Labanaris et al.: Dry Gangrene of the Penis
TheScientificWorldJOURNAL (2008) 8, 896–900
the patient’s age. In middle-aged and elderly men, the leading cause for their use is to increase sexual performance or due to autoerotic intentions, while in adolescents, use is due to the desire to increase erotic sensation during masturbation or due to sexual curiosity. Although they can increase sexual performance and sensation, using them on the semi-erect penis often results in the impossibility of their removal after erection; thus, leading from a simple penile engorgement to ulceration, necrosis, or even to severe vascular complications. Consequently, several clinical syndromes can occur: from mild nonsignificant vascular obstruction that resolves after decompression to severe penile gangrene. As the corpus spongiosum and urethra are covered by a thin layer of fibrous tissue, they are most susceptible to mechanical injury. However, gangrene is uncommon, probably because each corpus cavernosum has an individual artery, and the thickness of Buck’s fascia and corporeal tissue resists pressure on the deep vessels. Patients that present with dry gangrene are usually patients who have detected the problem earlier, but are feeling embarrassed about their situation, or patients who are mentally ill. As seen earlier, the aforementioned patient presented to us 2 days after he noted that his distal penis had begun to turn black. He admitted that he was feeling humiliated and did not want to share his problem even with a doctor.
What is of extreme importance is the clinical differentiation between dry gangrene due to ischemic disease and wet gangrene with infection. This is crucial for choosing the appropriate treatment. Wet gangrene is infectious in origin, and prompt surgical intervention is indicated to decrease associated morbidity and mortality. If left untreated, rapidly progressive tissue destruction, sepsis, and ultimately death can occur. Partial or total penectomy is the treatment of choice.
Although the causes of dry gangrene vary, treatment options are only two: partial penectomy or conservative management. Weiner and Lowe, reporting on a series of seven patients, found that delaying intervention usually required more extensive surgery and increased the risk of wound complications. Thus, they advocate aggressive surgical treatment initially, although they observed wound complications in one case that required several more surgeries. Simply observing these patients usually leads to subsequent liquefaction, infection, and urinary obstruction, which will necessitate surgical intervention with percutaneous suprapubic tube drainage and debridement.
The indication for conservative treatment usually involves small circumscribed lesions or high-risk multimorbid patients with generalized arterial occlusive disease. If conservative management is to be considered first, then circumcision should be at least performed (if the patient is not circumcised) in order to allow better observation of disease progression, as well as to allow dry healing. However, if the disease progresses by necrotic skin on the shaft, liquefaction, development of infection, crepitus, or induration of the shaft, then partial or total penectomy should be performed.
In conclusion, dry gangrene of the penis due to penile strangulation is a clinical condition that could lead to severe complications. What is of extreme importance is the clinical differentiation between gangrene due to ischemic disease and gangrene due to infection. Prompt diagnosis and treatment are essential to decrease associated morbidity and mortality, as well as to achieve good cosmetic and functional results.
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