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Methamphetamine abuse presenting as dysuria following urethral insertion of tablets
CASE REPORT drug abuse, methamphetamine; dysuria, drug abuse; methamphetamine, abuse
Methamphetamine Abuse Presenting as Dysuria Following Urethral Insertion of Tablets Foreign bodies are inserted into the male urogenital tract for a variety of motives, and patients m a y present with symptoms of dysuria, urinary retention, hematuria, discharge, or priapism. Concomitant psychopathology is seen frequently, necessitating a thorough psychiatric assessment with attention to other acts of self-mutilation, suicide attempts, psychosis, or substance abuse. We report the case of an abuser of methamphetamine who inserted a sustained-release form of medication into his urethra, with resulting mechanical and pharmacological trauma. [Ellison JM, Dobies DF: Methamphetamine abuse presenting as dysuria following urethral insertion of tablets. Ann Emerg Med March 1984;13:198-200.]
James M Ellison, MD David F Dobies, MD Boston, Massachusetts
INTRODUCTION Dysuria and other symptoms following the insertion of objects into the male urethra may result in a perplexing presentation. The gathering of accurate historical data is often impeded by the patient's feelings of shame or by a delusional mental state. The diagnosis of this condition demands a high index of suspicion when dysuria is seen in a patient who is impulsive, psychotic, intoxicated, demented, or has prior history of self-mutilation. Our patient presented with dysuria after inducing mechanical and pharmacological trauma to his urethra by inserting sustained-release methamphetamine tablets (Desoxyn). We believe this is the first reported case of urethral self-insertion of medication.
Address for reprints: James M Ellison, MD, Department of Psychiatry, New England Medical Center, Box 1007, 171 Harrison Avenue, Boston, Massachusetts 02111.
From the Emergency Psychiatry Service, New England Medical Center, Boston, Massachusetts. Received for publication February 14, t983. Revision received May 16, 1983. Accepted for publication July 25, 1983.
CASE REPORT A 40-year-old single, heterosexual man presented to an emergency department complaining of dysuria, urinary retention, and intermittent hematuria of recent onset. He denied other urinary symptoms, medical illness, or psychiatric symptoms. Physical examination revealed a swollen, tender penis. When questioned specifically, the patient denied having inserted any object into his urethra. Urinalysis revealed gross hematuria and pyuria. The patient was admitted to a urology service, where cystoscopy revealed the remains of six sustained-release methamphetamine tablets near the bladder outlet. The tablets were removed, penis and scrotum were debrided because of a staphylococcal infection, a suprapubic drainage tube was placed, and antibiotic therapy was begun. The patient's infection responded well to treatment. Subsequently transferred to a psychiatric ward because of psychotic behavior (talking to walls, singing disruptively), this patient persistently refused to explain how the tablets entered his bladder. He claimed they were prescribed by his physician for the treatment of narcolepsy and epilepsy, although there was no evidence he suffered from either. His past history revealed repeated visits to several psychiatric emergency services, where his consistent presentation (pressured speech, irritable mood, delusions of persecution and grandiosity, and clear sensorium) had been ascribed to his known abuse of stimulants. On two occasions he had been hospitalized for drug-free evaluation and the possibility had been considered that his primary psychiatric diagnosis was schizophrenia or mania. He had been seen once previously, under an assumed name, for urethral insertion of foreign objects (pieces of rubber, plastic, and paper). At that time he had also presented with dysuria, claiming 13:3 March 1984
Annals of Emergency Medicine
198/93
METHAMPHETAMINE ABUSE Ellison & Dobies
that it was the result of an injury sustained during an assault. There was no known history of other self-mutilation or of suicide attempts. The patient's disruptive psychotic behavior responded to treatment with perphenazine, 24 mg per day, and benztropine mesylate, 2 mg per day, His mental status revealed a fully oriented, vigilant man with moderately rapid speech. His affect was bland and the lack of concern about his selfdestructive behavior was remarkable. His thought process was coherent and logical, though limited in depth and abstraction. He denied hallucinations or delusions, though he adamantly maintained he required stimulant medications for the treatment of narcolepsy. Cognitive abilities were not notably impaired. He eventually was discharged for outpatient psychiatric follow-up, with a diagnosis of organic delusional disorder secondary to methamphetamine abuse. On a subsequent emergency visit he admitted to having inserted the methamphetamine tablets into his urethra in the course of sexual foreplay while intoxicated with alcohol.
