(339) Urologic and Psychiatric Considerations in Male Genital Self-Mutilation
Authors: Buford K , Lee J , Khurgin J , Lubin M 
Published: May 2023

Abstract

Introduction
Male genital self-mutilation (GSM) can be categorized into four subtypes – amputation, castration, mutilation, and combined amputation/castration. The most common psychiatric diagnosis associated with GSM is schizophrenia, followed by substance use disorders, personality disorders and gender dysphoria.

Objective
We discuss a case of amputation/castration GSM in a patient presenting without his severed organ. Treatment considerations in patients with active psychosis due to schizophrenia presenting with GSM are discussed.

Methods
A 30-year-old single male with a history of schizophrenia requiring multiple prior inpatient psychiatric admissions, obsessive compulsive disorder, and autism spectrum disorder presented to the Emergency Department with penile and bilateral testicular self-amputation. Upon inquiry regarding the method of injury, the patient stated “someone” instructed him to “cut off” his penis and testes with a pair of scissors. He subsequently disposed of his severed organs by flushing them down the toilet. Consent was obtained from the patient’s mother, who served as his healthcare proxy. He underwent operative intervention including penile “stump-plasty”, suture ligation of the bilateral spermatic cords, and scrotal Penrose drain placement with loose re-approximation of scrotal skin. He was admitted for inpatient psychiatric care for management of schizophrenia with active psychosis. Post-operatively he was observed repeatedly touching and contaminating his surgical site and developed a wound infection. The patient underwent operative wound exploration and washout on post-operative day 10. He convalesced well after completing a course of antibiotics for MRSA wound infection.

Results
Operative intervention options in patients presenting with GSM differ based on the presence or absence of the severed penis. In this patient who presented without the severed penis, possible operative intervention includes primary closure with urethral advancement (stump-plasty), debridement and delayed repair with skin grafting, and perineal urethrostomy. Our patient underwent stump-plasty, and was able to void while standing in the post-operative period. Penile replantation can be considered when the organ has not been discarded. Considerations in psychiatric patients presenting with self-inflicted injuries secondary to a psychotic episode include the patient’s ability to provide informed consent, insight into the patient’s condition, history and severity of mental illness, and increased likelihood of future attempts at self-harm. Severe schizophrenia is associated with increased perioperative complications, including sepsis, acute kidney injury, increased length of stay, and operative wound infections, as well as increased odds of having an adverse operative outcome. Risk factors for GSM include psychotic experiences, personality disorders, prior history of GSM, alcohol and drug use, guilt toward sexual feelings, and early father loss. Patients presenting with an acute episode of psychosis and GSM have increased risk of future GSM, with up to one-third of these patients making a repeated attempt at GSM.

Conclusions
In a patient with GSM who presents without the severed organ, the physician should consider the patient’s psychiatric history. In patients with an acute psychotic episode and severe schizophrenia, physicians should consider primary closure with urethral advancement versus perineal urethrostomy rather than delayed repair with skin grafting to avoid the risk of wound infection.

Disclosure
No