- Email: [email protected]
Bladder Perforation Associated with Hot Tub
321
CASE REPORTS Bladder Perforation Associated with Hot Tub
jsm_2008
321..324
Ryan P. Kopp, MD*, Paul E. Dato, MD,† and Roger L. Sur, MD* *University of California San Diego—Division of Urology, San Diego, California, USA; †Urology Specialty Associates, La Mesa, CA, USA DOI: 10.1111/j.1743-6109.2010.02008.x
ABSTRACT
Introduction. Bladder perforation is a rare and life-threatening event. Timely diagnosis may prevent further injury-related morbidity and mortality. Aim. To present a case of bladder injury associated with masturbation in a hot tub. Methods. This report describes a case of bladder perforation in a 54-year-old female who presented to the emergency department 2 days after masturbation with a water jet. Results. Following percutaneous drainage and intraoperative closure of the bladder, the patient was discharged on postoperative day four and has had no sequelae. Conclusion. Cross-sectional imaging and cystography can facilitate immediate diagnosis and expeditious treatment of bladder injury associated with masturbation in a hot tub. Kopp RP, Dato PE, and Sur RL. Bladder perforation associated with hot tub. J Sex Med 2011;8:321–324. Key Words. Cystotomy; Humans; Masturbation; Urinary Bladder/Injuries; Urinary Bladder/Surgery
Introduction
S
pontaneous bladder perforation is rare and may be a life-threatening injury. More commonly reported etiologies include malignancy, radiation exposure, fungal or bacterial cystitis, and foreign body-induced injuries [1–5]. Along with emerging knowledge of sexual behaviors in the medical literature [6,7], reports of urinary tract injuries related to sexual practices have become more prevalent and are more readily diagnosed [8–10]. Patients may present with hematuria, urinary symptoms similar to infection, and in some cases signs of peritonitis. Timely diagnosis, followed by surgical intervention when necessary, may prevent significant injuryrelated morbidity and mortality. We describe a case of a woman with bladder perforation related to masturbation in a hot tub. Case Report
A 54-year-old female presented to the emergency department after 2 days of lower abdominal pain. © 2010 International Society for Sexual Medicine
She was engaging in masturbation with a water jet in a hot tub two nights prior to presentation. The patient indicated that she used this form of masturbation previously, but for a shorter duration. It is unknown how many times she had engaged in this behavior in the past, nor what her usual sexual practices or encounters may have been. She denied insertion of any foreign object. Within one hour she noted bleeding from the genital area, new onset urinary frequency and urgency, and lower abdominal pain and bloating, but no gross hematuria. She developed anorexia and one episode of emesis. She reported progressive abdominal pain, dyspnea, fever, and chills, which prompted her to come to the emergency department. On presentation she seemed mortified regarding the cause and nature of her injury. Past medical history was significant for attention deficit disorder, depression, previous alcohol abuse, and chronic obstructive pulmonary disease. Her psychiatric medications included Ritalin, Wellbutrin, and Abilify. Past surgeries only included tubal ligation 20 years prior. Obstetrical history was gravida 10, para 4, aborta 6. J Sex Med 2011;8:321–324
322 On physical examination in the emergency department the patient was tachycardic with otherwise stable vital signs. The abdomen was distended and diffusely tender with tympanitic resonance and rebound tenderness. Genitourinary examination was significant for laceration and necrosis of the right internal labia. Rectovaginal septum was intact and no crepitus was present. There was tenderness to the external genitalia but no active bleeding or hematoma. Urinalysis revealed proteinuria, pyuria (5–10 white blood cells per high-power field [WBC/ hpf]), microscopic hematuria (>100 red blood cells/hpf), and bacteriuria (few). Serum laboratory results were significant for hyponatremia (Na = 125 mEq/L), acute renal insufficiency (blood urea nitrogen [BUN] 40 mg/dL, creatinine 2.8 mg/dL), leucocytosis (WBC 16.3 K/mL), and mild anemia (haemoglobin [Hgb] 12.3 g/dL). Abdominal/pelvic computerized tomography (CT) without contrast demonstrated findings of air in soft tissues of the pelvis, retroperitoneum surrounding the right kidney, and extraperitoneal area anterior to the bladder. No urinoma was identified. The patient was evaluated by a urologist (PED) who obtained a retrograde cystogram demonstrating extravasation of contrast into the anterior extravesical space, best visualized on the lateral view (Figure 1). The exact area of perforation was not clear, but it appeared to be near the bladder neck. The patient was initially admitted to the intensive care unit and cared for conservatively. Foley catheter was left in place because of gross hematuria; she was placed on IV fluids and broad spec-
Figure 1 Cystogram lateral view demonstrating extravasation of contrast anterior to the bladder.
