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\begin{document}

\title{Successful penile re-implantation after 8 hours post penile
self-mutilation}



\author[1]{Mohammed  Salem}%
\author[1]{Abdul Alherek}%
\author[1]{Francis Muangalayi}%
\author[1]{Alain Tshiala}%
\author[1]{Alain Mwamba Mukendi}%
\affil[1]{University of the Witwatersrand Johannesburg Faculty of Health Sciences}%


\vspace{-1em}



  
  \date{March 13, 2025}


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\selectlanguage{english}
\begin{abstract}
Penile self-mutilation is an infrequent form of self-harming behavior
seen primarily in patients with schizophrenia spectrum disorders and
rarely reported in those with major depressive disorders. We herewith
present a major depression related case of penile self-mutilation
successfully managed by macroscopic penile re-implantation performed 8
hours after the incident.%
\end{abstract}%



\sloppy


\textbf{Successful penile re-implantation after 8 hours post penile
self-mutilation}

\textsuperscript{1}Mohammed Saleh E.Khalifa
Salem,\textsuperscript{1}Abdul Alherek , \textsuperscript{1}Francis
Muangalayi, \textsuperscript{1}Alain Kabongo Tshiala,
\textsuperscript{1,2}Alain Mwamba Mukendi.

\textsuperscript{1}University of the Witwatersrand, Division of Urology,
Department of Surgery, Klerksdorp Hospital, Northwest, South Africa.

\textsuperscript{2} Department of Urology, Chris Hani Baragwanath
Academic Hospital, Soweto, South Africa

Mohammed ESK Salem

E-mail: mdsaleh55@hotmail.com

Abdul Alherek

E-mail: halasouthafrica@gmail.com

Francis Muangalayi

E-mail: francismuangalayi@yahoo.com

Alain Kabongo Tshiala

Email:

kabongo.alain19@gmail.com

*Corresponding Author

Alain Mwamba Mukendi

University of the Witwatersrand

Division of Urology

Department of Surgery

Chris Hani Baragwanath Academic Hospital

Soweto

Johannesburg, South Africa

Cel: 0027711576350

E-mail:\emph{alainmwamba2006@yahoo.fr}

\textbf{Abstract}

Penile self-mutilation is an infrequent form of self-harming behavior
seen primarily in patients with schizophrenia spectrum disorders and
rarely reported in those with major depressive disorders.

We herewith present a major depression related case of penile
self-mutilation successfully managed by macroscopic penile
re-implantation performed 8 hours after the incident.

\textbf{Key clinical message}

In this report, we present a major depression related case of penile
self-mutilation during a suicidal attempt successfully managed by a
multidisciplinary team with an impressive cosmetic and functional
outcome following macroscopic penile re-implantation performed by the
urology team 8 hours after the incident.

\textbf{Keywords} : self-penile mutilation, depression, psychiatric
disorders, multidisciplinary approach, re-implantation.

\textbf{1.Introduction}

Self-penile mutilation (SPM) is a rare urological emergency often
associated with psychiatric disorders. Penile mutilation in general may
result in life threatening hemorrhage therefore it requires immediate
surgical intervention {[}1,2,3{]}.

The~1\textsuperscript{st} SPM mentioned in the English literature was by
Strock in 1901 {[}4{]}. Many cases have been reported in African
countries like Kenya and Nigeria {[}5{]}. Self-inflicted injuries~to
external genitalia range from small cuts and lacerations to more complex
injuries like penile amputation~which is a serious challenge to the
urologist. The gold standard treatment for penile amputation is early
reimplantation which if successful should yield satisfactory functional
and cosmetic results {[}1,2,3{]}.

\textbf{2.Case report}

A 33-year-old South~African man and prison inmate was rushed to the
accident and emergency unit of Klerksdorp/Tshepong hospital complex
following a self-inflicted penile amputation and neck laceration due to
depression using a sharp knife. He was referred from a correctional
service centre in Northwest province to the Tshepong facility that deals
with trauma emergency cases and presented about 2 hours following
injury. Further interrogation revealed that he is known to have a
depressive illness. There was no history of drug or~alcohol abuse.

