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Introduction: Constricting devices or misappropriated means are either used to increase sexual performance or for autoerotic actions. They can lead to edema, maceration, to local infections up to Fournier gangrene or penile necrosis with or without involvement of the urethra. Injuries by these means are often challenging for the treating urologist., Case Report: A 22-year-old patient presented to the urological emergency clinic with strong penile pain and voiding difficulties. Within the scope of the clinical investigation a foreign body (frying pan handle) was found around the penis. The penis appeared to be edematous, and necrosis of the distal superficial penis segments was noted. Under local anesthesia the frying pan handle, after procurement of suitable instruments, was removed. Subsequently, a suprapubic catheter was inserted and a broad antibiotic therapy was initiated. An antiseptic local therapy completed the primary treatment. Eight weeks after the event an orthograde urethrogram was performed. The urethra appeared to behave a normal caliber without evidence for strictures or other patho-morphological changes. The final examination showed a nearly completely epithelialized glans penis, with an approximately 1-cent piece small epithelial defect., Conclusions: Constricting devices for the penis are used to increase the sexual performance or with autoerotic intentions. Removal of the constricting devices can become impossible secondary to a hefty swelling of the penis. The treatment consists, primarily, of an immediate decompression of the strangulated penis to ensure a free blood flow and an uninhibited micturition. The removal of the various objects requires in part craft instruments. A supplementary therapy must be selected based on existing additional complications., ((c) Georg Thieme Verlag Stuttgart - New York.)

Autoerotic manipulations of external male genitals resulting in mutilation with different degrees of severity are rare. We report the clinical case of a 12-year-old boy who injured his glans, left corpus cavernosum and corpus spongiosum with opened urethra as a consequence of autoerotic genital self-mutilation. According to our knowledge of the current literature this is the first description of autoerotic genital self-mutilation with a Moulinette. A Moulinette is a kitchen tool with an electric engine and an extremely fast rotary double knife, which is used to reduce food into small pieces, especially vegetables and fruits.

Background: Follow-up of patients with pelvic ring fractures and associated injuries of the lower urogenital tract was performed from January 2000 to October 2004. Analysis focused on incidence, fracture type, type of urogenital injury, associated intrapelvic lesions, mortality, and urologic outcome., Method and Results: The retrospective study included 18 of 111 patients (16.2%). Nine patients had a rupture of the urethra, six a rupture of the bladder, three a rupture of the penile root, and two a gonadal defect. The type of the pelvic ring fracture according to the AO classification was type A in 1, type B in 6, and type C in 11 cases. Fifteen patients (83.3%) were followed up clinically for a mean duration of 26 months (range: 12-66 months) after trauma. Seven patients were asymptomatic concerning the urogenital injury, five had erectile dysfunction, two had urethral stenosis, in one case associated with incontinence, and one patient with bilateral defect of the testicles was under hormone substitution therapy., Conclusion: Urogenital injuries, often associated with intrapelvic lesions in so-called complex pelvic trauma, are typical for high-grade pelvic ring fractures and have an essential prognostic value for the patient's morbidity and quality of life.

Male genital injury, although rarely life-threatening, demands prompt, appropriate management to prevent long-term sexual and psychological damage. However, because of the rarity and disparity of severe genital injuries, there is still no universal therapeutic strategy. Urethral injury, although rare, may be associated with substantial long-term morbidity such as fistulas and strictures. Injuries to the scrotum and its contents may cause impaired fertility, chronic pain, hypogonadism, and altered self-image. Penile injury may lead to pain, curvature, and erectile dysfunction. This article concentrates on reviewing the major etiologies and mechanisms of urethral and genital injuries in men and summarizes principles and strategies of treatment based on the guidelines of the European Association of Urology.

Constricting devices placed on the penis to improve sexual performance present a challenge to urologists. Various metallic and nonmetallic objects have been described -- plumbing cuffs, bull rings, wedding rings, plastic or rubber rings -- which usually could be removed by the combination of medical and operative treatment (decompression of the penis and glandular puncture) and craftsmen's techniques. We describe the case of a titanium thumb ring of 2 mm thickness which only could be removed by using an electric cutting tool.

A 61-year-old man was admitted to hospital with a partially severed penis. The head of the penis (glans) had been completely severed, and the skin of the shaft and the corpora cavernosa had been ripped open. In the hospital the patient reported that his penis got caught in the hose attachment of an old Kobold vacuum cleaner that he was using to inflate an air mattress. He later made contradictory statements in his report to the insurance company, so we were asked to reconstruct the circumstances of the accident. The literature available to us only makes clinical observations about similar accidents, always with the assumption that the vacuum cleaner was used during masturbation or in order to achieve an erection. According to our reconstruction of the accident and an investigation of the vacuum cleaner attachment, however, we could not rule out the possibility of a household accident as described by the patient.

