Case Report

An octogenarian male patient was transferred to the emergency department from a district hospital due to a self-inflicted penile injury he sustained two days prior. He had a history of benign prostatic hyperplasia and experienced acute urinary retention. Enduring severe pain and discomfort, he attempted to alleviate his symptoms by cutting his penis with a blade. He was found in a severely bleeding state and was brought to a nearby hospital where he received blood transfusion and wound dressing before being referred to our facility for further care. The patient also had a medical history of COPD, hypertension, ischemic heart disease, and benign prostatic hyperplasia, with no reported psychiatric illness. Upon admission, he was conscious and co-operative, with pulse rate of 96 per minute and blood pressure 110/70 mm Hg. Examination revealed a significant cut injury to the penile shaft, with both erectile tissues divided, and a catheter inserted through the injured urethra. Bleeding was observed from the proximal part of the penis, while the distal part showed signs of gangrene. After careful assessment and considering the patient’s age and the extent of tissue damage, a decision was made to perform a partial amputation of the penis under spinal anesthesia. The patient underwent the procedure successfully (Fig. 1), with subsequent uneventful recovery and discharge on the tenth day post-surgery, with a catheter in place. A pre-discharge psychiatric review was conducted, during which the psychiatrist counselled the patient but did not prescribe any medications. Follow-up care was recommended at the urology outpatient department for on-going management of benign prostatic hyperplasia. The patient is currently on Alpha 1 blocker.

Fig. 1
figure 1

A, B, C Mutilated penis—dorsal, ventral, and lateral views respectively showing near total transection of corpora cavernosa and complete transection of urethra

Full size image

Discussion

Self-inflicted injuries to the penis, a unique urological emergency, are categorized as phallicide for cases involving suicidal intent and “Klingsor syndrome” for those without suicidal intentions. [1] These conditions often affect young male individuals suffering from schizophrenia, transvestism, or religious and cultural conflicts. [2] The first recorded case dates back to Strock in 1901 [3].

The classic “Klingsor syndrome” is associated with self-mutilation of the genitalia driven by religious delusions. [1, 2] It draws its name from “Klingsor,” a fictional character in Wagner’s opera. [2] This concept expanded to encompass various factors, including the absence of a positive male role model during early development, overly controlling mothers fostering masochistic tendencies, pathological feminine traits in male children, rejection of body image, unresolved sexual conflicts, and feelings of anxiety, guilt, and the need for atonement. [4]

Similar patterns have been observed in patients with penile carcinoma, following surgery such as transurethral resection of posterior urethral valves in children, TURP in males and as a consequence of trauma. [5] The time elapsed from the incident to surgical intervention significantly influences the treatment approach. The preferred method involves microvascular replantation aimed at restoring a fully functional, erect penis without tissue loss. [6] However, non-microsurgical techniques have also shown favorable postoperative outcomes. Additional factors for successful outcome include viability of the amputated tissue, the condition of the recipient site, and the state of the remaining penile stump at the time of presentation. [6] Limited Indian literature on this subject (Table 1) highlights the uniqueness of our case, which is the first reported instance involving a patient with benign prostatic hyperplasia.

Table 1 Indian literature on “Klingsor” syndrome
Full size table