Genital Mutilation in Males.

PURPOSE OF THE REVIEW: Genital mutilation in males can range from minor injuries (cuts from a blade) to severe urological emergencies (testicular or penile amputation). Due to the rarity of these events, there is a lack of extensive reports, as most of the available literature is regarding single cases. Genital mutilation has been associated with psychotic and non-psychotic causes, psychiatric conditions, drug consumption, sexual practices, or even cultural or religious beliefs. It is crucial to perform a psychiatric evaluation of these patients to obtain the best therapeutic approach. This manuscript serves as a review of the currently available knowledge regarding male genital mutilation. RECENT FINDINGS: A great variety of reasons have been associated with genital mutilation. Previous authors have distinguished between those that present with a clear mental health precursor from cases with no psychotic background. Nevertheless, sometimes, it is difficult to make this distinction. Recently, reconstructive techniques for amputation cases have moved towards a microsurgical approach in order to improve outcomes. A holistic therapeutic approach must be performed to increase the chances of effective treatment. Close collaboration between urologists, psychiatrists, and emergency doctors is essential to ensure the best care for patients performing genital mutilation. Future publications must evaluate differences in treatment options and the impact that these have on the long-term well-being of patients undergoing genital self-mutilation.

Double penile fracture without urethral injury presenting after 7 days.

Penile fracture is the sudden rupture of the tunica albuginea of an erect penis due to blunt trauma. It is an uncommon uropathology which characteristically occurs when one or both of the turgid penile corpora cavernosa forcefully snap under an abrupt blunt trauma, usually during an aggressive sexual intercourse or noncoital manipulation. In the majority of cases, diagnosis is clinical. Surgical repair irrespective of the time of presentation results in accelerated recovery, reduced morbidity, and fewer short and long-term complication rates. We report the case of a 35-year-old banker who sustained a bilateral rupture of the tunica albuginea without urethral injury during a heterosexual intercourse. He presented 7 days after the trauma to our facility following the persistence of symptoms despite conservative management with herbal medicine. Following a clinical diagnosis of penile fracture, he had penile exploration under regional anesthesia using a degloving subcoronal incision. He subsequently had repair of both corporal tear after clot evacuation. The postoperative period was uneventful, and he was discharged on the 3rd day after the surgery. He had been followed up for 2 years with good erectile and functional outcomes. This case report reiterates the fact that late presentation is not a barrier to surgical management and good outcome.

Résumé La fracture pénile est la rupture soudaine de l'albuginea tunica d'un pénis en érection en raison d'un traumatisme contondant. C'est une uropathologie rare qui se produit typiquement quand un ou les deux de la cavernosa penile turgid de corpora s'enclenchent avec force sous un trauma émoussé brusque, habituellement pendant un rapport sexuel agressif ou une manipulation noncoital. Dans la majorité des cas, le diagnostic est clinique. La réparation chirurgicale indépendamment du temps de présentation a comme résultat le rétablissement accéléré, la morbidité réduite, et moins de taux à court et à long terme de complication. Nous rapportons le cas d'un banquier de 35 ans qui a soutenu une rupture bilatérale de l'albuginea de tunica sans blessure urétrale pendant des rapports hétérosexuels. Il s'est présenté 7 jours après le trauma à notre établissement suivant la persistance des symptômes en dépit de la gestion conservatrice avec la médecine de fines herbes. Après un diagnostic clinique de rupture pénienne, il a eu l'exploration pénienne sous l'anesthésie régionale utilisant une incision subcoronal degloving. Il a par la suite subi la réparation des deux déchirures corporelles après l'évacuation du caillot. La période postopératoire était calme, et il a été déchargé le 3ème jour après l'opération. Il avait été suivi pendant 2 années avec de bons résultats érectiles et fonctionnels. Ce rapport de cas réitère le fait que la présentation tardive n'est pas un obstacle à la gestion chirurgicale et au bon résultat. Mots-clés: Traumatisme contondant, fracture du pénis, rupture, tunica albuginea.

