Penile gangrene is a necrotic change in penile tissues with potentially severe systemic consequences. The symptoms of wet gangrene are represented by pain, swelling, the appearance of ulcers with fetid discharge, impaired urination, fever and severe intoxication. With dry gangrene, there is no purulent discharge, the skin is mummified and acquires a brown or black color. The diagnosis is established during examination, taking into account the data of analyzes, ultrasound, X-ray methods. Treatment involves total or partial penectomy, the appointment of antibiotics, detoxification therapy, correction of extragenital pathology associated with the initiation of penile gangrene.
ICD 10
N48.2 N48.8
General information
Gangrene of the penis (penile necrosis, penile gangrene) is a rarely occurring progressive pathology, which is a purulent‒necrotic melting of the tissues of the male genital organ with symptoms of general intoxication (in infectious form), necrosis and mummification of tissues (in dry form). It is more often diagnosed in men aged 50-79 years with serious background diseases, but it can occur in young people and children in the presence of appropriate causal factors. Pathology is not associated with seasonality and has no endemic zones, although, according to some sources, the infectious form is observed more often in African countries.
Causes
It has been proven that immunosuppression of any genesis aggravates the pathological process and increases the likelihood of gangrene. The classic risk factors are decompensated diabetes mellitus, end-stage chronic renal failure, cirrhosis of the liver, HIV infection, obesity, severe atherosclerosis, smoking, alcoholism and the use of psychotropic substances. A combination of several factors and a premorbid background aggravate the disease and worsen the prognosis. The main provoking reasons include:
An infected injury. Gangrene can be complicated by accidental damage to the penis, independent manipulations (introduction of an oil solution into the tissues of the organ, injection of drugs into the penile veins). Less often, the necrotizing reaction accompanies phalloplasty or other urological interventions (circumcision, urethral augmentation). Animal or insect bites, frostbite and burns, wounds, suppurated foreign body of the urethra can lead to penile necrosis. Microbial flora is represented by E. coli, staphylococci, streptococci, anaerobes, proteus, fungal pathogens.
Vascular disorders. Progressive vascular occlusion on the background of diabetic nephroangiopathy, priapism, venous thrombosis, paraphimosis, cholesterol embolism, sexual games with prolonged vasoconstriction, improper wearing of a uropreservative, perivascular invasion by a tumor lead to circulatory disorders. Ischemia triggers the process of necrotization. With secondary hyperparathyroidism caused by the end stage of renal failure (especially in patients on hemodialysis), diffuse vasculitis with vascular calcification develops. This leads to a decrease in blood flow and ischemic dry necrosis of the penis.
Pathogenesis
Narrowing of the vascular lumen and pericapillary edema in angiopathies contribute to increased permeability of the vascular wall, exudation and infiltration by plasma components of nearby structures. Against this background, the supply of nutrients and oxygen to the cells decreases to a critical level, and the accumulation of metabolic products occurs. Microbial flora is activated, which is associated with a background weakening of immune responses. The infection spreads to neighboring areas, increasing the necrosis zone, further tissue disintegration and pus discharge occur.
In the dry type of gangrene, there is no connection with the infectious agent. Immune reactions are aimed at separating diseased tissue from healthy tissue. The vital activity of bacteria slows down in drying conditions. Over time, penile self-amputation occurs. The pathogenesis of calcifying uremic arteriopathy against the background of secondary hyperparathyroidism in CRF has not been fully studied to date. It is believed that the condition is associated with hypercalcemia and hyperphosphatemia. The end result is the deposition of calcium deposits on the vascular wall, which disrupts blood circulation with the development of ischemic necrosis.
Symptoms
The manifestations of the disease depend on the form of gangrene. For dry gangrene, compaction and wrinkling of the skin of the penis due to dehydration, a change in its color to blue-black, loss of sensitivity (numbness) of the organ are typical. Pain in the penis is caused by spasm of the main arteries and collaterals. The affected area is colder to the touch than other tissues. The general condition suffers to a lesser extent, since there is no microbial intoxication, and as the process progresses, pain sensations decrease and disappear. One of the distinguishing features is the formation of a demarcation line separating healthy tissues from non—viable ones, which is a protective reaction. There is no tissue detachment, typically shrinkage, no odor. In advanced cases, the necrotic area can be amputated spontaneously.
Necrotization begins with the distal parts of the organ. If bacterial contamination occurs during incomplete mummification, the clinic resembles the symptoms of wet necrosis. The features include the gradual development of the disease: the man notes paresthesia, erectile dysfunction, pallor and numbness of the skin and the head of the penis, discomfort. Within a few months, the symptoms worsen. The lightning onset is typical for acute vascular catastrophe with compression or blockage of the main and collateral vessels, circulatory arrest in any part of the organ (embolism, crash syndrome, traumatic toxicosis). The longer the ischemia, the more likely it is that the changes will be irreversible.
Symptoms of infectious gangrene at the stage of progression include fever up to 40 ° C with chills, pronounced weakness, heavy sweat, tachycardia, decreased blood pressure, the appearance of purulent-necrotic ulcers with an unpleasant-smelling discharge, increased and total swelling of the organ, soreness in the inguinal lymph nodes. The pain syndrome is pronounced vividly, the general state of health is severe. There are no clear boundaries of necrotic transformation, bluish spots are visualized, which turn into ulcerative defects. With severe well-being, the pain may become less, which is not a clinical improvement, but indicates the death of nerve receptors.