DISCUSSION Foreign objects may arrive in the male urinary tract after ingestion (with subsequent passage into the bladder through a fistula 1) or penetration (eg, entry of a bullet into the urethra following a gunshot wound to the buttockS), but most frequently they are present as a result of insertion through the urethral meatus.3 The objects are often self-inserted, but also may be inserted by a sexual partnet, 4 left behind by a physician performing a procedure, s or forcibly inserted during an assault.3 Among the plethora of objects removed from male urethras are pencils, pens, pieces of straw,6 pieces of wax, hairpins, pins, catheters,7 thermometers, pipe stems, matches, fishbones, pebbles, beans, peas, splinters of wood, 4 pieces of bone,8 light bulbs,9 parts of surgical instruments, S and a leechJ o There is a curious tendency for urethrally inserted objects to migrate up the urethra to the bladder. It has been hypothesized that this results from alternating erection and relaxation, contractions of the perineal muscles, or "milking" the object up the urethra during efforts at extraction.7 Presenting symptoms of urethral foreign object have included dysuria, urinary retention, hematuria, 3 pria94/199
pism, 4 and pneumaturia. 1 Accurate historical information may be difficult to obtain from a patient who is ashamed or delusional. Several reports have commented upon the variety of motives for urethral insertion of objects, including curiosity (especially in children), erotic and masturbatory activities, 3 the attempt to prolong erection 4 or to relieve urinary retention, 6 the production of factitious symptoms, n the attempt to relieve tension 11 or depression, l~ and self-punishment for sexual urges. 11 The issue of concomitant psychiatric disorder in urethral self-inserters has been examined in two reports. Rada H called attention to the presence in his patients of disturbed sexual adjustment, dysphoric mood with tension relief produced by the act, and a persistent recurrence of the act. While some urethral inserters are schizophrenic or demented, Rada pointed out the predominance of borderline and antisocial personality disorders among his patients, who tended to be nonpsychotic at the time of their acts. Both Rada and M i t c h e l l 6 commented on the prevalence of selfmutilation and suicide attempts in urethral inserters. Campbell 3 noted that alcohol intoxication may accompany and facilitate urethral insertion. One of Mitchell's reported patients inserted objects into his urethra during episodes of benzedrine and alcohol intoxication, which is noteworthy in terms of our patient. 6 We have been unable to find previous reports in the English-language literature of urethral insertion of medication. We suspect that it may occur with greater frequency than is recognized. It was detected in our patient only because he had used sustainedrelease tablets with an insoluble matrix. In view of the likelihood of a misleading history, a urethral foreign object may be suspected when a patient who is intoxicated, delusional, demented, or suicidal presents with dysuria, hematuria, or discharge. Suspicion should be greater if the patient is known to be an impulsive individual or has a past history of self-mutilation or suicide attempts. If the patient has a past history of insertion of foreign objects into his urethra, the insertion of a new object must be ruled out. The presence of multiple objects should be considered. Urinalysis will reveal pyuria and, Annals of Emergency Medicine
often, hematuria. Metal objects or objects that have secondarily become encrusted with calcium will be seen on roentgenogram. A cystourethrogram may be necessary for localization. Admission and eystoscopy may be required for visualization and identification of the object(s). Removal of the foreign object depends on its size and location. Very proximal objects may be milked out of the urethra. If the object is located more distally, cystoscopic or even suprapubic removal may be necessary. Wax and paraffin have been removed by instilling xylol into the urethra and retaining it with penile clamps for one hour.7 Our patient volunteered no evidence of substance abuse or psychosis on initial emergency examination by a non-psychiatric physician. He also specifically denied having inserted into his urethra objects that were found during a cystoscopic examination. It appears that this patient is not atypical in p r e s e n t i n g w i t h b o t h urethral foreign objects and severe psychopathology. In view of this, we suggest a psychiatric consultation for thorough assessment of mental status and psychiatric history when urethral foreign bodies are encountered in the emergency department. The presence of impulsivity, s u b s t a n c e abuse, thought disorder, delusions, dementia or suicidality should be assessed, and a history of prior psychiatric treatment, self-mutilation, or suicide attempts should be sought.
