Editorial Comment: A Case of Intraperitoneal Bladder Rupture and Widespread Subcutaneous Emphysema Due to Self-Injurious Behavior in Paraphilia: Potential Roles of Hyperbaric Oxygen Therapy as an Adjunctive Treatment

Among the numerous paraphilic behaviors described, the practice most frequently encountered by urologists involves the insertion of foreign bodies into the urethra. Derived from Greek, the word polyembolokoilamania denotes the introduction of foreign objects into body orifices, with the range of objects employed limited only by human imagination.1 Although most reported cases involve the insertion of solid objects, the authors describe a unique case of a patient who habitually injected a jet of water from a hose into his urethra for autoerotic stimulation. In an unusual constellation of behaviors, the patient also engaged in subcutaneous self-injection of carbon dioxide.2 While the motivation for urethral stimulation as a form of autoeroticism is perhaps self-evident, the rationale for the practice of carbon dioxide injections remains obscure. A comprehensive, nonjudgmental psychiatric assessment might have yielded valuable insight into the motives and emotions underpinning this paraphilia and possibly mitigated the risk of further self-harm through these practices. The authors’ management of the case, which involved augmenting surgical repair with adjunctive hyperbaric oxygen therapy (HBOT), is commendable and undoubtedly unique. Nevertheless, the utilization of HBOT may have been unnecessary for the management of both sepsis and surgical emphysema. As the authors acknowledge, an appropriately informed and modified antibiotic regimen beyond the empiric piperacillin–tazobactam they used might have effectively addressed the secondary leucocytosis, obviating the need for HBOT. Moreover, as learned from cervicothoracic trauma, surgical emphysema typically resolves spontaneously once the underlying source is controlled. It is therefore reasonable to infer that both the emphysema and the associated chest wall discoloration (likely attributable to petechial hemorrhage) would have resolved spontaneously in this patient as well.