J Sex Med 2011;8:321–324
Kopp et al.
Figure 2 Computerized tomography abdomen and pelvis axial view demonstrating substantial extraperitoneal air and fluid anteriorly.
trum antibiotics. By hospital day two her WBC had normalized, serum sodium returned within normal range at 136 mEq/L, and serum creatinine had decreased to 2.2 mg/dL. On hospital day two the patient was transfused two units of packed red blood cells, as she had become anemic (Hgb 8.8 g/ dL), presumably caused by gross hematuria. Serum creatinine normalized by several days later. Persistent hematuria and worsening abdominal pain on hospital day five prompted a repeat abdominal/pelvic CT scan, which demonstrated a large anterior pelvic fluid collection (18 cm ¥ 6 cm) suggestive of a urinoma (Figure 2). Pelvic ultrasound demonstrated a 5 mm hole in the bladder communicating with an anterior fluid collection, which was percutaneously drained by interventional radiology. A total of 700 cc of serosanguinous fluid was drained and a 14 French drainage catheter was placed percutaneously in the anterior pelvis. Over the following day she had substantial high output to the pelvic drain and therefore a decision was made to proceed with definitive operative management. The patient underwent cystoscopy, examination under anesthesia, and exploratory laparotomy through a Pfannenstiel incision. A right labial tear immediately lateral to the urethral meatus did not communicate with the urinary tract. A 2.5 to 3 cm bladder rupture was noted in the low anterior bladder wall with a moderate
323
Bladder Perforation Associated with Hot Tub amount of clot and blood in the extraperitoneal space. Catheter position was confirmed in the bladder, which was then closed in two layers. Additionally, a small peritonotomy at the cranial aspect of the bladder was identified and closed. This intra-operative finding was retrospectively seen on re-review of the cross-sectional imaging. A drain was placed into the retropubic space and the wound closed. The patient did well postoperatively and was discharged on postoperative day four with drain removed and Foley catheter in place. Postoperative cystogram confirmed intact bladder about one week later. Patient was last seen 3 months after injury without sequelae; consequently no urodynamic or further anatomic assessment was performed. Discussion
Spontaneous bladder perforation is a rare and potentially life-threatening event. More common reports include rupture related to carcinoma of the bladder, infectious cystitis, or previous radiation exposure [1,2,4,5]. However, these etiologies are often found in elderly individuals with underlying disease, whether it be malignancy or disease states such as diabetes that are associated with poor wound healing and higher infection rates. Additionally, there are a moderate number of cases describing intrauterine devices migrating into the bladder, leading to perforation [3]. Although bladder perforation represents 10% of blunt pelvic trauma, to our knowledge this is the first report of a bladder perforation related to hot tub use. Alhajj et al. reviewed hot tub-, whirlpool-, and sparelated injuries and calculated that 19.8% of these occurred at the trunk or pubic region [11]. We surmise that the perforation occurred after longstanding high-pressure air and water were repeatedly forced retrograde through the urethra leading to overdistention of the bladder. Similar to this theory, bladder outlet obstruction and neurogenic bladder have been associated with spontaneous bladder perforation [2]. There are reports of masturbation-related urethral injuries in the literature dating back many years, and many of these patients may have had underlying psychiatric disease [8]. More recently, higher masturbation frequency has been associated with increased rates of depression [6]. Furthermore, although the majority of masturbation-related injuries are in men, there are a small number of reports of vesicovaginal fistulas in women that have resulted from insertion of foreign objects into the urethra,