REFERENCES 1. Wykes WN, Barker JR: Urethral discharge associated with ingested foreign body. Br Med J 1978;2:1751. 2. Iloreta A, Schutte H, Fernandez R, et al: Unusual cause of acute urinary retention. Urology 1979;14:291. 3. Campbell EW: Foreign bodies in the urinary tract, in Campbell MF (ed): Urology, ed 2. Philadelphia, WB Saunders, 1963, p 775-795. 4. Gutierrez R: Unusually long foreign body impacted in the urethra, causing painful priapism for seven days. Removal and cure by external urethrotomy. J Urol 1943;49:865-871. 5. Seery WH, Dorfman J, Smulewicz JJ: Iatrogenic foreign body in the posterior urethra. J Nat] Med Assoc 1976;68:63. 6. Mitchell WM: Self-insertion of urethral foreign bodies. Psychiatric Quarterly 1968;42:479-486. 7. Grewal RS, Francis J: Foreign bodies in the urethra. Int Surg 1967;48:591-593. 13:3 March 1984
8. Terhorst B: Harnverhalten durch ungew6hnlicher Fremdkorper. Z Urol Nephrol 1969;62:473-475. 9. Wenderoth U, Jonas U: Curiosity in urology? Masturbation injuries. Eur Urol 1980;6:312-313.
13:3 March 1984
10. Saha S, Saha I: Unusual foreign body causing bleeding per urethra. J Indian Med Assoc 1977;69:286-287. 11. Rada RT, James W: Urethral insertion of foreign bodies. A report of contagious
Annals of Emergency Medicine
self-mutilation in a maximum-security hospital. A r c h Gen P s y c h i a t r y 1982; 39:423-429. 12. Zafrullah M: Unusual foreign bodies in the male urinary bladder and urethra. Br J Clin Pract 1969;23:123-124.
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Methamphetamine Abuse Presenting as Dysuria Following Urethral Insertion of Tablets Foreign bodies are inserted into the male urogenital tract for a variety of motives, and patients m a y present with symptoms of dysuria, urinary retention, hematuria, discharge, or priapism. Concomitant psychopathology is seen frequently, necessitating a thorough psychiatric assessment with attention to other acts of self-mutilation, suicide attempts, psychosis, or substance abuse. We report the case of an abuser of methamphetamine who inserted a sustained-release form of medication into his urethra, with resulting mechanical and pharmacological trauma. [Ellison JM, Dobies DF: Methamphetamine abuse presenting as dysuria following urethral insertion of tablets. Ann Emerg Med March 1984;13:198-200.]
James M Ellison, MD David F Dobies, MD Boston, Massachusetts
INTRODUCTION Dysuria and other symptoms following the insertion of objects into the male urethra may result in a perplexing presentation. The gathering of accurate historical data is often impeded by the patient's feelings of shame or by a delusional mental state. The diagnosis of this condition demands a high index of suspicion when dysuria is seen in a patient who is impulsive, psychotic, intoxicated, demented, or has prior history of self-mutilation. Our patient presented with dysuria after inducing mechanical and pharmacological trauma to his urethra by inserting sustained-release methamphetamine tablets (Desoxyn). We believe this is the first reported case of urethral self-insertion of medication.
Address for reprints: James M Ellison, MD, Department of Psychiatry, New England Medical Center, Box 1007, 171 Harrison Avenue, Boston, Massachusetts 02111.
From the Emergency Psychiatry Service, New England Medical Center, Boston, Massachusetts. Received for publication February 14, t983. Revision received May 16, 1983. Accepted for publication July 25, 1983.
