How do urologists manage retained urethral foreign bodies and what are typical long‑term outcomes?
Executive summary
Urologists manage retained urethral foreign bodies with a hierarchy of approaches that prioritize minimally invasive extraction when feasible, escalating to endoscopic or open surgery for complex, migrated, or clustered objects, and pairing removal with imaging, antibiotics, and psychiatric assessment when indicated [1] [2] [3]. Typical long‑term outcomes are generally good when extraction is timely and non‑traumatic, but delayed care or traumatic removal can cause infection, stricture, fistula, recurrent retention, or—rarely—serious systemic complications [4] [5] [6].
1. How clinicians triage and image the problem: decide location, shape and risk
Initial management begins with history and physical exam, supplemented by targeted imaging—plain radiography for radiopaque items and bedside ultrasound or CT selectively for localization—because the object’s size, shape, and mobility determine whether transurethral, bedside, or open approaches are safest [7] [1] [8]. Early ultrasound can inform whether emergency‑department removal is reasonable versus specialist OR intervention, and most series report that advanced imaging beyond ultrasound/X‑ray is not routinely required [1] [2].
2. First‑line, minimally invasive extraction: manual 'milking' and endoscopic retrieval
When the foreign body is distal or palpable, gentle manual extraction—milking the object toward the meatus and grasping it—or transurethral cystoscopic removal with grasping forceps is preferred to minimize trauma; reviews and institutional series show manual extraction and endoscopic retrieval account for the majority of successful removals (manual extraction ~54% and endoscopic ~23% in one large single‑institution series) [9] [4] [10]. Endoscopic methods are touted as the most appropriate initial operative strategy because they preserve urethral integrity and allow inspection for mucosal injury [11].
3. When minimally invasive measures fail: escalation to open surgery and hybrid techniques
Open cystotomy or perineal urethrotomy is reserved for impacted, large, fragmented, magnetized, or otherwise unextractable chains of beads or clustered objects; case reviews of magnetic beads and other complex items show a meaningful proportion require open removal after failed endoscopic attempts [12] [2]. Novel bedside or ultrasound‑guided catheter‑based extraction techniques have been described to allow emergency teams, in consultation with urology, to remove unusual objects without immediate OR use in selected recurrent or straightforward cases [1].
4. Adjunctive care: infection control, urologic repair and psychiatric input
Antibiotics are indicated when infection or contamination is present, and cystoscopic inspection permits repair or staged procedures for mucosal lacerations, stone formation around an object, or retained catheter fragments; delayed sequelae such as stones, diverticula, or abscesses may require additional surgery [13] [2] [5]. Because many cases reflect autoerotic practice, intoxication, or underlying psychiatric illness, authors emphasize psychiatric evaluation and behavioral follow‑up to reduce recurrence, an often implicit but critical component of comprehensive care [11] [14].
5. Typical short‑term complications and rates reported
Postremoval complications reported across series include urinary tract infection, sepsis in a minority, urethral false passage or laceration, and occasional immediate need for open repair; one 15‑year institutional series documented urinary infection in seven episodes, sepsis in four, and urethral trauma in multiple cases [4] [6]. The clinical lesson across reviews is that minimally traumatic removal minimizes these risks, and that delayed presentation increases infection and complication rates [5] [2].
6. Long‑term outcomes: stricture, recurrent behavior, and rare systemic harms
Long‑term outcomes are usually favorable when extraction is complete and urethral trauma is minimized, but documented sequelae include urethral stricture, recurrent self‑insertion behaviors, chronic infections leading to stone or abscess formation, and in rare prolonged cases systemic complications such as bacteremia with distant seeded infections (discitis/osteomyelitis) requiring prolonged antibiotics and surgery [15] [5] [12]. Recurrence is common in populations with psychiatric comorbidity or paraphilic practice, so durable outcomes often depend as much on behavioral health interventions as on the technical success of removal [14] [11].
7. Uncertainties, biases and clinical judgment
Most literature comprises case series and reports, so estimates of complication rates and best practices reflect institutional experience and publication bias toward unusual or complicated cases; pragmatic decisions rely on object characteristics, local expertise, and shared decision‑making between emergency clinicians and urologists, with some centers developing protocols that allow selected ED removal under urology guidance [1] [3]. There is consensus across sources that the guiding principle is complete extraction with minimal urethral/bladder injury, balanced against the risks of delaying definitive operative care [10].