often in young women or adolescents. Many of the foreign objects have been aerosol cans or caps placed for self-gratification or contraception, respectively [8,9]. Additionally, many of these women were reluctant to admit what transpired. More common forms of self-stimulation, such as vibrator use, have rare side effects and are associated with more positive sexual function [7]. Although there are no previous reports of bladder perforation from hot tub use, there are two previous reports of females with pneumoperitoneum associated with a hot tub. One of these was a 56-year-old female who also had generalized abdominal pain, peritoneal signs, and pneumoperitoneum demonstrated by upright chest X-ray. There was no history of masturbation. The patient underwent exploratory laparotomy with no identifiable viscus injury [12]. The second case involved a 49-year-old female who had fallen into a hot tub [13]. CT scan also demonstrated pneumoperitoneum; however, she did not have any peritoneal signs and the case was managed conservatively. One potential explanation of pneumoperitoneum in these females is passage of air into the vagina and through the fallopian tubes. Our patient had a previous tubal ligation and more importantly had a bladder injury explaining the probable mechanism of intraperitoneal air. Early and accurate diagnosis may aid in preventing further morbidity or mortality related to the initial injury. Cases of bladder perforation may present with generalized abdominal pain or even peritoneal signs. Urinary symptoms commonly include hematuria and dysuria. In some cases the patient may be oliguric or anuric, with additional laboratory findings suggestive of acute renal failure [5,14]. Given the large urinoma identified in our patient, her initial elevation in BUN and creatinine was likely caused by reabsorption of urine. These values initially improved with Foley catheter drainage and eventually normalized after percutaneous drainage of urinoma. If bladder injury is suspected, use of radiographic imaging including CT or plain cystography may definitively demonstrate bladder perforation [13]. Conclusion
Bladder injury caused by masturbation in a hot tub represents a highly unusual presentation but nevertheless should be considered with the appropriate history. Cross-sectional imaging and cystography can facilitate immediate diagnosis and permit expeditious treatment. J Sex Med 2011;8:321–324
324 Corresponding Author: Roger Sur, MD, Division of Urology, UCSD, 200 W Arbor Dr MC 8897, San Diego, California, 92103-8897, USA. Tel: 619-5432630; Fax: 619-543-6573; E-mail: [email protected], [email protected] Conflict of Interest: None. Statement of Authorship
Category 1 (a) Conception and Design Ryan P. Kopp; Roger L. Sur (b) Acquisition of Data Ryan P. Kopp; Paul E. Dato (c) Analysis and Interpretation of Data Ryan P. Kopp; Paul E. Dato; Roger L. Sur
Category 2 (a) Drafting the Article Ryan P. Kopp (b) Revising It for Intellectual Content Ryan P. Kopp; Paul E. Dato; Roger L. Sur
Category 3 (a) Final Approval of the Completed Article Ryan P. Kopp; Paul E. Dato; Roger L. Sur References 1 Ahmed J, Mallick IH, Ahmad SM. Rupture of urinary bladder: A case report and review of literature. Cases J 2009;2:7004.