CASE REPORT A 40-year-old single, heterosexual man presented to an emergency department complaining of dysuria, urinary retention, and intermittent hematuria of recent onset. He denied other urinary symptoms, medical illness, or psychiatric symptoms. Physical examination revealed a swollen, tender penis. When questioned specifically, the patient denied having inserted any object into his urethra. Urinalysis revealed gross hematuria and pyuria. The patient was admitted to a urology service, where cystoscopy revealed the remains of six sustained-release methamphetamine tablets near the bladder outlet. The tablets were removed, penis and scrotum were debrided because of a staphylococcal infection, a suprapubic drainage tube was placed, and antibiotic therapy was begun. The patient's infection responded well to treatment. Subsequently transferred to a psychiatric ward because of psychotic behavior (talking to walls, singing disruptively), this patient persistently refused to explain how the tablets entered his bladder. He claimed they were prescribed by his physician for the treatment of narcolepsy and epilepsy, although there was no evidence he suffered from either. His past history revealed repeated visits to several psychiatric emergency services, where his consistent presentation (pressured speech, irritable mood, delusions of persecution and grandiosity, and clear sensorium) had been ascribed to his known abuse of stimulants. On two occasions he had been hospitalized for drug-free evaluation and the possibility had been considered that his primary psychiatric diagnosis was schizophrenia or mania. He had been seen once previously, under an assumed name, for urethral insertion of foreign objects (pieces of rubber, plastic, and paper). At that time he had also presented with dysuria, claiming 13:3 March 1984
Annals of Emergency Medicine
198/93
METHAMPHETAMINE ABUSE Ellison & Dobies
that it was the result of an injury sustained during an assault. There was no known history of other self-mutilation or of suicide attempts. The patient's disruptive psychotic behavior responded to treatment with perphenazine, 24 mg per day, and benztropine mesylate, 2 mg per day, His mental status revealed a fully oriented, vigilant man with moderately rapid speech. His affect was bland and the lack of concern about his selfdestructive behavior was remarkable. His thought process was coherent and logical, though limited in depth and abstraction. He denied hallucinations or delusions, though he adamantly maintained he required stimulant medications for the treatment of narcolepsy. Cognitive abilities were not notably impaired. He eventually was discharged for outpatient psychiatric follow-up, with a diagnosis of organic delusional disorder secondary to methamphetamine abuse. On a subsequent emergency visit he admitted to having inserted the methamphetamine tablets into his urethra in the course of sexual foreplay while intoxicated with alcohol.
DISCUSSION Foreign objects may arrive in the male urinary tract after ingestion (with subsequent passage into the bladder through a fistula 1) or penetration (eg, entry of a bullet into the urethra following a gunshot wound to the buttockS), but most frequently they are present as a result of insertion through the urethral meatus.3 The objects are often self-inserted, but also may be inserted by a sexual partnet, 4 left behind by a physician performing a procedure, s or forcibly inserted during an assault.3 Among the plethora of objects removed from male urethras are pencils, pens, pieces of straw,6 pieces of wax, hairpins, pins, catheters,7 thermometers, pipe stems, matches, fishbones, pebbles, beans, peas, splinters of wood, 4 pieces of bone,8 light bulbs,9 parts of surgical instruments, S and a leechJ o There is a curious tendency for urethrally inserted objects to migrate up the urethra to the bladder. It has been hypothesized that this results from alternating erection and relaxation, contractions of the perineal muscles, or "milking" the object up the urethra during efforts at extraction.7 Presenting symptoms of urethral foreign object have included dysuria, urinary retention, hematuria, 3 pria94/199
