Genitourinary Foreign Bodies

Context

Genitourinary foreign bodies (GUFB) can be a sensitive and embarrassing topic for patients who present to the Emergency Department (ED).1 Between 2010 – 2014 there were around 102000 visits to United States (US) EDs with GUFBs, with a national incidence of around 7.6 ED visits per 100,000 persons.1 When considering GUFBs in the paediatric population there were 27,755 national estimated childhood ED visits for suspected GUFB injuries during 2008 to 2017 including an estimated 7756 vaginal FBs, 7138 penile FBs, and 8359 rectal FBs (RFBs).2 The data for the UK is limited, however between 2010 and 2019, a total of 3,500 rectal foreign bodies were removed from adult patients in the National Health Service (NHS) in the UK.3 The majority of these cases occurred in men, with 2,888 removals (85.1%) recorded in adult males and 501 (14.9%) in adult females. On average, 389 foreign bodies were removed each year, resulting in the use of approximately 348 hospital bed-days annually. Over the nine-year period, this amounted to a total of 3,131 bed-days used for the management of rectal foreign body cases.

The underlying reasons for GUFB are vast and include everything from exploration, accidental insertion, sexual use through to assault.

This learning session is going to explore the management of GUFB in the Emergency Department. This session will not explore body packing, stuffing or concealing for drugs. For more information on this, see the RCEM Guideline Management of Suspected Internal Drug Traffickers 2020.

Definition

GUFBs can occur in all age groups from childhood through to the older adult. Table 1 summarises some of the data available on location, object and sex.1,3,4

In both adults and children GUFBs commonly found vaginally include retained tampons, sex toys, packets of drugs and toilet paper. Rectally this can include, sex toys, packets of drugs but also general household objects. Urethral objects include pencils and wires. When objects are placed in the urethra for sexual gratification, this is known as urethral sounding.5

The most common underlying reasons for GUFB in children are

• play or exploration
• trauma
• abuse

The underlying common causes in adults are

• sexual pleasure
• sexual or domestic abuse
• deliberate self harm
• penetrating trauma
• erosion or fistulisation from adjacent structures, such as a migrated IUD
• accidental, such as forgetting to remove a tampon or a retained condom
• drug smuggling
• whilst intoxicated
• in sex workers

Risk assessment

There is no formal risk assessment for GUFB. There are some important considerations which include:

What is the object? 

Sharp objects, batteries and magnets can be high risk for the patient injury but also for the clinician examining the patient. 

Why is the object there?

This is about the history of presentation and the consideration for any safeguarding issues or intimate partner violence. Was the patient involved solely? Was anyone else present? Was it consensual? Was this self-exploration? Is this appropriate for the age of the child? 

Clinical Assessment

History taking

The history for GUFB of any nature can be very vague depending on the nature of the GUFB and why it was inserted. For younger patients this may be due to age, embarrassment or due to lack of appreciation of the issue. For adult patients this may be similar, with one study suggesting up to 70% of patients with a RFB giving inaccurate histories.6

It is important to remain professional, non-judgemental and to keep an open mind to encourage patients to disclose the full details of the GUFB. Consultations should take place in a private cubicle, and patients should be reassured of confidentiality (unless there is a legal need to share information with other health professionals such as a safeguarding concern). This is especially true, as sometimes patients may have an undisclosed story of sexual assault or possibly an underlying psychiatric illness.7 

There is no formal national risk assessment or guideline for GUFB. There are some important considerations to elicit in the history which include:

What is the object?

• Risk to patient/clinician – Sharp objects, batteries and magnets can be high risk for the patient but also for the clinician examining the patient.
• Infection risk? Depending on the object, location and how long it has been present there for. A consideration of vaccination status – thinking about dirty metal objects and tetanus. Also the transmission risk for HIV, Hep B and C. This is particularly pertinent in the sharing of objects and where bodily fluids or bloods could be exchanged.
• Radiolucent / suitable for imaging?

When was it inserted?

• How long has it been there for?
• Is this the first time?

Where is it?

Why was it inserted / who inserted it?

• Highlight any safeguarding/DV concerns here
• Was it consensual?
• Was the patient involved solely?
• Was anyone else present?
• Was this self-exploration?
• Is this appropriate for the age of the child?

What else do I need to know?

• Could the patient be pregnant? Consider a pregnancy test or counselling for this.
• Any relevant risk factors e.g. previous surgeries in these areas or scarring?

Some societies have the following guidelines around the management of these different types of GUFB – British Association of Urological Surgeons (BAUS) consensus document: management of bladder and ureteric injuryAnorectal emergencies: WSES-AAST guidelines.

Things to bear in mind

It is important to elicit any symptoms suggesting a complication of GUFB (see table in “Differential Diagnosis”). All patients will need an examination of the relevant genital area and an abdominal examination as a minimum. Make sure it is safe to examine the patient, for yourself and the patient. For example, a digital rectal examination should not be performed if the GUFB is sharp in nature.