This paper reviews the current knowledge of the etiological pathogenesis of Peyronie's disease. De la Peyronie himself supposed a connection with venereal diseases. Herein, infectious, traumatic, autoimmune and genetic causes are discussed. An important hypothesis is that the recurrent microtraumatisation of the tunica albuginea during sexual intercourse leads to small lesions that activate processes of wound healing and development of fibrotic plaque. According to recent data, an association with the antigens of the HLA-system could be ruled out. Transforming growth factor beta (TGF-beta) seems to have an important impact due to its increased expression in the plaque. Furthermore it is possible to induce a condition similar to Peyronie's disease by intratunical injection of cytomodulin - a substance with TGF-beta-like activity - in an animal model. As in other fibrotic diseases, an imbalance between nitric oxide (NO) and reactive oxygen species (ROS) seems to be of importance. The most important new insights were gained from cell-culture models in which increased expression of basic fibroblast growth factor (bFGF), as well as a change in cell cycle regulation (p53) and cytogenetic instability were observed.

This paper reviews the current status of information on diagnostic and therapeutic management of penile fractures, focusing on the controversy between surgical vs. conservative treatment of this uncommon injury. Penile fracture, commonly defined as a rupture of the tunica albuginea and corpus cavernosum, is a serious urological disorder demanding surgical management. The diagnostic procedure classically consists of history taking, physical examination and urinary status. Determination of the extent of severity and location of the rupture in the tunica albuginea takes foremost priority and requires additional imaging procedures, such as ultrasound or cavernosography, which will impart enough diagnostic information for the correct choice of treatment. In some cases, the urethra is injured as well. Immediate surgical repair offers complete recovery for patients with penile fracture in most cases, even in the presence of urethral injury. Although penile fracture is easily recognized and can therefore be classified as a "first-look diagnosis", therapy remains controversial to date. The correct therapeutical approach is a vital factor in management, as the associated significant morbidity can result in complete loss of erectile function, painful erections or penis deviation. Early surgical treatment is strongly recommended because of the excellent results, shorter hospitalization, less morbidity and an early return to sexual activity.

Objective: Self-mutilation of the genitals in man is a rare phenomenon mainly occurring in young males. The importance of conflicts about the male role, difficulties with the male identification in childhood and feeling of guilt for sexual offences are discussed in the literature. The influence of developmental crisis on this symbolic form of automutilation will be discussed in our case report., Method: We present a case of a young schizophrenic man whose illness started in adolescence. He committed genital automutilation already in early adolescence, as a young male he autocastrated himself., Discussion: We demonstrate the connection of specific problems of development in adolescence and psychopathology. Autocastration will be discussed as a "psychotic" solution of the adolescent conflict of dependence., Conclusions: Developmental conflicts may be important pathoplastic factors who may lead to severe psychopathology and misbehavior. Additionally to a psychopharmacological treatment a specific adolescent- and conflictoriented psychotherapy for solving the developmental conflicts in young schizophrenic patients should be established.

All forms of pharmacological therapy result in a relaxation of the corporeal smooth muscle. Intracorporeal injection of vasoactive drugs was introduced around 15 years ago and still is the most effective therapy in erectile dysfunction. Resulting in a consistent success rate of 70-80% this form of therapy will find numerous applications, even after the introduction of effective oral agents such as sildenafil. Prostaglandin E1 and--less frequently used--the combination of papaverine and phentolamine are the mainstay of intracorporeal injection therapy. Intraurethral prostaglandin (MUSE) has recently become available and is somewhat less effective than injection therapy. Externally applied drugs (nitroglycerin paste on the penile shaft and minoxidil solution on the glans penis) have not succeeded in the long run. Vacuum erection devices represent a form of physical topical therapy that is very versatile and also effective but rather infrequently applied.

A 10-year old boy developed an arteriocavernosal fistula with a permanent penile erection (high-flow priapism) after a blunt perineal trauma. The diagnosis was established by Doppler ultrasound, blood gas analysis and angiography. A conservative treatment attempt with penile cooling and puncture of the cavernosal corpera with blood aspiration and etilefrine instillation failed to resolve the priapism. An embolization of both bulbocavernosal arteries was followed by an immediate detumescence. Normal functional erection was preserved. No recurrence was observed during a follow-up of 6 months.

A stallion got fatal injuries by kicks of a maiden mare because a so called "panic hook" untied spontaneously. The use of such hooks to secure mares during mating should therefore not be recommended.