On examination, he was hemodynamically stable, fully conscious, alert
but in pain, depressed, anxious, and had a wound on his left side in the
middle zone of the neck and an almost completely severed actively
bleeding penis (Fig 1). Bleeding was controlled by applying pressure to
the wound with~gauze swabs. The patient was initially managed according
to ATLS principles and tetanus prophylaxis was given. The~results of
hemoglobin, serum urea, electrolytes, and creatinine were within normal
limits. A CT angiogram scan was done and showed no major vascular injury
in the neck. Due to slate congestion to access CT angiogram, about 5
hours had passed from just waiting for images before being transferred
to the Klerksdorp part of the complex to the urology team that took over
the management of the patient and took him immediately to theatre for an
emergency surgery. The initial plan was to excise the distal portion of
the penis and proceed to completion of partial penectomy. The patient
was also counseled about a possible attempt to macroscopic
reimplantation. Upon intra-operative reassessment revealing that the
distal penile shaft was still viable. The decision was made to rather go
for reimplant with the hope to achieve good cosmetic and functional
outcomes.

The urethra was refreshened, spatulated and re-anastomosed over a 16
French catheter in a tension free fashion using continuous 4/0 vicryl
sutures. Both cavernosal bodies were sutured using interrupted 2/0
vicryl sutures, the neurovascular bundles approximated with interrupted
4/0 vicryl sutures and the skin closed with chromic 3/0 (Fig.2). The
surgery lasted about two and a half hours.

On day 1 post-operative the patient was seen by the psychiatrist who
concluded that he had major depression. The patient was kept in the ward
for a week then discharged on antibiotics, analgesia, and a
transurethral catheter.

Post-operative course was grossly uneventful, a very small area of skin
necrosis was noted on the distal part of~the glans in the first week
which was almost completely healed altogether with the wound by 4 weeks
when reviewed as an outpatient and the transurethral catheter was
removed. At 8 weeks post-operative, he reported good and rigid erection
with normal ejaculation but no sensation on the glans and up to 3 cm
proximally. The wound showed good cicatrization in progress (Fig.3) and
we noticed a mild meatal stenosis for which a dilatation was done. The
distal penile shaft felt more firmer than the rest of the~penis. There
was no blood flow within the~cavernosal bodies in the distal part of the
phallus on color Doppler ultrasound.

At 4 months follow up visit, he re-confirmed having good erections
during masturbations and reported in addition, a full recovery of
sensation on the penile skin. However, the glans was still numb. The
phallus looked cosmetically satisfactory (Fig.4) with a meatal stenosis
which was dilated, and he was advised to do intermittent
self-dilation.\textbf{3.Discussion}PSM~may be a~rare phenomenon often
associated with psychiatric disorders such as schizophrenia spectrum;
substance abuse; personality and gender dysmorphic disorders. Bipolar
and depression disorders are very uncommon associated condition with
very few cases reported {[}1,3{]}. The present case was associated with
depression and there was no substance abuse or psychosis.

There appears to be an increasing incidence but whether~this is due to
an increased level of reporting in recent years remains unclear
{[}1,3{]}. Although the act was considered unknown in Africa {[}6{]}.
The~overwhelming majority~of reported incidents occurred among single,
Caucasian males~in their 20s and 30s {[}7{]}. Our patient fell within
the age categories~apart from~being of African descent.

The primary~major literature review on PSM was published in 1979 with
few cases of genital self- mutilation reported thereafter involving both
genders {[}3,4,8{]}. The degree of mutilation, the predisposing
factors,~and therefore the~instruments used in the perpetration of this
irrational and dastardly act varies {[}5{]}. The instruments may include
knives as~utilized by the patient in~this case; blades; scissors;
chainsaw, and axe. Injuries sustained range from simple lacerations of
the scrotal skin~to complete~penile amputation. Our case had sustained
an almost completely severed penile injury.

The motivational factor~liable for~PSM varies. About one-tenth of
self-mutilators intended suicide~secondary to~depression and anxiety
{[}9{]}. PSM has been categorized either into 3~diagnostic subgroups:
schizophrenic patients, transvestites,~and people~with complex religious
and cultural beliefs or into phallicide without psychosis and klingsor
syndrome with psychosis {[}3,10{]}. In ours, phallicide is more
appropriate.

There is~a need for close follow-up of depressed patients to detect any
overt psychotic tendency in the future.~It is suggested that in the
presence of overt psychotic symptoms, PSM should be considered related
to psychotic depression {[}11,12{]}. As part of multidisciplinary team
management, psychiatric team assessed our patient and confirmed that he
was not psychotic. Early psychiatric involvement was crucial to
ascertain that there is no risk of repeating self-mutilation of
replanted penis.