J Sex Med 2011;8:321–324
Kopp et al. 2 Huffman JL, Schraut W, Bagley DH. Atraumatic perforation of bladder: Necessary differential in evaluation of acute condition of abdomen. Urology 1983;22:30–5. 3 Istanbulluoglu MO, Ozcimen EE, Ozturk B, Uckuyu A, Cicek T, Gonen M. Bladder perforation related to intrauterine device. J Chin Med Assoc 2008;71:207–9. 4 Mardani M, Shahzadi M, Rakhshani N, Rahnavardi M, Rezvani J, Sharifinejad A. Spontaneous perforation of urinary bladder secondary to Candida cystitis: Acute abdomen of urologic origin. Surg Infect (Larchmt) 2008;9:525–7. 5 Tabaru A, Endou M, Miura Y, Otsuki M. Generalized peritonitis caused by spontaneous intraperitoneal rupture of the urinary bladder. Intern Med 1996;35:880–2. 6 Brody S. The relative health benefits of different sexual activities. J Sex Med 2010;7:1336–61. 7 Herbenick D, Reece M, Sanders S, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by women in the United States: Results from a nationally representative study. J Sex Med 2009;6:1857–66. 8 Wenderoth U, Jonas U. Curiosity in urology? Masturbation injuries. Eur Urol 1980;6:312–3. 9 Fourie T, Ramphal S. Aerosol caps and vesicovaginal fistulas. Int J Gynaecol Obstet 2001;73:275–6. 10 Siddiqui NY, Paraiso MF. Vesicovaginal fistula due to an unreported foreign body in an adolescent. J Pediatr Adolesc Gynecol 2007;20:253–5. 11 Alhajj M, Nelson NG, McKenzie LB. Hot tub, whirlpool, and spa-related injuries in the U.S.: 1990–2007. Am J Prev Med 2009;37:531–6. 12 Inston N, Lake S. Pneumoperitoneum following hot tub usage. Ann R Coll Surg Engl 2000;82:350–1. 13 Williams TC, Kanne JP, Lalani TA. Hot tub jet-induced pneumoperitoneum. Emerg Radiol 2004;10:259–61. 14 Kato A, Yoshida K, Tsuru N, Ushiyama T, Suzuki K, Ozono S, Hishida A. Spontaneous rupture of the urinary bladder presenting as oliguric acute renal failure. Intern Med 2006;45: 815–8.
CASE REPORTS Bladder Perforation Associated with Hot Tub
jsm_2008
321..324
Ryan P. Kopp, MD*, Paul E. Dato, MD,† and Roger L. Sur, MD* *University of California San Diego—Division of Urology, San Diego, California, USA; †Urology Specialty Associates, La Mesa, CA, USA DOI: 10.1111/j.1743-6109.2010.02008.x
ABSTRACT
Introduction. Bladder perforation is a rare and life-threatening event. Timely diagnosis may prevent further injury-related morbidity and mortality. Aim. To present a case of bladder injury associated with masturbation in a hot tub. Methods. This report describes a case of bladder perforation in a 54-year-old female who presented to the emergency department 2 days after masturbation with a water jet. Results. Following percutaneous drainage and intraoperative closure of the bladder, the patient was discharged on postoperative day four and has had no sequelae. Conclusion. Cross-sectional imaging and cystography can facilitate immediate diagnosis and expeditious treatment of bladder injury associated with masturbation in a hot tub. Kopp RP, Dato PE, and Sur RL. Bladder perforation associated with hot tub. J Sex Med 2011;8:321–324. Key Words. Cystotomy; Humans; Masturbation; Urinary Bladder/Injuries; Urinary Bladder/Surgery
Introduction
S
pontaneous bladder perforation is rare and may be a life-threatening injury. More commonly reported etiologies include malignancy, radiation exposure, fungal or bacterial cystitis, and foreign body-induced injuries [1–5]. Along with emerging knowledge of sexual behaviors in the medical literature [6,7], reports of urinary tract injuries related to sexual practices have become more prevalent and are more readily diagnosed [8–10]. Patients may present with hematuria, urinary symptoms similar to infection, and in some cases signs of peritonitis. Timely diagnosis, followed by surgical intervention when necessary, may prevent significant injuryrelated morbidity and mortality. We describe a case of a woman with bladder perforation related to masturbation in a hot tub. Case Report
