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Two Cases of Genital Gangrene (Penile and Scrotal)
426
TRANSACTIONS OF PHILADELPHIA BRANCH
Two other points in the management of these patients should be mentioned. The pregnant woman is instructed to abstain from sexual intercourse and thus avoid the most likely source of her infection. An effort is made to bring her husband in for examination and treatment. In this we are not often successful. Few of the patients are of an intelligent cooperative type and one hesitates to arouse domestic strife. Especially does this become a delicate matter during the trying period of pregnancy. In conclusion we desire to state that our experiences with this complication of pregnancy convince us that: 1. Pregnant women having gonorrhea should be treated. 2. The treatment may be carried out without danger to the mother or child. 3. The methods employed should be adapted to the stage of the disease. 4. As a result of treatment it appears that the puerperal morbidity of the mother, and gonorrheal complications of the newborn are decreased. TWO CASES OF GENITAL GANGRENE (PENILE AND SCROTAL) S. W. MOORHEAD From the Urological Section, Department of Surgery, University of Pennsylvania
The two cases of genital gangrene presented are shown because of the rarity of the condition from which the first patient suffered, and because of the interesting nature of the onset of the disease in the second, while a patient in the hospital ward. Case 1. H . R., a Hebrew, fifty-four years old, applied for treatment for gangrene of the penis at the Out-patient Department of the Howard Hospital, June 25, 1926. Sixteen days previously he had developed two sores, one on each side of the glans. Two days later the entire glans had become black. Pain had been slight, "like pins." Examination showed the entire glans to be gangrenous. It was black, soft, flaccid, somewhat resembling an overripe plum. Sufficient odor was emitted to make admission to the ward undesirable. A dense
THE AMERICAN UROLOGICAL ASSOCIATION
Fm. 1
Fm. 2
427
428
TRANSACTIONS OF PHILADELPHIA BRANCH
mass of tissue could be felt extending backward from the glans one and a half inches beneath comparatively normal skin. The urine contained no glucose. The Wassermann reaction was negative. Two weeks later, the glans having been cut away in the mean time, the induration had extended back to the base of the penis. On July 16 after admission to the ward as incision was made on the dorsum of the penis near the base and a large fascial slough removed. One injection of neosalvarsan was given without notable effect. A month later he was readmitted, incisions at the sides of the penis near the base being required for the removal of additional sloughs of the
Fm. 3
ascia of the corpora cavernosa. Thereafter convalescence was continuous and uncomplicated save that for five days he had to be catheterized for urinary retention. Healing was complete early in September. At present, as you will observe, the penis presents an astonishingly normal appearance. The glans, of course, is missing and the urethral meatus is prominently placed on the end of the corpus spongiosum near the bottom of the scar. Farther back by palpation one can readily distinguish the corpora ca vernosa and the corpus spongiosum. Power of erection has been lost.
THE AMERlCAN UROLOGICAL ASSOCIATION
429
The second patient, who suffered from gangrene of the scrotum, was admitted because of calculous anuria and developed the scrotal condition as a postoperative complication. H. K., thirty-three years old, Jewish, was admitted to the Hospital of the University of Pennsylvania, September 22, 1927, because of calculous anuria. His right kidney had been removed ten years previously. A high ureterostomy, done shortly after admission as an emergency procedure, was followed by no untoward sequelae. Twelve days later a stone was removed from the lower portion of his left ureter. The day following this second operation there was marked intestinal distension. About noon he complained of pain and burning in the scrotum. At this time the organ was of normal size, bright red from mercurochrome. Tenderness was present in marked degree, but whether of the scrotal tissues or of the testicles could not be determined. Ten hours later the scrotum was greatly swollen, approximately 12 cm. in diameter. The bulk of the swelling seemed to be serum. The pain was very intense, exceeding that of the operative wound, though this was being strained by distended intestines; only an occasional peristaltic click could be heard. The following day there was desquamation of the superficial layers of the scrotal skin over an area 15 cm. in diameter. Two days later the scrotum was tympanitic and a line of demarcation was forming in its upper part. A small amount of gas and serum escaped on incision of the gangrenous area. On the eighth day most of the gangrenous skin was removed with forceps and scissors. Separation was slower than in most cases of scrotal gangrene, so that complete freedom from necrotic tissue was not established till the twentieth day. This delay was due to the unwonted depth of the inflammation, which involved the parenchyma of the left testicle and all superficial tissues. The incident pain was very great. (The right testicle was not inflamed.) However, there was no loss of tissue below the internal spermatic fascia. On the twenty-seventh day inflammatory swelling had largely disappeared, and the testicles were both covered with healthy granulations. While the right testicle was rapidly acquiring a scrotal covering, the left was so much exposed operative repair was indicated. This was carried out by undermining the skin laterally so that it could be approximated with three mattress sutures. The patient was discharged ten days later. Bacteriological examinations were disappointing. A gas organism
