A 56-year-old woman arrived at a Melbourne emergency department in July 2023 with right flank pain and a fever. She had never had a urinary tract infection in her life. Six months, several scans, multiple procedures, and one hysterectomy later, a gastroscope pulled a wooden toothpick out of her duodenum, and the infections stopped.
The case, written up by urologists at St Vincent's Hospital Fitzroy and Flinders University, was published in BJUI Compass in February. It is a single patient. What makes it worth reading is not the object but the sequence of reasonable-looking decisions that kept anyone from finding it.
Six Months, Multiple Scans, and an Object Nobody Reported
On that first visit, a CT of the kidneys, ureters, and bladder showed significant right-sided hydronephrosis, a backup of urine in the kidney. It also showed bulky uterine fibroids, which the team took to be the cause. That is a common and defensible read.
She had a stent placed in the right ureter. When the surgeon cannulated the ureteric opening, frank pus came out, and the ureter was noted to narrow high up near the kidney. She was discharged with a plan for hysterectomy to treat the fibroids and, by extension, the obstruction.
The hysterectomy was performed. In October 2023, the stent came out heavily encrusted, and her urine grew two species of Candida. She had been having recurrent urinary infections since July.
A follow-up CT intravenous pyelogram in December told the team the plan had not worked. The hydronephrosis was unchanged despite the hysterectomy. The scan also showed narrowing of the upper right ureter and, for the first time in a radiology report, a linear foreign body in her gastrointestinal tract, described as a fishbone.
A gastroscopy that month found inflammation but no object. In January 2024, contrast injected into her urinary system turned up in her duodenum, confirming an abnormal channel between kidney and bowel. A repeat gastroscopy the next day retrieved the culprit, which was not a fishbone. It was a toothpick.
By March, contrast no longer crossed into the duodenum, urine cultures were negative, and her kidney function had stayed normal throughout. Counting from her first symptom, an isolated bout of back pain in August 2022, the authors put the total arc at more than 18 months.
How a Toothpick Ends Up Inside a Kidney
Most swallowed objects are uneventful. The authors note that 80 to 90 percent pass on their own. Sharp ones behave differently, with gastrointestinal perforation reported in 10 to 15 percent of cases involving items such as toothpicks and fishbones, and consequences that range from abscess to peritonitis and sepsis.
The duodenum is where toothpicks tend to stop. It is the most commonly reported perforation site after toothpick ingestion, and the second part of it sits directly against the right kidney, which is what turns a bowel problem into a urinary one. A 2014 review of 136 published cases of accidental toothpick ingestion catalogued the injuries that follow.
Kidney involvement is rare but documented. A 2022 case in BMC Infectious Diseases described a 51-year-old with back pain, blood in the urine, and blood cultures repeatedly growing Streptococcus gordonii, an oral bacterium. Imaging found a toothpick running from the duodenum into the right kidney, and it came out endoscopically. That patient, unlike the Melbourne one, eventually recalled swallowing something while drinking a month earlier. Chinese endoscopists reported a similar kidney injury with hematuria in 2014.
Why Patients Almost Never Remember Swallowing It
The Melbourne patient had no recollection of ingesting anything. That is typical rather than exceptional, and it removes the single most useful clue from the history.
Wood is also a poor performer on imaging. Toothpicks are notoriously difficult to see on computed tomography, and can sit in a scan without announcing themselves. In this case, the authors report that the foreign body appeared on multiple CT scans and was not flagged on any of them at the time of reporting, or on later review after it had been identified. When it was finally described in December, it was described as the wrong material.
The clinical picture pushed in the wrong direction too. The authors attribute the delay largely to the fact that her symptoms were generalized urinary sepsis symptoms, which have many ordinary explanations, and she had a visible, plausible one sitting on her first scan. Signs that have flagged other cases, such as blood in the urine, were absent here.
What a Single Case Can and Cannot Tell Doctors
This is a case report, the lowest tier of clinical evidence. It cannot say how often foreign bodies masquerade as urologic disease, and it does not mean anyone with a urinary infection needs to be scanned for swallowed objects. The overwhelming majority of recurrent urinary tract infections have conventional causes.
The narrow lesson the authors draw is that when urinary sepsis keeps returning after the presumed cause has been treated, a foreign body belongs somewhere on the list. The signal here was not the infection. It was the hydronephrosis that did not improve after the fibroids were removed.
The authors declared no conflicts of interest. Anyone with repeated urinary infections, persistent flank pain, or fevers that do not resolve with treatment should ask their clinician what is being reassessed, rather than attempting to self-diagnose from a case report.
Key Questions Answered
What was actually wrong with this patient?
A swallowed toothpick lodged in her duodenum had eroded toward her right kidney, creating an abnormal channel between bowel and urinary tract that drove recurrent infections and blocked drainage.
Why was a hysterectomy performed?
Her first CT showed bulky uterine fibroids alongside right-sided hydronephrosis, and the fibroids were reasonably presumed to be compressing the urinary tract. The hydronephrosis did not improve afterward.
How did multiple CT scans miss a toothpick?
Wood is hard to see on CT. The authors report the object was present on prior scans but was not reported, including on later review, and was initially misidentified as a fishbone.
Did she recover?
Yes. After endoscopic removal, imaging showed the fistula had closed, urine cultures were negative, and kidney function remained normal.
Is this a common cause of urinary infections?
No. It is rare enough to be publishable. Recurrent urinary infections almost always have conventional explanations.
When should someone push for further investigation?
When infections keep recurring or obstruction persists after the presumed cause has been treated. That is a conversation to have with a clinician.