Restoration of erectile function by a combination of antiapoptosis by JNK inhibitor and preservation of smooth muscle or endothelium by hepatocyte growth factor in a rat model of cavernous nerve injury.

BACKGROUND: Because of structural alterations in the corpus cavernosum after radical prostatectomy (RP), post-RP erectile dysfunction remains a very difficult condition to treat. We aimed to determine if the combined administration of a Jun-amino terminal kinase (JNK) inhibitor and hepatocyte growth factor (HGF) in the immediate post-injury period would restore erectile function by antiapoptotic and pro-regenerative effects through the rectification of molecular pathways related to the structural integrity of the penis in a rat model of bilateral cavernosal nerve crush injury (CNCI). METHODS: A total of 70 rats were divided into five groups: Sham surgery (S), CNCI (I), and once-daily intraperitoneal administration of 10.0 mg/kg JNK inhibitor + twice-weekly intracavernosal administration of low-dose (2.1 µg), medium-dose (4.2 µg), or high-dose (8.4 µg) HGF (I + J + LH or I + J + MH or I + J + HH, respectively) in the immediate post-injury period. Erectile responses to electrostimulation (1.0, 3.0, and 5.0 V), histological staining, caspase-3 activity, and Western blotting were evaluated 9 days after surgery. RESULTS: Group I showed lower intracavernosal pressure (ICP)/mean arterial pressure (MAP) after stimulation at each voltage, lower area under the curve (AUC)/MAP after stimulation at each voltage, less smooth muscle (SM) content, a lower SM/collagen ratio, higher caspase-3 activity, increased cJun phosphorylation, decreased protein expression of PECAM-1, decreased cMet phosphorylation, and decreased endothelial nitric oxide synthase (eNOS) phosphorylation compared to Group S. The SM content, SM/collagen ratio, protein expression of ICP/MAP, or AUC/MAP after stimulation at each voltage in Group I + J + LH were partially restored, despite the normalization of cJun phosphorylation and caspase-3 activity. The ICP/MAP, AUC/MAP, caspase-3 activity, SM content, protein expression of PECAM-1, cJun phosphorylation, cMet phosphorylation, and eNOS phosphorylation in both Groups I + J + MH and I + J + HH were restored to the levels observed in Group S, while the SM/collagen ratio was significantly improved but not completely normalized. CONCLUSIONS: Our data indicated that the combined administration of a JNK inhibitor and medium or high-dose HGF to nerve-injured rats in the immediate post-injury period after CNCI may restore erectile function to a level comparable to the normal level by suppressing cavernosal apoptosis and preserving the integrity of SM or endothelium via rectification of the cJun and cMet/eNOS pathways.

Histopathological effects of aloe vera on wound healing process in penile fracture model: an experimental study

Background/aim: This study assessed the histopathological effects of aloe vera (AV) on penile fractures (PF) formed experimentally in rat model. Materials and methods: Thirty-two Wistar adult male rats (220 to 250 g) were used. The PF model was created experimentally with a number 15 lancet. After the interventions, all of the rats were randomly and equally divided into 4 groups. In the first group, incision was not closed (group C). In the second group, AV was locally applied onto incision without suturing for 3 days (group AV). In the third group, the incision line was closed primarily (group PR). In the last group, AV was applied to primary repair region for 3 days (group PAV). All groups were compared to each other according to presence of fibrosis, inflammation, and hyperemia-bleeding. Results: Hyperemia and bleeding were seen in all groups with varying degrees and the difference between groups was insignificant (p = 1.000). According to inflammation, there was a significant difference between all groups (p = 0.031). No significant inflammation was observed in group AV and therefore, group AV had a better score than group PR (p = 0.026). In group PAV, inflammation was less seen than group PR, however, the difference was insignificant (p = 0.119). According to fibrosis, group AV and group PAV had same fibrosis rates. Fibrosis was observed in 2 (25%) rats in each group. When group PR was compared with group AV and group PAV, there were no significant differences according to cavernosal tissue healing with fibrosis (p = 0.132 and p = 0.132, respectively). Conclusion: Local application of AV onto the PF region without closing with suture decreased inflammation in rats.

