Idiopathic Gangrene of the Penis
Correspondence Address :
H. C. Srikantaiah, Department of General surgery, M.S. Ramaiah
Medical College, Bangalore-560054, Karnataka, India.
Idiopathic Gangrene of the Penis
This rare clinical scenario was unraveled to us postoperatively, following abdominal surgery for intestinal obstruction.
Idiopathic gangrene of the penis is an extremely rare clinical disease involving the entire length of the penis, with no obvious arterial, systemic and / or infective pathology(1). This made us write a paper and report such an unheard of clinical situation.
A 65 years old male patient presented to us with vomiting, nausea and pain in the abdomen of 1 weekâ€™s duration, with the pain in the abdomen worsening since the past 3 days. There was no history of trauma or any sepsis in the genital / perineal area. On general examination, the patient was found to be sick and in pain. Abdominal examination revealed a distended abdomen which was soft and with no features of peritonitis, but with high pitched bowel sounds. The per rectal examination was unremarkable and relevant investigations were done.
A Ryleâ€™s tube was inserted, with a bilious aspirate. X-ray of the abdomen in the erect posture revealed multiple air fluid levels.
With a working provisional diagnosis of acute intestinal obstruction, he was posted for exploratory laparotomy, which revealed a dilated jejunum in its entire length, a stricture at the proximal ileum 20cms from the ileo-caecal junction; with a band at the stricturous segment. The level was with an impending gangrene, however with no serosal or peritoneal contamination; the rest of the GIT was evaluated thoroughly and was found to be normal. Resection and end to end anastomosis was done in 2 layers.
The patient made an uneventful recovery and was started on a liquid diet on the 5th post-operative day; he moved his bowels on the 6th postoperative day and was ambulant.
On the 7th postoperative day, we noticed a duskiness of the shaft of the penis. The patientâ€™s bladder was catheterized, with a good urine output.
To our surprise, the duskiness was found to be progressing day by day, with no obvious features of systemic toxicity.
The gangrene progressed to the entire length of the penis in spite of using only the Foleyâ€™s catheter and not having used a condom catheter was our clinical dilemma. This patient was on low molecular weight heparin from the postoperative day 3 prophylactically and his coagulation profile was essentially normal.
On the 8th postoperative day, the abdominal drains were removed and the patient was put on soft solids orally. An ultrasound of the abdomen revealed nothing remarkable, except for postoperative changes. The patient was on broad spectrum antibiotics and a blood count revealed mild leucocytosis.
On the 10th postoperative day, his condition seemed to have worsened and he was toxic with features of septicaemia. A portable ultrasound of the abdomen which was done in the SICU, was essentially normal. The patientâ€™s condition started to deteriorate and he succumbed on day 14.
Idiopathic gangrene of the penis is an extremely rare and unusual ischaemic necrosis of the male external genitalia and it poses difficulties in its management (2)(3)(4)(5) (6). Reports on the idiopathic penile and/ or scrotal gangrene are relatively rare in the recent past.
The aetiology of the disease, which is characterized by a sudden onset, most commonly without prodromal symptoms, is still not fully understood. Ischaemic penile gangrene leads to mummification and auto-amputation (1). Penile gangrene is a hallmark of severe systemic vascular disease (1). Despite the high mortality rate which is associated with ischaemic penile gangrene in diabetic patients with or without renal failure (4), an aggressive management is recommended for those who are not terminally and /or moribund (7).
Surgical intervention (debridement) at the onset of wet gangrene will avoid septic complications (5). However, total penectomy is advisable, depending on the general condition of the patient.
To conclude, this case is unusual and bewildering, being limited to the penile shaft only, with no obvious detectable source of aetiology. Only few cases have been reported so far. (Table/Fig 1) (Table/Fig 2).
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