Complications
Early complications include acute urinary retention, septic shock with multiple organ failure, the spread of penile gangrene to the scrotum and fascia (Fournier gangrene). The earlier the patient seeks help, the more likely it is to avoid extremely negative consequences, and in other cases ‒ to save life. Penile necrosis of infectious genesis without adequate therapy and surgical treatment leads to death in 100% of cases. Late complications after discharge from the hospital, depending on the volume of the operation performed, include erectile dysfunction, chronic pain syndrome, penile deformity, Peyronie’s disease.
Diagnostics
In each case, the urologist or surgeon determines the diagnostic algorithm individually. Differential diagnosis is carried out with a malignant tumor at the stage of decay, cavernitis, erosive balanoposthitis, cellulite, erysipelas. The patient is urgently examined by a vascular surgeon, therapist, resuscitator and other specialists. The advantage in the current situation is on the side of therapeutic, but not diagnostic actions. To confirm penile necrosis, the following analyses and imaging methods may be useful:
- Examination of blood and urine. In a general blood test, leukocytosis with a shift of the formula to the left, toxic granularity of neutrophils, accelerated erythrocyte sedimentation rate, and sometimes anemia are determined. Biochemical parameters are examined: urea, creatinine, lipid profile, glucose, blood electrolytes, PTH (parathyroid hormone). For general urinalysis, leukocyturia, proteinuria, cylindruria, bacteriuria are typical.
- Cultural analyses. With gangrene (wet), sowing is carried out on the nutrient media of blood, purulent secretions and urine. Diagnostics is carried out to confirm sepsis, determine the microbial composition and select the optimal drug. Prior to this, drugs are prescribed empirically. Given that the microbial flora of individuals with immunosuppression may be represented by atypical pathogens, the results of culture seeding may be important.
- Radiation diagnostics. Ultrasound of the penis and iliac vessels with a Doppler in some cases indicates the absence of blood flow in the cavernous or dorsal arteries. With a CT scan of the pelvis, vascular calcification can be visualized. To assess the blood supply to the affected area, penile arteriography is performed. Currently, due to the invasiveness, angiography is used only when CT and ultrasound are unavailable.
Penile gangrene treatment
Necrotization in infectious gangrene and the risk of septicemia is an indication for emergency surgical treatment with the appointment of antibiotics with the widest possible spectrum of action and detoxification. In the case of total ischemia with necrotization, the administration of heparin is ineffective. With the fact of injury, tetanus prevention is carried out. Therapeutic measures include:
- Penectomy. The volume of the operation depends on the area of the lesion. In relatively “mild” cases of gangrene, without spreading to the penis body, the damaged tissues are excised. With total necrosis, penectomy is performed, with necrosis only of the head, distal amputation of the penis is performed. The need for surgical treatment for dry necrosis remains a subject of discussion, but most specialists in the field of urology and andrology are of the opinion that early partial penectomy and treatment of the underlying disease prevent the spread of the wound, leave the opportunity to maintain a longer penis length and are able to improve the quality of life.
- Detoxification therapy. The patient is intravenously injected with albumins, crystalloid solutions. All methods of blood purification from toxins (hemosorption, plasmapheresis) relevant only for wet necrotizing. Despite the massive detoxification therapy carried out before, during and after the intervention, age-related patients with severe concomitant pathology develop complications incompatible with life.
- Antibacterial therapy. Antibiotics are prescribed immediately upon admission of the patient to the hospital, without waiting for the results of bacteriological seeding. Drugs capable of resisting the multi-resistance of microflora include cephalosporins, lincosamides (clindomycin), combinations of piperacillin – tazobactam, ampicillin – sulbactam, ticarcillin – clavulanate in combination with metronidazole and aminoglycosides. When the fungal flora is isolated, amphotercin B or caspofungin is prescribed.
- Physical therapy. Hyperbaric oxygenation involves the supply of oxygen at elevated atmospheric pressure to the tissues, which stimulates the formation of new blood vessels and leads to an increase in the dissolution of oxygen in plasma. The processes of repair (granulation, epithelization) occur faster. HBO contributes to the death of anaerobic microflora, as macrophages are activated in the inflammatory focus. Irradiation with a low-intensity helium-neon laser, ultrasonic cavitation, irrigation with an oxygen or ozone air mixture of the wound surface accelerate the rejection of purulent-necrotic tissues and healing.
Prognosis and prevention
The prognosis for life is influenced by many circumstances, including the general condition. In patients with chronic kidney disease and diabetes mellitus in the decompensation stage, mortality is close to 100%. Young patients with paraphimosis, priapism, and a ring on the base of the penis can be successfully operated on. The quality of life depends on the volume of surgery (partial or complete penectomy), restoration of erectile function with the help of falloprosthesis after recovery. Prevention includes adequate therapy and control of complications in diabetes mellitus and kidney failure, taking medications against calcifylaxis, rejection of dangerous sexual devices, correct selection of the size of the uropreservative, early administration of antibiotics for penis injury, a healthy lifestyle, etc.