[Penile strangulation: about two patients living in rural areas]. / Strangulation du pénis: à propos de deux cas en milieu rural.

Penile strangulation is a clinical condition requiring emergency management. Several metallic or non-metallic objects can be placed around the penis to improve sexual performance or for auto-erotic purposes. We report the case of two schizophrenic patients aged 25 and 33years hospitalized in the Emergency Department due to penile strangulation by metal ring. The ring was placed at the level of the glans foreskin groove 3 days before in one case and at the level of the root of penis 2 days before in the other. There was no urinary disorder in both patients. Ring ablation was performed with taxis under local anesthesia in one case and under sedation followed by double ring section using an electric saw in the other case.

Effect of Ginkgo biloba Extract (EGb-761) on Recovery of Erectile Dysfunction in Bilateral Cavernous Nerve Injury Rat Model.

OBJECTIVE: To investigate whether the therapeutic effect of Ginkgo biloba extract (GBE) in a rat model can improve erectile dysfunction after bilateral cavernous nerve injury. METHODS: Forty-three male Sprague-Dawley rats underwent cavernous nerve crush injury and were randomized into 4 groups, including: vehicle only, high-dose GBE, medium-dose GBE, and low-dose GBE. Eight animals underwent sham operation. Four weeks later, erectile function was assessed by cavernous nerve electrostimulation, and penile tissue was collected for histologic analysis. RESULTS: Significant recovery of erectile function was observed in the high-dose GBE group in a dose-dependent manner as compared with the vehicle-only group (P <.001). The high-dose GBE group had a significant increase in neurofilament-1 expression (P <.001), preservation of neural nitric oxide synthase nerve fibers of the dorsal penile nerve (P <.05), and increased smooth muscle cell content (P <.001) compared with the vehicle-only group. In addition, high-dose GBE markedly augments the smooth muscle-to-collagen ratio (P <.05) and reduces the apoptotic index. CONCLUSION: Administration of GBE increases neuron survival and preserves the neural nitric oxide synthase nerve fiber and contents of the corpus cavernosum after bilateral cavernous nerve injury. These implications indicate the beneficial effects of GBE use in the repair of the cavernous nerve and recovery of erectile function after radical prostatectomy.

Restoration of erectile function by suppression of corporal apoptosis, fibrosis and corporal veno-occlusive dysfunction with rho-kinase inhibitors in a rat model of cavernous nerve injury.

PURPOSE: We determined whether Rho-kinase inhibition would improve corporal veno-occlusive dysfunction by suppressing apoptosis and fibrosis via normalization of the Rho-kinase driven pathways related to the 2 structural alterations in a rat model of cavernous nerve crush injury. MATERIALS AND METHODS: A total of 30 male 10-week-old male Sprague Dawley® rats were equally divided into 3 groups, including sham surgery, cavernous nerve crush injury and cavernous nerve crush injury treated with fasudil. The treated group received fasudil (30 mg/kg) daily for 4 weeks starting day 1 postoperatively. Electrostimulation and dynamic infusion cavernosometry were performed 4 weeks postoperatively. Penile tissue was processed for imm unohistochemistry, double immunofluorescent and Masson trichrome staining, TUNEL, caspase-3 activity assay and Western blot. RESULTS: The cavernous nerve crush injury group showed significantly lower intracavernous pressure/mean arterial pressure, and higher maintenance and drop rates than the sham surgery group. Rho-kinase inhibition in the injury plus fasudil group restored erectile responses and dynamic infusion cavernosometry parameters. Increased apoptosis, decreased immunohistochemical staining of α-SMA and increased caspase-3 activity were noted in the injury group. In that group densitometry revealed increased ROCK1 expression, increased MYPT1 phosphorylation, decreased Akt phosphorylation, decreased Bad phosphorylation and a decreased Bcl2-to-Bax ratio. A significantly decreased smooth muscle-to-collagen ratio and increased fibroblast pCofilin were also observed in the injury group, as was increased phosphorylation of cofilin, a downstream effector of LIMK2. Rho-kinase inhibition in the injury plus fasudil group alleviated the histological and molecular dysregulation. CONCLUSIONS: Our data suggest that early inhibition of Rho-kinase after cavernous nerve crush injury may prevent corporal apoptosis and fibrosis by suppressing the Akt/Bad/Bax/caspase-3 and LIMK2/cofilin pathways, preventing corporal veno-occlusive dysfunction and erectile dysfunction.

