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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2011  |  Volume : 22  |  Issue : 2  |  Page : 359-361
Penile gangrene: A devastating and lethal entity


Department of Urology, Chhatrapati Shahuji Maharaj Medical University, (CSMMU, formerly King George's Medical University (KGMU), Lucknow, UP, India

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Date of Web Publication18-Mar-2011
 

How to cite this article:
Singh V, Sinha RJ, Sankhwar S N. Penile gangrene: A devastating and lethal entity. Saudi J Kidney Dis Transpl 2011;22:359-61

How to cite this URL:
Singh V, Sinha RJ, Sankhwar S N. Penile gangrene: A devastating and lethal entity. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2017 Jul 20];22:359-61. Available from: http://www.sjkdt.org/text.asp?2011/22/2/359/77646
To the Editor,

Penile gangrene is seen infrequently, but is associated with significant morbidity and mor­tality. [1] Gangrene of the penis may be dry or infective and the causative factors may be trau­matic, infective or vascular. [2] Distinction bet­ween infectious and dry gangrene is essential since the clinical management of these two subsets differs markedly.

Infectious gangrene of the male genitalia is commonly referred to as Fournier gangrene or necrotizing fasciitis, which may be idiopathic or may result from dermal or colorectal di­seases or may occur following genito-urinary procedures. [1] In approximately 95% of cases, a source of infection can be identified. The most common source is urethra following stricture disease; rectum following perianal abscesses, fissures, fistula; genito-urinary trauma or ins­trumentation. Fournier gangrene is an absolute emergency where time to diagnosis and treat­ment can significantly influence the morbidity and mortality. [3] Dry gangrene, however, is cla­ssically vascular in origin and warrants prompt attention. [3] Herein, we describe our experience of managing eight patients with penile gan­grene at our center over the last 10 years.

We retrospectively reviewed the records of eight patients with either partial or total gan­grene of the penis, who were managed from January 1999 to December 2008 at our center. The study was approved by the Institutional Ethics Committee.

The demographic characteristics, associated co-morbidities and predisposing factors are de­picted in [Table 1]. The mean age of the patients was 48 years (range 35-63 years). Fournier type of gangrene was seen in five patients and dry gangrene in three [Figure 1] and [Figure 2]. Over­all, six patients had complete and two had par­tial gangrene [Table 2]. One of the patients was a renal transplant recipient on maintenance triple immunosuppressive medication, who had graft dysfunction with deranged renal parameters. One patient died due to septicemia with disse­minated intravascular coagulopathy before he could be taken for definitive treatment (total penectomy). Five of the remaining seven pa­tients died within one year of follow-up.
Figure 1: Partial gangrene of penis.

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Figure 2: Perineal urethrostomy following total penectomy.

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Table 1: Demographic characteristics of the patients.

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Table 2: Treatment outcome of these patients.

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The predisposing factors found in the study patients included perianal abscess and peri­urethral abscess in two patients each and ste­nosis of the anastomosed segment of the ure­thra, stricture of the urethra, left ischio-rectal abscess and, ano-rectal fistula in one patient each. Additionally, four of the patients had dia­betes mellitus, one was a renal transplant re­cipient on immunosuppression, while one had acute lymphoblastic leukemia.

Gangrene of the penis is a devastating con­sequence following infection or vascular (arte­rial) compromise, [1],[2],[3],[4] and it is crucial to ascer­tain whether the gangrene is infectious or dry. Fournier gangrene requires prompt interven­tion because if left untreated, it rapidly causes progressive tissue destruction, sepsis and ulti­mately death. [4],[5]

The most common cause of vasculogenic (is­chemic) penile gangrene is diabetes mellitus with end-stage renal disease leading to secon­dary hyperparathyroidism. This condition cau­ses calciphylaxis of penile arteries, leading to decrease in blood flow. [3],[5] The less commonly reported causes of dry gangrene include tour­niquet syndrome, priapism, venous thrombo­sis, anticoagulant therapy and heroin injection into the femoral vessels. [5],[6] Ischemic gangrene of male genitalia is a hallmark of severe systemic vascular disease. Diabetics with penile gangrene have a high mortality rate. [7]

The treatment options for dry gangrene in­clude surgical intervention or observation while awaiting auto amputation of the demarcated tissue. [3],[5] Patients with atherosclerosis resulting from underlying diabetes mellitus and chronic renal failure are predisposed to infection and often have extensive history of hospitalization. Frequently, these patients have terminal di­sease by the time a urologist is consulted to evaluate the gangrene.