FIG. 4
FIG. 5 430
THE AMERICAN UROLOGICAL ASSOCIATION
431
was grown under anaerobic conditions, but the tube was broken before the bacterium could be identified. Subsequent efforts revealed only contaminants. In the absence of bacteriological data I hazard the opinion that in this patient the condition was due to bacilli which gained access to the blood stream from the intestine as a result of the extreme distension, which in turn was due to reflex inhibition of peristalsis from irritation of the stripped peritoneum. A relatively benign infection of the ureterotomy incision probably had similar etiology. This suppositious method of infection unfortunately does not account for the occurrence of the disease as it is usually encountered, attacking men in perfect health. However, it seems a reasonable explanation of the pathogenesis in the present case. It seems probable that a variety of organisms may be responsible for idiopathic gangrene of the scrotum. In the case under discussion except for its ability to destroy scrotal tissue the pathogenicity of the causative organism was low. The patient was in great pain, but after peristalsis was reestablished he was never alarmingly ill. His highest temperature was 101.2°. Other patients have had marked hyperpyrexia, and many have died in a few days. The mortality among five cases treated in the University Hospital in the last six years was 40 per cent. In examining this patient you will notice that the scrotum is normal on casual inspection, and that the testicles are freely movable beneath the skin.
DISCUSSION Dr. MOORHEAD (closing): The bacterial cause of the penile gangrene (first case) may well have been the vibrio and spirochaete observed by Corbus and others. Yet the case is noteworthy because of the development of the condition after ritual circumcision and the extensive destruction of tissue in the absence of the anaerobic conditions engendered by a tight phinosis.
TRANSACTIONS OF PHILADELPHIA BRANCH
Two other points in the management of these patients should be mentioned. The pregnant woman is instructed to abstain from sexual intercourse and thus avoid the most likely source of her infection. An effort is made to bring her husband in for examination and treatment. In this we are not often successful. Few of the patients are of an intelligent cooperative type and one hesitates to arouse domestic strife. Especially does this become a delicate matter during the trying period of pregnancy. In conclusion we desire to state that our experiences with this complication of pregnancy convince us that: 1. Pregnant women having gonorrhea should be treated. 2. The treatment may be carried out without danger to the mother or child. 3. The methods employed should be adapted to the stage of the disease. 4. As a result of treatment it appears that the puerperal morbidity of the mother, and gonorrheal complications of the newborn are decreased. TWO CASES OF GENITAL GANGRENE (PENILE AND SCROTAL) S. W. MOORHEAD From the Urological Section, Department of Surgery, University of Pennsylvania
The two cases of genital gangrene presented are shown because of the rarity of the condition from which the first patient suffered, and because of the interesting nature of the onset of the disease in the second, while a patient in the hospital ward. Case 1. H . R., a Hebrew, fifty-four years old, applied for treatment for gangrene of the penis at the Out-patient Department of the Howard Hospital, June 25, 1926. Sixteen days previously he had developed two sores, one on each side of the glans. Two days later the entire glans had become black. Pain had been slight, "like pins." Examination showed the entire glans to be gangrenous. It was black, soft, flaccid, somewhat resembling an overripe plum. Sufficient odor was emitted to make admission to the ward undesirable. A dense
THE AMERICAN UROLOGICAL ASSOCIATION
Fm. 1
Fm. 2
427
428
TRANSACTIONS OF PHILADELPHIA BRANCH
mass of tissue could be felt extending backward from the glans one and a half inches beneath comparatively normal skin. The urine contained no glucose. The Wassermann reaction was negative. Two weeks later, the glans having been cut away in the mean time, the induration had extended back to the base of the penis. On July 16 after admission to the ward as incision was made on the dorsum of the penis near the base and a large fascial slough removed. One injection of neosalvarsan was given without notable effect. A month later he was readmitted, incisions at the sides of the penis near the base being required for the removal of additional sloughs of the
Fm. 3
ascia of the corpora cavernosa. Thereafter convalescence was continuous and uncomplicated save that for five days he had to be catheterized for urinary retention. Healing was complete early in September. At present, as you will observe, the penis presents an astonishingly normal appearance. The glans, of course, is missing and the urethral meatus is prominently placed on the end of the corpus spongiosum near the bottom of the scar. Farther back by palpation one can readily distinguish the corpora ca vernosa and the corpus spongiosum. Power of erection has been lost.