Complete penile amputation during ritual neonatal circumcision and successful replantation using postoperative leech therapy.

Circumcision is the most common surgical procedure in males in the United States, and minor complications are not uncommon. Major complications like partial penile amputations have been reported with successful replantation. Complete penile amputations in adult males have been described, and successful replantation has been reported with increasing success. We report a case of complete penile amputation at the penopubic junction using a Mogen clamp in a 7-day-old neonate with replantation using postoperative leech therapy. To our knowledge this is the first time leech therapy has been used postoperatively for neonatal penile amputation.

A new nonsurgical technique for managing zipper injuries.

Zipper injuries are highly distressing to patients and often difficult to manage. Several management techniques are described in the literature. Many are complex and laborious, requiring sophisticated instruments in skilled hands, or even rely on a formal operation. This new technique involves the release of entrapped penile skin from a zipper by cutting the zipper tape and teeth immediately superior and inferior to the zipper connector and using a needle holder to pull the zipper apparatus apart following the application of lubrication and appropriate use of local analgesia. This novel technique is quick, nontraumatic and requires readily available equipment. It has been used successfully in two patients who were ineligible for a circumcision.

Both immediate and delayed intracavernous injection of autologous adipose-derived stromal vascular fraction enhances recovery of erectile function in a rat model of cavernous nerve injury.

BACKGROUND: Intracavernous injection of cultured adipose-derived stem cells (ADSCs) effectively restores erectile function in cavernous nerve (CN)-injured rats when administered at the time of injury. However, culturing exposes ADSCs to the risk of contamination and dedifferentiation. OBJECTIVE: Explore the effect of uncultured autologous adipose-derived stromal vascular fraction (SVF) on improving erectile function in a rat model of CN injury when administered at the time of injury or 4 wk after injury. DESIGN, SETTING, AND PARTICIPANTS: Eighty-nine male Sprague Dawley rats were randomly divided into four groups. CN injury or sham surgery was performed at the start of the study, and rats were treated with either SVF or vehicle. Functional testing and histologic analysis were performed 12 wk after CN crush or sham surgery. INTERVENTION: We used intracavernous injection of saline immediately after CN crush (n=23), intracavernous injection of SVF immediately after CN crush (n=17), intracavernous injection of SVF 4 wk after CN crush (n=23), or sham surgery (n=26). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We studied intracavernous pressure (ICP) response to CN electrostimulation and performed histologic examination of midpenile cross-sections. Data were analyzed using one-way analysis of variance followed by the Tukey-Kramer test. RESULTS AND LIMITATIONS: Both immediate and delayed treatment with SVF resulted in a significantly increased ICP-to-mean arterial pressure ratio compared with the vehicle-treated group. Both immediate and delayed treatment with SVF significantly increased expression of neuronal nitric oxide synthase and neurofilament in dorsal penile nerves compared to the vehicle group. Furthermore, the smooth muscle-to-collagen ratio within the corpus cavernosum was significantly improved in both of the SVF groups compared to vehicle-treated rats. The main limitation of the study is the lack of determination of the SVF components. CONCLUSIONS: Uncultured autologous SVF injected immediately or 4 wk after CN crush improved erectile function, promoted nerve regeneration, and prevented fibrosis of the corpus cavernosum following CN injury.

Injections of adipose tissue-derived stem cells and stem cell lysate improve recovery of erectile function in a rat model of cavernous nerve injury.