The amputated phallus should be wrapped in saline-soaked gauzes and
placed in a sealed plastic bag which is stored in ice slush ``bag in
bag'' {[}2{]}. Our patient had his amputated penis still attached
ventrally to a stalk but covered with saline moistened gauzes. He spent
about 7 hours before from the incident to the time he was seen by the
urology team and taken immediately for emergency theatre.

Early replantation of the amputated penis is the gold standard. There
have been reports of successful microscopic and macroscopic
reimplantation. Distal penile amputation is technically difficult to
repair, particularly vascular anastomosis due to small vessels
{[}2,8{]}.

The amputation in this case was at mid penile shaft and no microvascular
technique was used.

Ischemic time is paramount for a successful reimplantation. Tissues with
less muscles such as penis can survive 24 hours of ischemia. Successful
reimplantations have been carried out with a cold-ischemic time of fewer
than 16 hours {[}2,3,8{]}. Whereas some researchers have attempted
anastomosis with a cold-ischemic time~of more~than 16 hours with a less
favorable result {[}13{]}. The event~of microvascular technique has
improved success with regard to penile reimplantation. Our patient's
ischemic time was about 8 hours, and no ice was used. The outcome of the
surgery was satisfactory.

Complications resulting from PSM varied~consistently with~the severity
of the injury inflicted and the extent of surgical repair undertaken
{[}14{]}. Reported postoperative complications include failed
reimplant,~male erectile dysfunction, urethral stricture, urinary
fistula formation, sloughing of the distal urethra and penile skin.~ Of
note, if the cause of index injury not attended to properly there is a
risk of repeat self-mutilation, death from excessive hemorrhage, or
succumb to suicide by completing it {[}15{]}. Numerous reviews and
individual case reports have highlighted the inconsistencies that
exist~in this~subgroup of patients and the myriad of motivational
factors behind this unique form of deliberate self-harm {[}16{]}. The
identification~of these~at-risk remains as difficult as ever.
Even~tougher~is identifying those patients at risk of repeating this act
and those that will go on to complete the suicide intent. {[}17{]}.

Our patient was followed several weeks after discharge by the
multidisciplinary team and besides the meatal stenosis for which he is
currently of self-intermittent dilatation, none other of the above
complications were observed.

\textbf{Conclusion}Successful management of self-penile mutilation
should include a multidisciplinary team in pre and postoperative period.
It should be treated as an emergency without delays. A multidisciplinary
post operative follow ups are crucial part of care and should reassess
holistically the patient to prevent repetition of the self-harm and
completion of the suicidal act. Despite the severity of the trauma
involving the penis and taking into account the ischemic time,
replantation should be considered as part of therapeutic options guided
by pre and intraoperative re-evaluation. A final and definitive
intraoperative decision as in our case led to a successful
re-implantation with satisfactory cosmetic and functional results.

\textbf{Acknowledgments}

None

\textbf{Conflict of interest statement}

The authors declare no conflicts of interest.

\textbf{Funding source}

None.

\textbf{Author contributions}

Mohammed Salem : responsible for the integrity of the data, contributed
in drafting, revision and approval of the last version of the
manuscript; Abdulhamed Alherek: Contributed to drafting and approval of
the manuscript; Francis Maungalayi : Contributed to drafting and
approval of the manuscript; ; Alain Kabongo Tshiala : Contributed to
drafting and approval of the manuscript; Alain Mwamba Mukendi: Guarantor
of the manuscript and contributed in drafting, incorporation of
co-authors feedbacks, revision, and final submission composition.

\textbf{References}

\begin{enumerate}
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\item
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\end{enumerate}

\textbf{Figures legend}

Fig 1. Pre-operative image showing almost completely severed penis at
midshaft dorsally.

Fig 2. Immediate post-surgery image showing successful anastomosis and
catheter in situ.

Fig 3. 8 weeks post-surgery image showing good healing in process.

Fig 4. 4 months post-surgery image showing good cosmetic result.

\textbf{CONSENT}

Written informed consent was obtained from the patient for publication
of this manuscript and accompanying pictures. A copy of the written
consent is available for review by the Editor-in-Chief of this journal.

\textbf{Hosted file}

\verb`Figures reimplantation.docx`  available at \url{https://authorea.com/users/590849/articles/627017-successful-penile-re-implantation-after-8-hours-post-penile-self-mutilation}

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