Penis, external genital organs, mutilation, amputation, schizophrenia

Self-injury is defined as an intentional act on one’s organs without a suicidal intention ^[1]. Genital auto-mutilation is one of the rare and more complex forms, both psychopathologically and symbolically ^[2]. It constitutes a serious urological emergency ^[3]. The prognosis is marked by the repercussions on the psycho-social level, then those on the urinary and sexual functions of the organ ^[4]. The authors report a new observation of self-mutilation in a schizophrenic patient with a history of attempted genital auto-mutilation.

A 29-year-old patient, followed for schizophrenia for 2 years on neuroleptics treatments with poor compliance who has attempted to amputate his testicles a week earlier brought once again to the emergency department by his family following auto--amputation of his penis in the toilet approximately some hours before the admission. The clinical examination revealed a calm patient in hemorrhagic shock with an amputated penis at its base, active bleeding, and a scrotal wound in the process of healing (Figure 1). Hemostatic measurements were taken in the emergency room and the patient was taken to the intensive care unit for resuscitation. After stabilization, he was referred to the operating room. After thorough washing with saline and antiseptic, perfect control of the hemostasis was ensured with identification of the urethra and the corpus cavernosum. A bladder catheterization was easily performed with a foley catheter 18 (Figure 2). The final gesture consisted of a urethrostomy, placement of a drain, and suturing of the different planes (Figure 3). The postoperative follow-up was simple. The patient is regularly followed up with his psychiatrist.

Genital self-mutilation is a urological emergency rarely encountered in practice. It constitutes a drama by its manner of occurrence and its clinical presentation. In case of heavy bleeding, a state of hemorrhagic shock may set in and require resuscitation. The mainstay of treatment is emergency surgery and psychiatric advice. This follow-up must be regular and assess an intention of recurrence. Beyond the functional prognosis (micturition and sexual), there is a problem with body image.
Penile amputation has been classified into three groups: self-mutilation, criminal amputation, and traumatic accident ^[5]. Self-mutilation, an unusual situation in daily urological practice, is a rare phenomenon. It occurs in the majority of cases in a psychotic setting but can be secondary to drug or alcohol abuse. Treatment and management vary according to the severity of the lesions, the time required for consultation, and the mental state of the patient ^[6].
The man has an ambivalent relationship with his body. As an object of care, revered, the body can also be the site of mutilating practices. Men have always marked their bodies in ritual practices ^[7]. Self-mutilation would be reported in mythology, ethnology, and some religious and contemporary rituals ^[2]. The first self-castration in history is reported by Lucien of Samosata who relates the legendary story of Combatus. He is a young Syrian of great beauty who had received from his king the important mission to accompany Queen Stratonice on her journey to Hierapolis in Phrygia. He decided to emasculate himself before the departure and to lock his genitals in a box that he entrusted to the king. This sacrifice enabled him to confound his slanderers on his return and was worth to him to be filled with honors by the king ^[8].
The incidence of this disease is not well known, the majority of cases do not seem to be reported by the patient or the family ^[9]. Black et al. identified three particular groups at risk for genital self-harm: schizophrenics, transvestites, and men with religious or cultural conflicts ^[10].
The current standard of treatment for this infrequent injury is replanting with the approximation of the urethra, corpus cavernosum, and microsurgical anastomosis of the dorsal vein, arteries, and nerves. This technique is considered to reduce immediate and longterm postoperative complications ^[11]. Certain conditions are necessary to replant the amputated penis and predict the success of the surgery: state of the viability of the organ, state of the graft bed, or stump of the penis at the time of injury. The amputated part must be wrapped in gauze soaked in saline solution and placed in a sterile bag ^[12]. If reimplantation is not possible, hemostasis with skin ureterostomy is performed ^[13].
In our context, given the contexts in which the procedure occurred and the time of presentation, we were unable to attempt reimplantation. Our attitude was, first of all, to stabilize the patient and transport him to the operating room with perfect control of hemostasis, regularization of the stump, and urethrostomy.

Self-mutilation of the penis is a rare situation in urological practice. It frequently occurs in schizophrenia. The management is multidisciplinary and may involve the resuscitator, the urologist, and the psychiatrist. The surgical attitude in an emergency depends on the severity of the lesions and the time of consultation. It must be done to preserve the functions of the penis as much as possible.

Authors’ contributions

All the authors contributed substantially to the design and production of this article.

Conflicts of interest

All authors declared that there are no conflicts of interest.

Ethics approval

Not applicable.

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