INTRODUCTION: Erectile dysfunction (ED) remains a major complication after radical prostatectomy. The use of adipose tissue-derived stem cells (ADSCs) has shown promising results for the treatment of ED. However, the mechanisms of action for stem cell therapy remain controversial, with increasing evidence pointing to paracrine pathways. AIM: To determine the effects and to identify the mechanism of action of ADSC and ADSC-derived lysate in a rat model of cavernous nerve (CN) crush injury. METHODS: Thirty-two male Sprague-Dawley rats were randomly divided into four equal groups: one group underwent sham operation, while three groups underwent bilateral CN crush. Crush-injury groups were treated at the time of injury with intracavernous injection of ADSC, lysate, or vehicle only (injured controls). Erectile function was assessed by CN electrostimulation at 4 weeks. Penile tissue was collected for histology. MAIN OUTCOME MEASURES: Intracavernous pressure increase upon CN stimulation; neuronal nitric oxide synthase (nNOS) content in the dorsal penile nerve; smooth muscle content, collagen content, and number of apoptotic cells in the corpus cavernosum. RESULTS: Both ADSC and lysate treatments resulted in significant recovery of erectile function, as compared with vehicle treatment. nNOS content was preserved in both the ADSC and lysate group, with significantly higher expression compared with vehicle-treated animals. There was significantly less fibrosis and a significant preservation of smooth muscle content in the ADSC and lysate groups compared with injured controls. The observed functional improvement after lysate injection supports the hypothesis that ADSCs act through release of intracellular preformed substances or by active secretion of certain biomolecules. The underlying mechanism of recovery appears to involve neuron preservation and cytoprotection by inhibition of apoptosis. CONCLUSIONS: Penile injection of both ADSC and ADSC-derived lysate can improve recovery of erectile function in a rat model of neurogenic ED.

Erectile function restoration after repair of excised cavernous nerves by autologous vein graft in rats.

INTRODUCTION: Cavernous nerves (CNs) injury is the main cause of erectile dysfunction (ED) following radical prostatectomy. Its restoration remains challenging. AIM: To investigate the feasibility of erectile function recovery by autologous vein graft after bilateral CNs being excised in a rat model. METHODS: A total of 36 adult male Sprague-Dawley rats were randomized into three groups. A 5mm segment of CN was excised bilaterally in group B and C. In group B, a 7-mm segment of autologous saphenous vein was interposed at the defect site bilaterally, with two nerve stumps inserted into the vein lumen. Group C underwent no repair. Group A was accepted a sham operation. 4 months later, apomorphine tests were performed on each rat, followed by injection of 4% fluorogold into bilateral corpus cavernous. 5 days later, after monitoring intracorporal pressure (ICP) changes induced by electrostimulation of CN, rats were sacrificed and their bilateral major pelvic ganglions were obtained for detection of fluorogold, and penile tissues of middle shaft were obtained for detecting nitric oxide synthase-containing nerve fibers in penile dorsal nerves. MAIN OUTCOME MEASURES: Erectile function was assessed by apomorphine test and ICP monitoring. CN regeneration was judged by fluoroglod tracing and nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase staining. RESULTS: Apomorphine tests resulted in 58% rats with erectile responses in group B, whereas no erection was observed in group C. ICP monitoring also demonstrated a significant recovery in erectile function in group B compared with group C. Much more and brighter fluorogold coloring cells were examined in major pelvic ganglions of group B than those of group C. NADPH-diaphorase staining also showed much more positive fibers were detected in penile dorsal nerves in group B than in group C. CONCLUSION: Autologous vein graft could provide a guide channel to induce CN regeneration and successfully restore autonomic erectile function after CNs being excised in rats.

Resurfacing of total penile full-thickness burn managed with the Versajet hydrosurgery system.

Reconstruction of penile skin loss resulting from various causes is a challenge for clinician. Especially in a potent man, functional and cosmetic outcomes are demanded. Conservative treatment with topical agents is not enough for the full-thickness burn although hypertrophic scar and secondary contracture usually occurs. Resurfacing of total penile full-thickness burn after wound management with the Versajet hydrosurgery system (a water-jet powered debrider) is described for the first use in our hospital.

Losartan preserves erectile function after bilateral cavernous nerve injury via antifibrotic mechanisms in male rats.