The General Medical Council (GMC) in the United Kingdom (UK) recommends that for intimate examinations a chaperone should be offered to patients.8

For a child or young person (CYP) the GMC states you must assess their capacity to consent to the examination. If the CYP lacks capacity to consent, you should seek consent from their parent or person with legal parental responsibility.9

When there is a suggestion of sexual assault, consider the forensic aspect and the need for referral to the sexual assault referral centre (SARC). Unless the situation is immediately life-threatening, you should seek advice from the police or SARC before making any intervention, to avoid contaminating evidence.

The table below discusses some of the differentials to consider with a GUFB. The list is not meant to be exhaustive.

Key clinical features of GUFB1,6,7

Investigations are usually determined by what the object is, where it is located and if the patient is systemically unwell. 

Bloods

Blood tests are unlikely to be needed for every patient. They may be indicated if the patient  is systemically unwell or if there is a need for theatre.

Imaging

Not all patients will need imaging. This will need to be decided upon on a case-by- case basis depending on where the object is located and what it is.

An abdominal x-ray can be useful if the object is radiopaque. Below are some example images

Image 1: Example of object in the rectum

Image 2: Example of object in the vagina

Image 3: Example of object in the urethra

If the object is not radiopaque, or there is concern about abdominal injury a Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) scan may be indicated.

Specialised imaging such as urethrograms may be needed for looking at the urethra specifically.

Point of care ultrasound (PoCUS) and GUFB identification

There is some increasing evidence around the role of PoCUS to help identify and aid the removal of GUFB. Some of this is summarised below in table 2.16-20

Microbiology

If there is any discharging substance, sending a swab to microbiology will likely be helpful to guide any additional treatment with antibiotics. 

When objects are removed and depending on how long it has been there, swabs or the object itself may benefit from being sent to microbiology. This could be useful for culturing. 

For urethral objects, urinary microbiology, culture and sensitivity (MC & S) may be helpful also looking for haematuria. 

Ultimately GUFBs need to be removed. What the object is, where the object is and if there are any complications to the removal process, will guide how this is managed.

There are some guiding principles to consider:

Acutely unwell patients

For acutely unwell patients where this is likely due to a GUFB, standard ABCDE and resuscitation, will be needed as appropriate. The specifics of how to resuscitate are covered in some of the following RCEM Learning Modules or Advanced Life support guidelines.

Major Haemorrhage in the ED

Bowel perforation? Pretty convincing

Abdominal pain without shock

The ABCDE Approach

Complications as mentioned previously, in unwell patients could include sepsis, perforation of a viscous or bleeding. If possible and safe in this context the object should be removed. If not, specialist teams will likely need to be involved. Usually, this will likely need some imaging to help guide what the underlying issue is.

If and when to remove?

Deciding what to remove is challenging and there is no real formal advice out there. At one end of the spectrum, some GUFB (mainly uncomplicated vaginal FB) can be removed in the ED, with the use of a speculum and forceps. There is an RCEM Learning blog post on the use of speculums in the ED available here. If a GUFB is removed in the ED, it is important to ensure it is intact, with no part left inside the patient. At the other end, some GUFB will require operative intervention to remove the object and repair associated injuries. If it can’t be removed in ED or there is any doubt concerning its removal, early discussion with the relevant specialties is advised. This will be urology for urethral objects, general surgeons for rectal objects and gynaecology for vaginal objects. Where these get removed i.e. theatre or in an outpatient setting, will be led by the specialist teams.

Special Considerations

• Retained condoms need consideration for emergency contraception, HIV post exposure prophylaxis (PEP) and sexually transmitted infections.
• Consider whether antibiotics may be required for certain objects. This is especially important for objects that may have been there for a long time. Antibiotics will certainly be indicated if there is evidence of active infection, such as pelvic inflammatory disease, prostatitis and urethritis or urinary tract infection. Where possible send cultures and swabs. Please remember this list is not exhaustive.
• Consider safeguarding and intimate partner violence in all presentations, all ages and all genders.
• Button batteries and magnets will need urgent assessment due to their high risk of perforation, especially when multiple are present.

Discharge advice

A further important consideration on discharge is sharing some practical advice to reduce recurrences. For GUFB inserted for sexual exploration, make sure you do not kink-shame or judge people’s sexual practices. Advice could include the use of waterbased lubricant, making sure objects have a flange so they can be easily removed and making sure objects are clean. 

• Not considering that a GUFB could be in the differential diagnosis especially in children. 
• Being unintentionally judgemental and not building a rapport.
• Not thinking about the sequelae such as abdominal or pelvic organ perforation, obstruction or more broadly sepsis.
• Failing to identify and act on safeguarding or domestic violence concerns.

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