Report of the case of a 78-year-old man who was found dead with complete amputation of the penis and parts of the scrotum. Cause of death was fatal hemorrhage. Since penis and the knife were missing at the scene and the blood stains were confined to the bed but not in the further apartment, further traces were disposed, the son of the deceased was suspicious of murder. The confession of the suspect in trial claimed a suicidal self-castration; this claimed self-inflicted genital mutilation was in part in accordance with objective findings.

We report a case of successful penis replantation in a young man with psychotic state and self-emasculation. For replantation we used microsurgical techniques. Success depends on microsurgery and postoperative management. Postoperative care consists in (1) improvement of microcirculation, (2) broad-spectrum antibiotic treatment, (3) blood flow control on a strict hourly schedule, (4) safe supra-pubic urinary diversion, and (5) an elevating dressing for the penis to ensure the blood flow.

Suicide of a 31 year old man with multiple slashes and stab wounds including complete amputation of penis, scrotum and testicles is reported. Wound patterns in genital self-mutilations are discussed. Despite serious loss of blood the reported survival periods are remarkable; death from bleeding seems to be rare. A review of similar cases shows that self-castrations as well as other self-inflicted genital mutilations are usually associated with psychiatric disorders and transsexuality or hypersexuality.

By the case of a subtotal traumatical amputation of the penis seen in our services, we discuss the advantages of a replantation by microsurgical technique. After presentation of the operational procedure and the management of the postoperative course the results of a thorough examination by questioning, physical examination, neurological examination including EMG testing of the bulbo-cavernous-reflex, Rigiscan NTM and angiography of the penal arteries are discussed. A review of the literature shows the advantages of the microsurgical technique but also the astonishing results by the former, conventional technique which still presents a possibility if microsurgery is not available.

The case history of a 51 year-old man with paranoid-hallucinatory schizophrenia is presented. Very intensive autoaggressive actions (cutting off the ears, partial amputation of the penis, eating of the amputated pieces, sawing off the left lower leg) led to very unusual autopsy findings (i.e. the glans of the penis was found in the colon). The cause of death was prolonged exsanguination.

Between 1985 and 1988, a total of 62 patients with penile deviations underwent corporoplasty; 26 (average age 22.2 years) of the patients had congenital, mainly ventrally directed deviations and 36 (average age 51.7 years), acquired, mainly dorsally directed deviations most of which were due to Peyronie's disease. With a follow-up of at least 6 months (range 6 months to 3 1/2 years), 92.3% of the patients with congenital deviations and 72% of those with acquired curvatures expressed unqualified satisfaction with the results of surgery and said they would agree to the operation again. There were few complications: one patient experienced hematoma requiring reoperation and one patient, a skin necrosis resulting from incorrect wound dressing; three patients complained of recurrence of the angulation, which resulted from plication of the tunica albuginea alone without excision in all three. These results justify the statement that the original Nesbit procedure is the method of choice in both congenital and acquired penile deviations and yields a high success rate. Only in patients with relevant impairment of erectile capacity does the primary insertion of an penile prosthesis seems to be justified.

We report on a 23-year-old male patient showing sclerosing lipogranuloma of the genitalia and surface ulceration of the penis. Histologic investigation revealed a granuloma of the foreign body type spreading both dermally and subcutaneously and showing cavities of varying sizes, resembling Swiss cheese, which were partly coated with macrophages. Histochemical tests with Sudan Ill, Sudan-black B and OsO4, as well as chromatographic analysis confirmed the presence of a hydrophobic unpolar lipid, such as liquid paraffin.

5 cases of penile fracture are described. 2 patients were referred directly and received immediate surgical treatment. The corpus cavernosum was exposed and the tunica albuginea repaired with absorbable sutures. The other 3 patients were referred from 10 to 19 days after the initial injury. On admission 2 of the were experiencing deviation of the erect penis, one also had painful erection. They too were explored and the tunica albuginea sutured to correct the deformity. All 5 patients were treated post-operatively with a broadspectrum antibiotic, an anti-inflammatory agent and tranquilizers to prevent erections. Except for one patient with delayed wound healing there were no complications of the operation. The long-term results were good, all patients experiencing satisfactory straight erections.

Two patients had an avulsing injury of the penis with considerable loss of skin. One was bitten by a dog and the other lost the skin when his clothes were caught by a rotating machine and thus the skin was stripped off by traction and crushed. The detached skin was resutured immediately after injury and in both cases the cosmetic and functional result was more than satisfactory. Though it is not easy to judge the extent of the crush injury in this type of an accident, we feel--even when going against common literature (skin grafting usually is suggested)--that resuturing of the skin is a highly successful method.

