Genital self-amputation or the Klingsor syndrome: Successful non-microsurgical penile replantation
A 29-year-old man, unmarried, with a history of schizoaffective personality disorder, but non-compliant with the antidepressant and antipsychotic medication, was admitted for self-cutting of penis 2 cm distal from the mons of the pubis.\nAt the admission, mental examination revealed apathetic and conscious patient but uncooperative. Eye contact was poor, speech was inaudible. There was no suicidal intent.\nAt the urological examination, we found a subtotal cut of the penis, interesting the anterior and lateral parts of the penile skin, and a clear cut trough cavernosal bodies, and urethra. The penis remained suspended only by a thin posterior part of the skin [Figures and ]. The patient received two intravenous antibiotics.\nImmediately the patient was addressed in the operating room. The microsurgery was not available and the only chance to attempt to save the functionality of the organ was a non-microsurgical replantation of the amputated penis. A suprapubic cystostomy was first performed. The operation started about 5 hours after the trauma.\nA 16-Fr silicon catheter was inserted through the urethra of the amputated part and the proximal urethral stump and passed on into the bladder. End-to-end urethral anostomosis was made with a two-layer closure over a using 5-0 polyglycolic acid [].\nAfterwards the cavernous bodies of the penis were connected with 3-0 polyglycolic acid continuous suture.\nWe did not perform anastomosis of the dorsal vein, artery or the nerve. Buck's and dartos fascia were reapproximated, and the skin was closed.\nThe patient was transferred to the inpatient psychiatric unit for further management.\nTwenty-four hours after the surgery, we did not observe any skin necrosis and the urethral mucosa showed a reassuring pink colour.\nOne week after the surgery, the patient in an agitation crisis pulled up his foley catheter.\nWe removed the cystostomy catheter 2 weeks later, after that the normal micturation was acquired.\nThe clinical exam 1 month after surgery showed a viable penis [Figures and ], with a pink urethral mucosa, and a normal sensation. The patient reported normal micturition and spontaneous morning erections 3 months after surgery. Those results were maintained 1 year after surgery.\nDuring the psychiatric interview patient reported that the act was preceded by religious delusions and hallucinations: He was hearing voices and feeling guilty, and thought that God would punish him.\nThe psychiatrist ordered lithium 900 mg/day, sertraline 50 mg/day and risperidone 3 mg/day. The patient was fully remitted at the first month.