PURPOSE: Angiotensin II is a known mediator of smooth muscle vasoconstriction and fibrosis. It up-regulates thrombospondin-1, a major activator of latent transforming growth factor-beta. Transforming growth factor-beta induces vascular fibrosis via intracellular SMAD signaling pathways. We evaluated the effect of treatment with the angiotensin II type 1 receptor antagonist losartan on erectile function in the rat following bilateral cavernous nerve injury. MATERIALS AND METHODS: A total of 36 adult male rats were divided equally into 6 groups, including group 1-sham surgery with cavernous nerve exposure only plus vehicle, group 2-sham surgery plus oral low dose losartan (10 mg/kg per day), group 3-sham surgery plus high dose losartan (40 mg/kg per day), group 4-bilateral cavernous nerve injury (3-minute crush using a hemostat clamp) plus vehicle, group 5-bilateral cavernous nerve injury plus low dose losartan and group 6-bilateral cavernous nerve injury plus high dose losartan. Seven days following surgery erectile function was measured by electrically stimulating the cavernous nerves and monitoring intracavernous pressure. Penile tissue was collected for Western blot analysis of fibronectin, transforming growth factor-beta, thrombospondin-1, alpha-actin, and phosphorylated and total SMAD2 and SMAD3 expression. RESULTS: Erectile function was significantly decreased after bilateral cavernous nerve injury compared with that after sham surgery (p <0.01). Low and high dose losartan preserved erectile function after bilateral cavernous nerve injury compared to that in vehicle controls (p <0.01 and <0.05, respectively). Fibronectin, pSMAD2, pSMAD3, transforming growth factor-beta-1, thrombospondin-1 and alpha-actin expression was up-regulated, and total SMAD2 and SMAD3 expression was down-regulated in the penis after bilateral cavernous nerve injury. Each dose of losartan after bilateral cavernous nerve injury significantly attenuated the up-regulated expression of fibronectin (p <0.01), pSMAD2 (p <0.05) and thrombospondin-1 (p <0.05), and up-regulated total SMAD2 (p <0.05). CONCLUSIONS: These data suggest that fibrotic activators in the penis may cause decreased erectile function after bilateral cavernous nerve injury. Angiotensin II type 1 receptor antagonism may counteract this effect and promote erectile function preservation for conditions associated with penile fibrosis.

Surgical debridement of mineral pitch and nonviable penile tissue using water-jet power: a preliminary report.

OBJECTIVE: To report our experience of debriding genital wounds embedded with mineral pitch (MP) from asphalt, using a water jet-powered surgical tool, the Versajet Hydrosurgery System (VHS, Smith and Nephew, Key Largo, FL) before reconstruction. PATIENTS AND METHODS: We used the VHS for penile debridement in two patients. The first was 42-year-old Hispanic man involved in a truck-bike accident, who was dragged approximately 60 m after the collision. He presented with 25% body-surface abrasion impregnated with MP. The scrotal soft tissue had been lost and both testicles were exposed and ruptured, with no viable tissue. Moreover, the distal two-thirds of the penile urethra and the ventral glans were completely damaged and his penis entirely degloved. Several procedures were required for surgical debridement and reconstruction, including the skin grafting to 25% of his body surface. All surgical debridement was done with the VHS. A modified Thiersch-Duplay urethroplasty was used over a 16 F Foley catheter to reconstruct the missing urethra. The second patient was a 32-year-old man with no previous medical history, who presented with Fournier's gangrene after a penile abrasion following unprotected sexual intercourse. He required several surgical debridements. The VHS was applied to an 8 x 10 cm area, followed by a free-radial graft to the inferior epigastric. RESULTS: The clinical follow-up was 9 and 6 months, respectively; both patients had satisfactory granulation tissue and proper wound healing. Neither of the patients had infection after surgical debridement with the VHS, even when used in the case of Fournier's gangrene. CONCLUSION: The VHS appears to be effective for genital soft-tissue surgical debridement even when the tissue is impregnated with MP or infected, without causing any spread of infection. Larger series and a longer follow-up are needed to validate the effectiveness of the VHS in managing complex genital wounds.