Presentation on theme: "Penile Self-amputation"— Presentation transcript:
1 Penile Self-amputation Mytsyk YulianAssoc. Proff., Ph.D.Ukraine,Danylo Halytskyi Lviv National Medical University Department of Urology
2 Case reportPatient , 55 y.o., was urgently admitted to Urology Department based on Lviv’s Emergency hospital with complains on penile bleeding, painful and difficult urination.General health status was satisfactory. Patient was sociable, efficiently answered the questions.
3 Fig.1. Local inspection of the inguinal region revealed penile stump with moderate bleeding. Scrotum and surrounding femoral tissues didn’t show any signs of injury.
4 Based on the patient’s relative’s testimony that were present on admission, 8 hrs ago the patient in the state of acute psychosis on the delirium ground committed penile self-amputation by means of scissors.Fig.2. Amputated penis was delivered to the clinic along with the patient.
5 Fig.3. Amputated penis was washed with sterile saline, wrapped in saline-soaked gauze, placed in a sterile bag and immersed in iced water.
6 Question to Faculty:Surgical re-implantation should be performed within _____ hours after the amputation?
8 The patient was consulted by microvascular surgeon and psychiatrist. Urinalysis, CBC and coagulation tests were performed. Hemoglobin level was 100 g/L that evidenced against massive bleeding caused by self-injury. Coagulation tests results were within normal range.Loss of the penile viability (signs of the irreversible changes in tissues, necrosis) was stated on inspection of the amputated penis despite of the performed measures, organ replantation was impossible.
9 Fig.4. The patient was managed with surgical treatment in the 1st 30 minutes following admission: initial surgical management with putting stitches on the damaged tissues.
10 Fig.5. The bleeding was arrested by putting catgut stitches into corpus spongiosus of the stump and ligation of the penile dorsal artery. The terminal urethral part was stitched to the penile stump, a permanent Foley catheter (#18 Ch.) was placed into the bladder. The balloon was filled with 15 ml.
11 Fig. 6. The wound was bandaged with sterile dressing Fig.6. The wound was bandaged with sterile dressing. The patient was administered with 400 mg of ciprofloxacin i/v during manipulation to prevent postoperative bacterial complications.
12 In postoperative period the patient was managed with: antibacterial therapy during 6 days (ciprofloxacin, 400 mg i/v),pain relieving treatmentregular wound d-bridement with dressings were performed.The course of the postoperative treatment was without complications.On the 6th day the Foley catheter was extracted, the self- maintained urination via penile stump was renewed.The wound was covered with granulations, edema and inflammation were reduced. The patient was transferred on follow-up treatment to the resident clinic with dressings in hospital.The stitches were put off on the 10th day after surgery.
13 Fig.7. Two weeks following surgery a complete wound surface healing by primary intention was stated, a secondary meatus was formed. The patient complained on slight difficulties in urination. He had refused from reconstructive operations.
14 Two months following surgery patient was repeatedly admitted to the Urology Department with complains on difficult urination, dripping urination, pollakiuria, nocturia.Urinary bladder sonography was performed, 100 ml of the residual urine was revealed.Urethrography revealed postoperative urethral stricture.The patient was performed endoscopic urethral dissection after which the urination was restored.Other postoperative complications were not registered.
15 DiscussionThe first documented case of penile replantation was reported in by Ehrich who realigned the penile structures without anatomizing the blood vessels or nerves (1).The first microvascular replantation was reported by Cohen and colleagues in 1977 (2).The incidence of the external genital organs trauma constitutes % of all penetrating urologic traumas in townsfolk population (3).In addition to cosmetic and functional deficits such injuries result in serious psychological consequences (4).1. Ehrich WS. Two unusual penile injuries. J Urol. 1929;21:2. Cohen BE, May JW Jr, Daly JS, Young HH. Successful clinical replantation of an amputated penis by microneurovascular repair. Case report. Plast Reconstr Surg. 1977;59:3. Zhong Z, Dong Z, Lu Q, et al. Successful penile replantation with adjuvant hyperbaric oxygen treatment. Urology. 2007;69:983.e3-5.4. Darewicz J, Gatek L, Malczyk E, Darewicz B, Rogowski K, Kudelski J. Microsurgical replantation of the amputated penis and scrotum in a 29-year-old man. Urol Int. 1996;57:197-8.
16 Penile amputation (PA) – usually represents the act of self-castration that is predominantly performed by young males in the acute psychotic state (1).Penile slash wounds have relatively high incidence and frequently are attended with it’s amputation (2).The penile stump is managed similar to penectomy if an amputated penis is not delivered to the clinic or it had lost its viability (3).Clinical case assessment demonstrated that despite of the serious injury that frequently results in massive hemorrhage the general patient state remains satisfactory and results of clinical tests may be within normal range. In given case the patient complained only on discomfort during urination.1. Fuller A, Bolt J, Carney B. Successful microsurgical penile replantation after a workplace injury. Urol Int ;78:10-2.2. Rana A, Johnson D. Sequential self-castration and amputation of penis. Br J Urol. 1993;71:750.3. Bhanganada K, Chayavatana T, Pongnumkul C, et al. Surgical management of an epidemic of penile amputations in Siam. Am J Surg. 1983;146:
17 Regardless of the meta-analysis data which states that irreversible ischemic changes in the amputated organ develop after 12 hrs, we registered the signs of ischemia and irreversible ischemic changes in penile tissues following 8 hrs after self-injury. That can be explained by patient’s age, history (55 y.o., continuous alcohol abuse and therefore possible cardio-vascular disease, atherosclerosis), in the same time when the average patient’s age with similar injuries is 30 y.o. based on the literature data.In proximate postoperative period we haven’t register any infectious inflammatory complications that evidenced the efficacy of antibiotic prevention and therapy.In distant postoperative period the patient developed only one complication – urethral stricture that was removed by means of endoscopy.A Winter’s spongiocavernosal shunt may improve venous drainage following replantation.(1).1. Fuoco M, Cox L, Kinahan T. Penile amputation and successful reattachment and the role of winter shunt in postoperative viability: A case report and literature review. Canadian Urological Association Journal. 2015;9(5-6):E297-E299.