From Traditional Management of Mental Illness to Self-Mutilation of the Penile : A Case Report

Introduction: Self-mutilation of the external genitalia is rare. It occurs most often on a psychotic ground. Case Report: Mr. P.O. 25-year-old, a dress maker, admitted to the urological emergency for self-section of the penile. The patient had cut his penile with a razor blade and the amputated distal extremity had been thrown in the water closet. The patient was admitted 19 hours after the act of self-harm. Clinical examination had found a stable hemodynamic status, a section of the penile at its root. Psychiatrically schizophrenia evolving for 08 months was diagnosed. An attempt of penile reconstruction was performed. The patient benefited serum and tetanus vaccine, antibiotic and neuroleptics. The parents asked to go home against medical advice the 5th day. Conclusion: The management of self-mutilation of external genitalia is multidisciplinary including surgery and psychiatry.


Introduction
Self-mutilation of the external genitalia is rare [1]- [3].It is defined as the willful destruction of the tissues of the * Corresponding author.
external genitalia without conscious intent to die [4]- [7].Multidisciplinary is the key word in the management of self-harm.The management is surgical but mainly psychiatric.We report a case of self-section of penile in a schizophrenic patient to describe our therapeutic strategy and to bring out the difficulties of a long-term monitoring in the African context.

Case Report
Mr P.S 25-year-old, a dress maker, admitted to the urological emergency unit of Yalgado Ouédraogo University Hospital of Ouagadougou for self-section of the penile.The patient who lived in a neighboring country would be returned to Burkina Faso to treat psychiatric disorders with a traditional healer.The troubles have been evolving for eight months.For parents, the patient had cut his penile with a razor blade and the amputated distal extremity had been thrown in the water closet.The patient was taken to a clinic where a haemostatic dressing was made and it was referred to the urological emergency unit.We received the patient 19 hours after the act of self-harm.Clinical examination had found a stable hemodynamic status, a section of the penile at its root (Figure 1).Elsewhere there is no wound.Psychiatrically we noted a dissociative syndrome with bizarre behavior.We had noted a delusional syndrome with a delusion of persecution and hallucinatory mechanism.We performed in the surgical room a surgical debridement with an attempt of penile reconstruction.This necessitated a partial mobilization of residual cavernous and spongy body from ischial pubic branches and a section of the suspensory ligament of the penile.He received serum and tetanus vaccine, two antibiotics ceftriaxone and metronidazole.Psychiatrically schizophrenia was diagnosed and the patient received treatment with neuroleptics.But after removal of the catheter on the fith day and resumption of normal urination, parents asked to go home against medical advice (Figure 2).They wanted to continue treatment to the village with the traditional healer.We went to visit the patient in his village after 05 months.He had a normal urination and continued his treatment with prayer groups (Figure 3).We got the family informed consent to publish this study.

Discussion
Self-mutilation of the external genitalia is rare [1] [2].It is a phenomenon which has a predominantly male [1] [5] [7].The first case of genital self-mutilation was published in English literature by Strock in 1901 [4].This scarcity is related to the fact that genital mutilation is rarely reported by families [8]- [10].Usually only the major self-injury is reported.The major self-mutilation occurs mostly on a psychotic field [1] [3] [6].About 87% of cases of genital self-mutilation occur in a psychotic context including 51% of decompensated schizophrenia [11].Self-harm in the nonpsychotic context is rare [2].Several factors govern the act of self-harm in the psychotic but what is determinant seems to be feelings of guilt associated with sex drive [1].The act is due to delusions or feelings of sexual guilt [2].In our patient, psychiatric disorders such delusions of persecution have evolved for eight months.Living in a world where he would be persecuted, our patient found in self-mutilation a strategy to draw attention to himself because he is a "man persecuted".
In our case penile replantation was not possible because the amputated distal extremity was not available.If penile replantation is possible, it should always be attempted in a better period [8].We performed then the penile elongation technique by partial mobilization of residual cavernous and spongy body from the ischiopubic branches.The suspensory ligament of the penile was also sectioned.This avoids the perineal urethrostomy.Best results are obtained by this technique both functionally and esthetically.Abdellatif B. et al. reported a case of traumatic amputation of the penis by electricity.Penile reconstruction by mobilizing cavernosa gave good results [12].It remains alternative when penile replantation which must be made before the 6 th hour is impossible because of ischemia and infection risk.However successful penile replantation after the 16th hour was reported and this through microsurgery [3].So even if the distal extremity of the amputated penile was available, the consultation period for our patient associated with the unavailability of microsurgery would not allow reimplantation.
The management of self-mutilation should be multidisciplinary.Any surgery that will ignore the mental dimension of self-harm would jeopardize success.It would be illusory to perform penile reimplantation in a longtime psychotic patient.Recurrences are frequent.Kaboré F. A. et al. reported a case of a recurrent penile self-amputation on a schizophrenic field [13].
In Africa and particularly in Burkina, traditional healers have an important place in the management of mental illness.The collective unconscious considers mental illness as due to genius and therefore modern medicine can't do anything.Thus the patient is often seen in medical consultation at the stage of decompensation with somatic symptoms.This is the case of our patient.The role of religion is also important.The phenomenon of healing prayers is growing and many patients abandon modern medicine and are turning to these "miracle makers".This is the case of our patient whose parents decided to continue treatment with healers and prayer groups.But very often the last resort remains modern medicine.This makes it very difficult to monitor these patients.

Conclusion
Self-mutilation of the penile is rare.The management has two components that are complementary: It is urological but mainly psychiatric.Modern medicine and some religious and traditional beliefs should not oppose.We believe they can coexist because the interests of the patient come first.

Figure 2 .
Figure 2. Result on the 5th postoperative day.

Figure 3 .
Figure 3. Result after 5 months: We went to visit the patient in his village.