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Trophic Ulcer Resulting from the Use of the Cunningham Clamp: A Report of Two Cases
TROPHIC ULCER RESULTING FROM THE USE OF THE CUNNINGHAM CLAMP A
REPORT OF
Two
CASES
KYRIL B. CONGER From the Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich.
Various types of penile clamps for the control of urinary incontinence have been employed for some time. Of these, the one designed by Cunningham of Boston has probably enjoyed the most popularity. It is a sponge-rubber shod clamp with a hinge at 1 end and a toothed catch at the other, designed to compress the pendulous urethra and prevent dribbling when the patient is up and about. We have had occasion to use this clamp on 2 patients, both of whom had neurogenic bladders with partial incontinence and complete anesthesia of the genitalia due to traumatic lesions of the lower spinal cord. In both patients rather deep ulcers developed at the point of contact with the clamp. These were undoubtedly trophic ulcers due to pressure on anesthetic areas. One case was accompanied by such fibrosis at the point of ulceration that a marked elephantiasis of the penis developed which still persists despite a corrective plastic operation. It is our contention that it is unwise to use any pressure device on the penis to control incontinence when that incontinence is due to a partial or complete transverse myelitis. Case 367420. G. B., age 41, on August 20, 1935 fell 40 feet from the roof of a barn, sustaining compression fractures of T 12 and L 1 vertebrae, with a complete transverse myelitis of that section of the spinal cord. Following an initial period of atonia he had a reflex neurogenic bladder with periodic emptying contractions, but was annoyed by dribbling incontinence between voidings. Because of this, he was given a Cunningham clamp on October 23, 1939. Six months later he noticed gradually increasing edema of the shaft of the penis; 9 months later he had 2 definite ulcers on the dorsal and ventral surfaces of the penis at the point of contact with the clamp. Despite this, he continued to wear the clamp, and next returned to the clinic on October 21, 1940 at which time he had a deep ulcer on both the dorsal and ventral surfaces of the penis, with marked edema and swelling of the penis to 2½ times its normal size distal to this (fig. 1). Eight days of elevation, bakes and hot wet dressings failed 342
TROPHIC ULCER FROM CUNNINGHAM CLAMP
343
to reduce the edema, although the ulcer started to heal in slowly, so an extensive circumcision with removal of much of the edematous tissue was carried out. He was discharged 2 weeks later with his ulcers almost completely healed, but a persistent and marked penile elephantiasis. Case 197428. L. H., fell from a bridge on September 24, 1939 and suffered compression fractures of D 8 and L 1, with a transverse myelitis of the conus. He subsequently had a neurogenic bladder with 150 cc capacity and with periodic contractions induced by credeing, but had a dribbling incontinence between voidings. He had a complete saddle anesthesia. On April 13, 1940
FIG. 1. Ulceration and elephantiasis of penis, (Case 1) at the time of admission. The glans is located approximately ½the distance from the penoscrotal angle.
he was given a Cunningham clamp. He returned 3 months later having noticed 1 week previously an ulcer 1.5 cm. in diameter on the ventral surface of the penis. On discontinuance of the clamp the ulcer healed in slowly. The patient later resumed use of the clamp, shifting its position daily, but has not been seen since that time. From these 2 cases it is apparent that penile clamps should be used with caution in the management of incontinence due to neurogenic disease of the bladder. If they are to be employed, the patient should be warned to shift their position frequently and to discontinue them at the first indication of ulceration or edema.
REPORT OF
Two
CASES
KYRIL B. CONGER From the Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich.
Various types of penile clamps for the control of urinary incontinence have been employed for some time. Of these, the one designed by Cunningham of Boston has probably enjoyed the most popularity. It is a sponge-rubber shod clamp with a hinge at 1 end and a toothed catch at the other, designed to compress the pendulous urethra and prevent dribbling when the patient is up and about. We have had occasion to use this clamp on 2 patients, both of whom had neurogenic bladders with partial incontinence and complete anesthesia of the genitalia due to traumatic lesions of the lower spinal cord. In both patients rather deep ulcers developed at the point of contact with the clamp. These were undoubtedly trophic ulcers due to pressure on anesthetic areas. One case was accompanied by such fibrosis at the point of ulceration that a marked elephantiasis of the penis developed which still persists despite a corrective plastic operation. It is our contention that it is unwise to use any pressure device on the penis to control incontinence when that incontinence is due to a partial or complete transverse myelitis. Case 367420. G. B., age 41, on August 20, 1935 fell 40 feet from the roof of a barn, sustaining compression fractures of T 12 and L 1 vertebrae, with a complete transverse myelitis of that section of the spinal cord. Following an initial period of atonia he had a reflex neurogenic bladder with periodic emptying contractions, but was annoyed by dribbling incontinence between voidings. Because of this, he was given a Cunningham clamp on October 23, 1939. Six months later he noticed gradually increasing edema of the shaft of the penis; 9 months later he had 2 definite ulcers on the dorsal and ventral surfaces of the penis at the point of contact with the clamp. Despite this, he continued to wear the clamp, and next returned to the clinic on October 21, 1940 at which time he had a deep ulcer on both the dorsal and ventral surfaces of the penis, with marked edema and swelling of the penis to 2½ times its normal size distal to this (fig. 1). Eight days of elevation, bakes and hot wet dressings failed 342
TROPHIC ULCER FROM CUNNINGHAM CLAMP
343
to reduce the edema, although the ulcer started to heal in slowly, so an extensive circumcision with removal of much of the edematous tissue was carried out. He was discharged 2 weeks later with his ulcers almost completely healed, but a persistent and marked penile elephantiasis. Case 197428. L. H., fell from a bridge on September 24, 1939 and suffered compression fractures of D 8 and L 1, with a transverse myelitis of the conus. He subsequently had a neurogenic bladder with 150 cc capacity and with periodic contractions induced by credeing, but had a dribbling incontinence between voidings. He had a complete saddle anesthesia. On April 13, 1940
FIG. 1. Ulceration and elephantiasis of penis, (Case 1) at the time of admission. The glans is located approximately ½the distance from the penoscrotal angle.
he was given a Cunningham clamp. He returned 3 months later having noticed 1 week previously an ulcer 1.5 cm. in diameter on the ventral surface of the penis. On discontinuance of the clamp the ulcer healed in slowly. The patient later resumed use of the clamp, shifting its position daily, but has not been seen since that time. From these 2 cases it is apparent that penile clamps should be used with caution in the management of incontinence due to neurogenic disease of the bladder. If they are to be employed, the patient should be warned to shift their position frequently and to discontinue them at the first indication of ulceration or edema.