THE AMERlCAN UROLOGICAL ASSOCIATION
429
The second patient, who suffered from gangrene of the scrotum, was admitted because of calculous anuria and developed the scrotal condition as a postoperative complication. H. K., thirty-three years old, Jewish, was admitted to the Hospital of the University of Pennsylvania, September 22, 1927, because of calculous anuria. His right kidney had been removed ten years previously. A high ureterostomy, done shortly after admission as an emergency procedure, was followed by no untoward sequelae. Twelve days later a stone was removed from the lower portion of his left ureter. The day following this second operation there was marked intestinal distension. About noon he complained of pain and burning in the scrotum. At this time the organ was of normal size, bright red from mercurochrome. Tenderness was present in marked degree, but whether of the scrotal tissues or of the testicles could not be determined. Ten hours later the scrotum was greatly swollen, approximately 12 cm. in diameter. The bulk of the swelling seemed to be serum. The pain was very intense, exceeding that of the operative wound, though this was being strained by distended intestines; only an occasional peristaltic click could be heard. The following day there was desquamation of the superficial layers of the scrotal skin over an area 15 cm. in diameter. Two days later the scrotum was tympanitic and a line of demarcation was forming in its upper part. A small amount of gas and serum escaped on incision of the gangrenous area. On the eighth day most of the gangrenous skin was removed with forceps and scissors. Separation was slower than in most cases of scrotal gangrene, so that complete freedom from necrotic tissue was not established till the twentieth day. This delay was due to the unwonted depth of the inflammation, which involved the parenchyma of the left testicle and all superficial tissues. The incident pain was very great. (The right testicle was not inflamed.) However, there was no loss of tissue below the internal spermatic fascia. On the twenty-seventh day inflammatory swelling had largely disappeared, and the testicles were both covered with healthy granulations. While the right testicle was rapidly acquiring a scrotal covering, the left was so much exposed operative repair was indicated. This was carried out by undermining the skin laterally so that it could be approximated with three mattress sutures. The patient was discharged ten days later. Bacteriological examinations were disappointing. A gas organism
FIG. 4
FIG. 5 430
THE AMERICAN UROLOGICAL ASSOCIATION
431
was grown under anaerobic conditions, but the tube was broken before the bacterium could be identified. Subsequent efforts revealed only contaminants. In the absence of bacteriological data I hazard the opinion that in this patient the condition was due to bacilli which gained access to the blood stream from the intestine as a result of the extreme distension, which in turn was due to reflex inhibition of peristalsis from irritation of the stripped peritoneum. A relatively benign infection of the ureterotomy incision probably had similar etiology. This suppositious method of infection unfortunately does not account for the occurrence of the disease as it is usually encountered, attacking men in perfect health. However, it seems a reasonable explanation of the pathogenesis in the present case. It seems probable that a variety of organisms may be responsible for idiopathic gangrene of the scrotum. In the case under discussion except for its ability to destroy scrotal tissue the pathogenicity of the causative organism was low. The patient was in great pain, but after peristalsis was reestablished he was never alarmingly ill. His highest temperature was 101.2°. Other patients have had marked hyperpyrexia, and many have died in a few days. The mortality among five cases treated in the University Hospital in the last six years was 40 per cent. In examining this patient you will notice that the scrotum is normal on casual inspection, and that the testicles are freely movable beneath the skin.
DISCUSSION Dr. MOORHEAD (closing): The bacterial cause of the penile gangrene (first case) may well have been the vibrio and spirochaete observed by Corbus and others. Yet the case is noteworthy because of the development of the condition after ritual circumcision and the extensive destruction of tissue in the absence of the anaerobic conditions engendered by a tight phinosis.