pism, 4 and pneumaturia. 1 Accurate historical information may be difficult to obtain from a patient who is ashamed or delusional. Several reports have commented upon the variety of motives for urethral insertion of objects, including curiosity (especially in children), erotic and masturbatory activities, 3 the attempt to prolong erection 4 or to relieve urinary retention, 6 the production of factitious symptoms, n the attempt to relieve tension 11 or depression, l~ and self-punishment for sexual urges. 11 The issue of concomitant psychiatric disorder in urethral self-inserters has been examined in two reports. Rada H called attention to the presence in his patients of disturbed sexual adjustment, dysphoric mood with tension relief produced by the act, and a persistent recurrence of the act. While some urethral inserters are schizophrenic or demented, Rada pointed out the predominance of borderline and antisocial personality disorders among his patients, who tended to be nonpsychotic at the time of their acts. Both Rada and M i t c h e l l 6 commented on the prevalence of selfmutilation and suicide attempts in urethral inserters. Campbell 3 noted that alcohol intoxication may accompany and facilitate urethral insertion. One of Mitchell's reported patients inserted objects into his urethra during episodes of benzedrine and alcohol intoxication, which is noteworthy in terms of our patient. 6 We have been unable to find previous reports in the English-language literature of urethral insertion of medication. We suspect that it may occur with greater frequency than is recognized. It was detected in our patient only because he had used sustainedrelease tablets with an insoluble matrix. In view of the likelihood of a misleading history, a urethral foreign object may be suspected when a patient who is intoxicated, delusional, demented, or suicidal presents with dysuria, hematuria, or discharge. Suspicion should be greater if the patient is known to be an impulsive individual or has a past history of self-mutilation or suicide attempts. If the patient has a past history of insertion of foreign objects into his urethra, the insertion of a new object must be ruled out. The presence of multiple objects should be considered. Urinalysis will reveal pyuria and, Annals of Emergency Medicine
often, hematuria. Metal objects or objects that have secondarily become encrusted with calcium will be seen on roentgenogram. A cystourethrogram may be necessary for localization. Admission and eystoscopy may be required for visualization and identification of the object(s). Removal of the foreign object depends on its size and location. Very proximal objects may be milked out of the urethra. If the object is located more distally, cystoscopic or even suprapubic removal may be necessary. Wax and paraffin have been removed by instilling xylol into the urethra and retaining it with penile clamps for one hour.7 Our patient volunteered no evidence of substance abuse or psychosis on initial emergency examination by a non-psychiatric physician. He also specifically denied having inserted into his urethra objects that were found during a cystoscopic examination. It appears that this patient is not atypical in p r e s e n t i n g w i t h b o t h urethral foreign objects and severe psychopathology. In view of this, we suggest a psychiatric consultation for thorough assessment of mental status and psychiatric history when urethral foreign bodies are encountered in the emergency department. The presence of impulsivity, s u b s t a n c e abuse, thought disorder, delusions, dementia or suicidality should be assessed, and a history of prior psychiatric treatment, self-mutilation, or suicide attempts should be sought.
REFERENCES 1. Wykes WN, Barker JR: Urethral discharge associated with ingested foreign body. Br Med J 1978;2:1751. 2. Iloreta A, Schutte H, Fernandez R, et al: Unusual cause of acute urinary retention. Urology 1979;14:291. 3. Campbell EW: Foreign bodies in the urinary tract, in Campbell MF (ed): Urology, ed 2. Philadelphia, WB Saunders, 1963, p 775-795. 4. Gutierrez R: Unusually long foreign body impacted in the urethra, causing painful priapism for seven days. Removal and cure by external urethrotomy. J Urol 1943;49:865-871. 5. Seery WH, Dorfman J, Smulewicz JJ: Iatrogenic foreign body in the posterior urethra. J Nat] Med Assoc 1976;68:63. 6. Mitchell WM: Self-insertion of urethral foreign bodies. Psychiatric Quarterly 1968;42:479-486. 7. Grewal RS, Francis J: Foreign bodies in the urethra. Int Surg 1967;48:591-593. 13:3 March 1984
8. Terhorst B: Harnverhalten durch ungew6hnlicher Fremdkorper. Z Urol Nephrol 1969;62:473-475. 9. Wenderoth U, Jonas U: Curiosity in urology? Masturbation injuries. Eur Urol 1980;6:312-313.
13:3 March 1984
10. Saha S, Saha I: Unusual foreign body causing bleeding per urethra. J Indian Med Assoc 1977;69:286-287. 11. Rada RT, James W: Urethral insertion of foreign bodies. A report of contagious
Annals of Emergency Medicine
self-mutilation in a maximum-security hospital. A r c h Gen P s y c h i a t r y 1982; 39:423-429. 12. Zafrullah M: Unusual foreign bodies in the male urinary bladder and urethra. Br J Clin Pract 1969;23:123-124.
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