergency. A young man who practices body building had a problem. He wanted to develop the muscles of the pelvis which he used to pump back and forth while having sex. He figured if he placed a large weight on his penis and had sex with his partner, it would work. The only problem is that it got a bit swollen and wouldn't come off. No cutting tool can go through this one (not even ortho instruments). Fortunately, he was uncircumcised, and with a Penrose, a lot of jelly, and even more patience, I was able to pull it off (see next slide).
A 49-year-old woman presented with a UTI unresponsive to oral antibiotics and associated with passage of reddish urine. An IVU revealed a faintly opaque, sausage-shaped foreign body within the pelvis measuring 8 cm x 2.5 cm and confirmed the object to be intravesical. The patient was questioned about unusual sexual practises and admitted to allowing her husband to use a "carrot" in her urethra to stimulate her during sex for the past 3 years. She denied any stress incontinence but admitted to marked urgency. Her MSU revealed Enterobacter sakazakii sensitive to gentamicin. She was consented for a cystoscopy with video imaging under antibiotic cover, with the probability of a small cystotomy to remove the large foreign body. At cystoscopy a "carrot" was found in the bladder. The proximal head end of the "carrot" was too large to remove transurethrally. The "carrot" was successfully removed via a small cystotomy.
Sanjeev Bandi, MD, Queensland, Australia
While at the La Jolla VA hospital, I was called to the ER. There was an elderly man with global aphasia (couldn't talk or even wink in response to questions). He had a piece of plastic pipe that went all the way through his glans penis. There was a metal hook which attached to the midpoint of the pipe and exited the meatus. It was a simple matter to remove it, but no one knew why he had such a piercing in the first place.
Michael McCarthy, MD, Carlsbad, California
The patient was a 22-year-old man who presented to the ER on New Year's Eve with a history of intermittent hematuria. On physical exam, the ER physician noted a "rock-hard prostate." The urologic consultant obtained additional history from the patient, who reluctantly told him that he had been drinking heavily at a New Year's Eve party 1 year previously, and "an angry ex-girlfriend put a thermometer in my penis while I was passed out." On repeat rectal exam, the urologist determined that the hard object was above the patient's small prostate, probably within the bladder. KUB showed a thermometer and a large stone in the lower pelvis. The patient was prepped and taken to the operating room, where cystoscopy confirmed the diagnosis. The thermometer, encased in a large stone, was removed through a suprapubic incision. Recovery was uneventful and the patient was lost to follow-up.
Henry E. Parfitt, MD, Fayetteville, North Carolina
An incontinent, moderately demented 93-year-old Irish missionary was referred from his nursing home for a catheter insertion to assist with long-term bladder management; a uridome was not suitable, as he was uncircumcised and had a wide urethral meatus. Upon close inspection of the glans penis, a subincision was noted on the ventral aspect.
The patient had worked for more than 30 years as a missionary with aboriginal communities in central Australia and described how he acquired the subincision during a rite-of-passage ceremony approximately 60 years ago. He was held down on the backs of aboriginal men while another aboriginal elder used a flint stone to make the incision. The patient said these ceremonies were only performed on scorching hot days so that the hot sand and dirt could be used to tamponade the wound, and he described how the blood from the wound was shared among the aboriginals, who ingested and spread the blood onto their bodies during the subincision ceremony.
Sanjeev Bandi, MD, and Brent Gilbert, MD, Queensland, Australia
The William P. Didusch Center for Urologic History is located at the headquarters of the American Urological Association in Linthicum, Maryland, outside of Baltimore. The museum is named in honor of William P. Didusch, a world-renowned medical artist at the Johns Hopkins Brady Urological Institute, and the first curator of the museum. The museum opened in 1971 and houses a variety of exhibits which are open to visitors. Additional resources are available online at urologichistory.museum.
The William P. Didusch Center for Urologic History
Previous
Next 
