Glans necrosis produced by trauma during masturbation.

Penile necrosis is a very rare and serious pathology that can result, in most cases, in partial or total penis amputation (Montoya-Martinez, Otero-Garcia, Lopez-Samano, Gonzalez-Martinez, & Serrano-Brambila, 2006). In the few cases described in the literature, there are different causes that can produce glans or penile necrosis. Some of these causes include the presence of poorlycontrolleddiabetes(Lopez-Paciosetal.,2003),finalstage of chronic renal failure due to the existence of calciphylaxis (Ohta, Ohomori, Mizukami, Obi, & Tanaka, 2007; Sorensen, Long, Wessells, & Kuan, 2007; Tarrass & Benjelloun, 2008), and systemic vasculitis (Congregado-Ruiz et al., 2002; Gillitzer et al., 2004; Karademir, Senkul, Atasoyu, Yildirim, & Nalbant, 2005). However, other less common factors have been reported to cause necrosis of the penis, such as intracavernous injection of substances (Hornez et al., 2010; Sighinolfi et al., 2004), topical (Zabala-Egurrola et al., 1989) or systemic (Talbert & Wood, 2011) use of drugs, drug abuse such as cocaine (Carey & Dinsmore, 2004), infections (Jensen, Zachariae, & Gronhoj Larsen, 2010), paraphimosis (Raman, Kate, & Ananthakrishnan, 2008), and secondarily to the surgical treatment of various diseases of the penis and urethra (Alvarez-Mugica et al., 2007; Barnes, Ben Chaim, & Kessler, 2006; Sagar, Sagar, & Shah, 2005). Some cases of penile necrosis present arterial microthrombosis that produce occlusive changes and consecutively induce hypoxia and tissue necrosis. We report the case of a 52-year-old man, with a history of schizophrenia, substance abuse, and poorly controlled diabetes mellitus, who presented to the emergency room referred by the primary care physician due to the presence of edema in the penis that was necrotic on the ventral surface of the foreskin (Fig. 1a).Afteradetailedhistory, thepatientacknowledgedthat, 5 daysbefore,hesufferedtraumato thegenitalareawhilehewas sitting on a horse and masturbating with his clothes off (rubbing on the skin of the animal), denying any drug use or injection of substances into the penis. Theexaminationrevealedfever (38.3 )andsignsofsepsis (C Reactive Protein 36 mg/dl, 21,500 leukocytes [87 % PMN]) along with glucose of 520 mg/dl, metabolic acidosis (pH 7.1), and also gas in the subcutaneous tissue of the foreskin observed in the pelvic CT (Fig. 2a). It was decided to surgically remove the necrotic area, checking the presence of necrosis in the ventral glans (Fig. 1b). We started conservative antibiotic treatment with linezolid and meropenem,aswellassupportelectrolytes.Thecultureof tissue resected was positive for Enterococcus faecium sensitive to linezolid, so meropenem was suspended. Considering the possibility of priapism due to an arteriovenous fistula as a result of trauma during masturbation, a penile arteriography was performed, which proved to be normal (Fig. 2b). The toxic study performed on the patient was negative. At 5 days after the first surgical exploration, it showed a complete dry necrosis of the glans and foreskin edges (Fig. 1c), so we decided to remove the glansandprepuceoftheedges, resolvingtheproblem(Fig. 3a,b). As mentioned previously, necrosis of the penis is a rare disease (Tarrass & Benjelloun, 2008), which usually presents as a torpid evolution in patients with diabetes mellitus or advanced chronic renal failure due to microvascular problems (LopezPacios et al., 2003; Ohta et al., 2007). In the case presented, we believe that the trigger was masturbating in contact with a horse and secondary trauma, which could have produced an infection in the area, demonstrated by positive culture and a subsequent poor outcome due to diabetes mellitus, which produces microvascularalterationsandcontributes toaworseningof theclinical situation.Althoughpenilenecrosis inpsychiatricpatients is rare, M.A.Arrabal-Polo (&) M.Pareja-Vilchez C.Lahoz-Garcia S. Gonzalez-Torres P. Valderrama-Illana M. Arrabal-Martin Urology Department, San Cecilio University Hospital, 18, Oloriz Doctor Avenue, 18912 Granada, Spain e-mail: arrabalp@ono.com