A 54-year-old female presented to the emergency department after 2 days of lower abdominal pain. © 2010 International Society for Sexual Medicine
She was engaging in masturbation with a water jet in a hot tub two nights prior to presentation. The patient indicated that she used this form of masturbation previously, but for a shorter duration. It is unknown how many times she had engaged in this behavior in the past, nor what her usual sexual practices or encounters may have been. She denied insertion of any foreign object. Within one hour she noted bleeding from the genital area, new onset urinary frequency and urgency, and lower abdominal pain and bloating, but no gross hematuria. She developed anorexia and one episode of emesis. She reported progressive abdominal pain, dyspnea, fever, and chills, which prompted her to come to the emergency department. On presentation she seemed mortified regarding the cause and nature of her injury. Past medical history was significant for attention deficit disorder, depression, previous alcohol abuse, and chronic obstructive pulmonary disease. Her psychiatric medications included Ritalin, Wellbutrin, and Abilify. Past surgeries only included tubal ligation 20 years prior. Obstetrical history was gravida 10, para 4, aborta 6. J Sex Med 2011;8:321–324
322 On physical examination in the emergency department the patient was tachycardic with otherwise stable vital signs. The abdomen was distended and diffusely tender with tympanitic resonance and rebound tenderness. Genitourinary examination was significant for laceration and necrosis of the right internal labia. Rectovaginal septum was intact and no crepitus was present. There was tenderness to the external genitalia but no active bleeding or hematoma. Urinalysis revealed proteinuria, pyuria (5–10 white blood cells per high-power field [WBC/ hpf]), microscopic hematuria (>100 red blood cells/hpf), and bacteriuria (few). Serum laboratory results were significant for hyponatremia (Na = 125 mEq/L), acute renal insufficiency (blood urea nitrogen [BUN] 40 mg/dL, creatinine 2.8 mg/dL), leucocytosis (WBC 16.3 K/mL), and mild anemia (haemoglobin [Hgb] 12.3 g/dL). Abdominal/pelvic computerized tomography (CT) without contrast demonstrated findings of air in soft tissues of the pelvis, retroperitoneum surrounding the right kidney, and extraperitoneal area anterior to the bladder. No urinoma was identified. The patient was evaluated by a urologist (PED) who obtained a retrograde cystogram demonstrating extravasation of contrast into the anterior extravesical space, best visualized on the lateral view (Figure 1). The exact area of perforation was not clear, but it appeared to be near the bladder neck. The patient was initially admitted to the intensive care unit and cared for conservatively. Foley catheter was left in place because of gross hematuria; she was placed on IV fluids and broad spec-
Figure 1 Cystogram lateral view demonstrating extravasation of contrast anterior to the bladder.
J Sex Med 2011;8:321–324
Kopp et al.
Figure 2 Computerized tomography abdomen and pelvis axial view demonstrating substantial extraperitoneal air and fluid anteriorly.
