From silence to diagnosis: A rare case of a rubber tube in a deaf-mute patient’s bladder and urethra

Technical Summary: A Rare Case of a Rubber Tube in a Deaf-Mute Patient's Bladder and Urethra

Problem Statement
Lower urinary tract foreign bodies are an uncommon urological presentation that frequently pose significant diagnostic challenges, particularly in patients with communication barriers such as deaf-mutism. While a diverse array of objects (e.g., wires, thermometers, beads) have been reported in the literature, rubber tubes represent a distinct subset often associated with autoerotic stimulation or psychiatric conditions. The pliable nature of rubber allows for insertion but predisposes the object to coiling, knotting, or fragmentation within the bladder, complicating retrieval. In deaf-mute patients, the inability to provide a clear history often leads to delayed diagnosis, allowing foreign bodies to act as nidi for stone formation and cause chronic morbidity, infection, or obstructive uropathy.

Methodology
This case report details the clinical management of a 54-year-old male with congenital deaf-mutism who presented with a week of abnormal behavior, including constant manipulation of the scrotum and urethra, and urination through a bag covering the penis. Due to the patient's inability to communicate, the diagnostic approach relied heavily on:

1. Family History and Physical Exam: Noting abnormal behaviors and palpating a foreign body sensation along the urethra, though no object was visible at the meatus.
2. Imaging: Computed Tomography (CT) was utilized to visualize the radiolucent tube opacity within the urinary bladder and urethral ductal structures, alongside bladder wall thickening suggestive of urocystitis.
3. Laboratory Analysis: Urinalysis confirmed significant leukocytosis (2,575/µL) and erythrocytosis (351/µL).
4. Intervention: Following a failed initial attempt at blind extraction using vascular forceps, an endoscopic approach was employed under general anesthesia. A ureteroscope was inserted to visualize the tubular foreign body, which was then grasped with a ureteral forcep and withdrawn.

Key Results

• Diagnosis: Imaging successfully identified a coiled rubber tube spanning the bladder and urethra, confirming the suspicion of self-insertion despite the lack of patient testimony.
• Extraction: The foreign body, measuring approximately 28 cm in length, was successfully removed via the ureteroscope. The tube was retrieved intact without cracking or fragmentation.
• Post-Operative Findings: Cystoscopy revealed mild mucosal injury to the urethra and bladder but confirmed no residual foreign material. A urinary catheter was placed and removed on the second postoperative day.
• Outcome: The patient experienced an uneventful recovery. Follow-up pelvic CT imaging showed no residual foreign bodies or major complications.

Significance and Claims
The paper posits that clinicians and family members must maintain a high index of suspicion for intravesical foreign bodies in deaf-mute patients presenting with unexplained lower urinary tract symptoms, recurrent infections, or unusual behaviors. The authors emphasize that in populations with communication barriers, imaging techniques are frequently essential for diagnosis, as clinical examination alone is often insufficient.

The case highlights the importance of a systematic diagnostic approach and individualized surgical planning. Specifically, the authors note that while endoscopic removal is successful in 85–90% of cases, the pliable nature of rubber tubes requires careful handling to avoid fragmentation. Furthermore, the paper asserts that optimal outcomes require multidisciplinary care involving urology, psychiatric evaluation (to address potential paraphilic disorders or abnormal motivations), and caregiver education to prevent recurrence through environmental modifications.