The development of highly frequent transducers has created new diagnostic possibilities for the sonography in the area of the body of the penis. We controlled the valency of this technique on our patients. While the usual clinical and radiological methods still predominate in the diagnostics of traumas of the penis and diseases of the cavernous bodies, the ultrasound gives new possibilities of the exact classification in the carcinoma of the penis and the induratio penis plastica. Thus the basis for the development of alternative therapeutic methods is given.

For skin replacement on the penis and scrotum, only a free split-skin graft (about 0.45 mm in thickness) can be considered in cases where local flaps are not available. The transplant is fixed on the denuded penis with a special thermoplast splint, which ensures healing in. Additional sedation is necessary. Pedicle flaps taken from some distance away are too voluminous for the penis and not adequate. Cases with eschars and granulation tissue must be carefully cleaned to avoid hypertrophic scars. Covering can also be achieved with mesh-grafts in these cases.

Under the heading "acute diseases of the external genital organs" affections of the scrotal contents and the penis (without urethra) demanding immediate therapy are summarized. Crucial is the differential diagnosis epididymitis vs. torsion of the spermatic cord for an error may have very serious consequences for the patient as well as for the physician undertaking primary care. As to the other acute diseases of the scrotal contents the increasingly important role of scrotal sonography is stressed. Among the relatively rare acute affections of the penis traumatic rupture of the corpus cavernosum and priapism of various origin deserve particular interest because delayed wrong treatment may lead to loss of erectile potency.

Three cases with injuries of the penis are reported, 3 further cases are mentioned. These cases were 3 suicides, 2 cases, where the injury was inflicted by another person and 1 case with injury caused by a dog. Differential diagnosis is discussed.

We report about the postoperative course and late result in a case of successful reimplantation of a totally amputated penis. A small urethral fistula closed spontaneously during the postoperative. Follow-up at five years shows a satisfactory cosmetical and functional result.

Based on 12 patients with posttraumatic erectile dysfunction due to pelvic fractures, ruptures of urethra and straddle-trauma, the diagnostic and therapeutic means in the management of erectile failure are discussed. The most frequent etiology encountered in posttraumatic erectile failure were combined arterial-neurogenic lesions followed by insufficiencies of the venae profundae penis as a sequelae of pelvic fractures or symphyseal ruptures. Promising therapeutic alternatives represent injections of cavernous bodies with vasoactive drugs, penile implants and also in suitable cases penile revascularization procedures.

A 20 year old patient is reported who suffered traumatic amputation of both testicles, the proximal skin of the penis and the scrotum. Scrotal reconstruction was achieved with a sensitive free dorsalis pedis flap.

Although amputation of the penis is a rare problem, a complete reconstruction of all penile structures should be attempted in one stage. This way the best chance for full rehabilitation of the patient can be achieved. A microsurgical reimplantation with microsurgical sutures of arteries, veins, nerves and urethra after total amputation of the penis is reported. Eight months after surgery normal appearance and function, including a good urine flow and absence of urethral stricture, capability of erection and nearly normal sensitivity, was found.

In total excoriation of the penis and scrotum caused by injury the immediate manifestations of new skin cover are seen within 8-12 hrs. In the sense of a "postponed emergency" the usual wound toilet should be performed, a bladder catheter introduced, and penis lowered into a subcutaneous tunnel beneath the abdomen. However, in every case, the ultimate goal is formation of a new skin covering via a split skin flap. The testicles should be lowered into a pouch on the thigh where they will not suffer thermal damage.

A case report of a penis- and scrotum amputation in a 28-year old patient, caused by a moped accident, is presented. The penis replantation is discussed as are the postoperative problems.

The successful replantation of a penis by micro- and uro-surgery is described. Therapeutic methods against oedema are proposed.

A description of aetiology, symptomatology, and diagnosis of traumatic lesions of the bladder, urethra, and genital organs is followed by a critical discussion of therapy. Contributions to these topics coming from round-table discussions, held at several international urological meetings during the past few years, are considered. Important points concerning traumatic lesions of the bladder, and the male, female, and infant urethra are stressed. Consideration is given to diagnostic methods and to surgical methods relative to localisation, degree, and age of urethral lesion. Complications resulting with and without therapy are laid down.

Penile deviation has been gaining in importance as a symptom of several diseases. There are congenital forms (congenital penile deviation, hypo- and epispadias) as well as acquired forms (induratio penis plastica, traumatic deviation, urethral manipulation syndrome). History and autophotography are the most important diagnostic procedures. The therapeutic procedure is corporaplasty according to Nesbit-Kelâmi.

Our experiences in the treatment of 5 patients suffering from penile fracture are presented. The clinical picture is determined by defect size, localization and injury of the urethra. The functional results of early operative management are good and the literature reports are confirmed.