trum antibiotics. By hospital day two her WBC had normalized, serum sodium returned within normal range at 136 mEq/L, and serum creatinine had decreased to 2.2 mg/dL. On hospital day two the patient was transfused two units of packed red blood cells, as she had become anemic (Hgb 8.8 g/ dL), presumably caused by gross hematuria. Serum creatinine normalized by several days later. Persistent hematuria and worsening abdominal pain on hospital day five prompted a repeat abdominal/pelvic CT scan, which demonstrated a large anterior pelvic fluid collection (18 cm ¥ 6 cm) suggestive of a urinoma (Figure 2). Pelvic ultrasound demonstrated a 5 mm hole in the bladder communicating with an anterior fluid collection, which was percutaneously drained by interventional radiology. A total of 700 cc of serosanguinous fluid was drained and a 14 French drainage catheter was placed percutaneously in the anterior pelvis. Over the following day she had substantial high output to the pelvic drain and therefore a decision was made to proceed with definitive operative management. The patient underwent cystoscopy, examination under anesthesia, and exploratory laparotomy through a Pfannenstiel incision. A right labial tear immediately lateral to the urethral meatus did not communicate with the urinary tract. A 2.5 to 3 cm bladder rupture was noted in the low anterior bladder wall with a moderate
323
Bladder Perforation Associated with Hot Tub amount of clot and blood in the extraperitoneal space. Catheter position was confirmed in the bladder, which was then closed in two layers. Additionally, a small peritonotomy at the cranial aspect of the bladder was identified and closed. This intra-operative finding was retrospectively seen on re-review of the cross-sectional imaging. A drain was placed into the retropubic space and the wound closed. The patient did well postoperatively and was discharged on postoperative day four with drain removed and Foley catheter in place. Postoperative cystogram confirmed intact bladder about one week later. Patient was last seen 3 months after injury without sequelae; consequently no urodynamic or further anatomic assessment was performed. Discussion
Spontaneous bladder perforation is a rare and potentially life-threatening event. More common reports include rupture related to carcinoma of the bladder, infectious cystitis, or previous radiation exposure [1,2,4,5]. However, these etiologies are often found in elderly individuals with underlying disease, whether it be malignancy or disease states such as diabetes that are associated with poor wound healing and higher infection rates. Additionally, there are a moderate number of cases describing intrauterine devices migrating into the bladder, leading to perforation [3]. Although bladder perforation represents 10% of blunt pelvic trauma, to our knowledge this is the first report of a bladder perforation related to hot tub use. Alhajj et al. reviewed hot tub-, whirlpool-, and sparelated injuries and calculated that 19.8% of these occurred at the trunk or pubic region [11]. We surmise that the perforation occurred after longstanding high-pressure air and water were repeatedly forced retrograde through the urethra leading to overdistention of the bladder. Similar to this theory, bladder outlet obstruction and neurogenic bladder have been associated with spontaneous bladder perforation [2]. There are reports of masturbation-related urethral injuries in the literature dating back many years, and many of these patients may have had underlying psychiatric disease [8]. More recently, higher masturbation frequency has been associated with increased rates of depression [6]. Furthermore, although the majority of masturbation-related injuries are in men, there are a small number of reports of vesicovaginal fistulas in women that have resulted from insertion of foreign objects into the urethra,