Weiner and Lowe noted 57% mortality rate in their seven patients within six months of initial presentation. [8] Stein et al noted 71% mor­tality rate in their series at six months of follow-up. [2]

Fournier gangrene refers to any synergistic necrotizing infection of the external genitalia or perineum. [9] A predisposing factor such as diabetes, chronic ethanol or intravenous drug abuse, cancer, or HIV infection can be identi­fied in nearly all such cases. [3],[5],[9],[10] Foul, feculent odor with crepitus is the classical finding. Prompt surgical debridement is the norm and if needed, suprapubic cystostomy should be per­formed. The definitive management is either partial or total penectomy depending upon the extent of involvement. A permanent perineal urethrostomy is needed in patients undergoing total penectomy. Despite aggressive management, the estimated mortality rates range from 7 to 75%. [10]

Our study suggests that gangrene of the penis is life-threatening urological complication. Dis­tal penile involvement should be managed by partial penectomy and complete gangrene should be managed by total penectomy and perineal urethrostomy. Associated co-morbidities should be treated aggressively because they are the cause of death in most of these patients.

 
   References Top

1.Spirnak JP, Resnick MI, Hampel N, Persky L. Fournier's gangrene: Report of 20 patients. J Urol 1984;131:289-91.  Back to cited text no. 1
[PUBMED]    
2.Stein M, Anderson C, Ricciardi R, Chamberlin JW, Lerner SE, Glicklich D. Penile gangrene associated with chronic renal failure: report of 7 cases and review of the literature. J Urol 1994;152:2014-6.  Back to cited text no. 2
[PUBMED]    
3.Weiner DM, Lowe FC. Gangrene of the male genitalia. AUA Update series 1998. Lesson 6, Vol XVII, 42-7  Back to cited text no. 3
    
4.Lowe FC, Brendler CB. Penile gangrene: a complication of secondary hyperparathyroidism from chronic renal failure. J Urol 1984;132: 1189-91.  Back to cited text no. 4
[PUBMED]    
5.Lowe FC. Gangrene of the male genitalia. In: Operative Urology. Edited by F.F. Marshall. Philadelphia: W.B. Saunders Co, Chapt 50, 1991;377-96.  Back to cited text no. 5
    
6.Somers WJ, Lowe FC. Localized gangrene of the scrotum and penis: A complication of heroin injection into the femoral vessels. J Urol 1986;136:111-3.  Back to cited text no. 6
[PUBMED]    
7.Agarwal MM, Singh SK, Mandal AK. Penile gangrene in diabetes mellitus with renal fai­lure: A poor prognostic sign of systemic vas­cular calciphylaxis. Indian J Urol 2007;23:208-­10.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Weiner DM, Lowe FC. Surgical management of ischemic penile gangrene in diabetics with endstage atherosclerosis. J Urol 1996;155:926­-9.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Spirnak JP. Fournier's gangrene: A true uro­logic emergency. Contemp Urol 1992;2:46-52.  Back to cited text no. 9
    
10.Lamb RC, Juler GL. Fournier's gangrene of the scrotum. A poorly defined syndrome or a misnomer? Arch Surg 1983;118:38-40.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Vishwajeet Singh
Department of Urology, Chhatrapati Shahuji Maharaj Medical University, (CSMMU, formerly King George's Medical University (KGMU), Lucknow, UP
India
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PMID: 21422647

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