often in young women or adolescents. Many of the foreign objects have been aerosol cans or caps placed for self-gratification or contraception, respectively [8,9]. Additionally, many of these women were reluctant to admit what transpired. More common forms of self-stimulation, such as vibrator use, have rare side effects and are associated with more positive sexual function [7]. Although there are no previous reports of bladder perforation from hot tub use, there are two previous reports of females with pneumoperitoneum associated with a hot tub. One of these was a 56-year-old female who also had generalized abdominal pain, peritoneal signs, and pneumoperitoneum demonstrated by upright chest X-ray. There was no history of masturbation. The patient underwent exploratory laparotomy with no identifiable viscus injury [12]. The second case involved a 49-year-old female who had fallen into a hot tub [13]. CT scan also demonstrated pneumoperitoneum; however, she did not have any peritoneal signs and the case was managed conservatively. One potential explanation of pneumoperitoneum in these females is passage of air into the vagina and through the fallopian tubes. Our patient had a previous tubal ligation and more importantly had a bladder injury explaining the probable mechanism of intraperitoneal air. Early and accurate diagnosis may aid in preventing further morbidity or mortality related to the initial injury. Cases of bladder perforation may present with generalized abdominal pain or even peritoneal signs. Urinary symptoms commonly include hematuria and dysuria. In some cases the patient may be oliguric or anuric, with additional laboratory findings suggestive of acute renal failure [5,14]. Given the large urinoma identified in our patient, her initial elevation in BUN and creatinine was likely caused by reabsorption of urine. These values initially improved with Foley catheter drainage and eventually normalized after percutaneous drainage of urinoma. If bladder injury is suspected, use of radiographic imaging including CT or plain cystography may definitively demonstrate bladder perforation [13]. Conclusion
Bladder injury caused by masturbation in a hot tub represents a highly unusual presentation but nevertheless should be considered with the appropriate history. Cross-sectional imaging and cystography can facilitate immediate diagnosis and permit expeditious treatment. J Sex Med 2011;8:321–324
324 Corresponding Author: Roger Sur, MD, Division of Urology, UCSD, 200 W Arbor Dr MC 8897, San Diego, California, 92103-8897, USA. Tel: 619-5432630; Fax: 619-543-6573; E-mail: [email protected], [email protected] Conflict of Interest: None. Statement of Authorship
Category 1 (a) Conception and Design Ryan P. Kopp; Roger L. Sur (b) Acquisition of Data Ryan P. Kopp; Paul E. Dato (c) Analysis and Interpretation of Data Ryan P. Kopp; Paul E. Dato; Roger L. Sur
Category 2 (a) Drafting the Article Ryan P. Kopp (b) Revising It for Intellectual Content Ryan P. Kopp; Paul E. Dato; Roger L. Sur
Category 3 (a) Final Approval of the Completed Article Ryan P. Kopp; Paul E. Dato; Roger L. Sur References 1 Ahmed J, Mallick IH, Ahmad SM. Rupture of urinary bladder: A case report and review of literature. Cases J 2009;2:7004.
J Sex Med 2011;8:321–324
Kopp et al. 2 Huffman JL, Schraut W, Bagley DH. Atraumatic perforation of bladder: Necessary differential in evaluation of acute condition of abdomen. Urology 1983;22:30–5. 3 Istanbulluoglu MO, Ozcimen EE, Ozturk B, Uckuyu A, Cicek T, Gonen M. Bladder perforation related to intrauterine device. J Chin Med Assoc 2008;71:207–9. 4 Mardani M, Shahzadi M, Rakhshani N, Rahnavardi M, Rezvani J, Sharifinejad A. Spontaneous perforation of urinary bladder secondary to Candida cystitis: Acute abdomen of urologic origin. Surg Infect (Larchmt) 2008;9:525–7. 5 Tabaru A, Endou M, Miura Y, Otsuki M. Generalized peritonitis caused by spontaneous intraperitoneal rupture of the urinary bladder. Intern Med 1996;35:880–2. 6 Brody S. The relative health benefits of different sexual activities. J Sex Med 2010;7:1336–61. 7 Herbenick D, Reece M, Sanders S, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by women in the United States: Results from a nationally representative study. J Sex Med 2009;6:1857–66. 8 Wenderoth U, Jonas U. Curiosity in urology? Masturbation injuries. Eur Urol 1980;6:312–3. 9 Fourie T, Ramphal S. Aerosol caps and vesicovaginal fistulas. Int J Gynaecol Obstet 2001;73:275–6. 10 Siddiqui NY, Paraiso MF. Vesicovaginal fistula due to an unreported foreign body in an adolescent. J Pediatr Adolesc Gynecol 2007;20:253–5. 11 Alhajj M, Nelson NG, McKenzie LB. Hot tub, whirlpool, and spa-related injuries in the U.S.: 1990–2007. Am J Prev Med 2009;37:531–6. 12 Inston N, Lake S. Pneumoperitoneum following hot tub usage. Ann R Coll Surg Engl 2000;82:350–1. 13 Williams TC, Kanne JP, Lalani TA. Hot tub jet-induced pneumoperitoneum. Emerg Radiol 2004;10:259–61. 14 Kato A, Yoshida K, Tsuru N, Ushiyama T, Suzuki K, Ozono S, Hishida A. Spontaneous rupture of the urinary bladder presenting as oliguric acute renal failure. Intern Med 2006;45: 815–8.