A rare presentation of genital self-mutilation in a patient of schizophrenia

INTRODUCTION

Self-mutilation is described as the deliberate destruction or alteration of body tissue without conscious suicidal intent. Behaviours that involve damaging bodily tissues without intending suicide are defined as self-mutilation. The most common types of self-mutilation are damaging the skin, eyes and genitals.^1,2 Genital Self-Mutilation (GSM) is a rare and severe form of self-injurious behaviour that is usually described in conjunction with psychotic disorders with delusions and hallucinations. Risk factors for GSM include commanding hallucinations, religious delusions, substance abuse, and social isolation.^2-4 Self-inflicted injuries range from simple lacerations of the external genitalia to complete amputation of the penis and testes. In most cases, genital mutilation is common.^4,5 In a group of 52 cases of GSM, Greilsheimer and Groves found 87% of the patients to be psychotic and 13% of the patients to be non-psychotic. Some authors have further identified three groups of at-risk men: psychotics, character-disordered individuals including transsexuals, and individuals under socio-cultural influences.⁶ The major psychotic illnesses in these patients included delusions in chronic paranoid schizophrenia and commanding hallucinations.^2,6 The non-psychotic cases included character disorders, transvestism, and complex religious or cultural beliefs. There have been sporadic cases of non-psychotic GSM in the literature.^1,4 Various forms of psychopathology have been postulated in such cases.

We present here a special form of self-infliction in a patient who come to our casualty with self-hammered nails into his both scrotum.

CASE REPORT

A 28-year-old man came to our casualty along with his mother with the complaint of self-hammered nails in his both scrotum 15 days back and with fear of not able to have any child in future after marriage. He is currently unmarried. After thoroughly talking to the patient and his mother and investigating all the previous documents, we came to know that patient was a known case of Schizophrenia since 3-4 years and was under treatment for the same, but he was not taking his medications on regular basis. We also came to know that the patient was indulged in 4-5 legal court cases and as per previous documentation his mother was also psychotic patient but she was denying for the same and hence she was not under any treatment. Patient also gave history of 1-2 suicidal attempts. Patient expresses cause of his self-hammering of nail into his scrotum due to his poor socio-occupational status.

The physical examination revealed an average conscious built patient (weight 62 kg, height 160 cm). On local examination two nails were appreciated in both of his scrotum. There were no tenderness. Right scrotal nail was visible whereas left scrotal nail was not visible, buried inside the scrotum with both of his testis palpable away from hammered nail and freely mobile. There were no any bleeding noted from both scrotum (Figure1).

The primary removal of nails was attempted under local Anaesthesia and both the nails were removed from both of his scrotum (Figure 2, 3 and 4).

The patient has been under regular follow-up in both the departments i.e. Surgery and Psychiatry and he is doing well. His scrotal wound has been healed well and his psychological status is stable at present.

DISCUSSION

GSM is a rare phenomenon. The most common self-mutilating behaviour is cutting one’s own wrist, which is usually committed by adolescents or by the mentally retarded for attention-seeking purposes, to resolve tension, or as an epidemic behaviour. Rarely, self-mutilation has a serious nature that leads the patient to attempt to amputate his penis, castrate himself, extract his eye or amputate his hand.¹ The vast majority of reported cases have occurred among single, white males in their 20s and 30s.^3,5,7 Our patient fit into these gender and age groups.

The degree of mutilation, the predisposing factors, and the instruments used in the perpetration of this irrational, extraordinary act vary. The instruments that have been used include kitchen knives, blades, scissors, a chainsaw, and an axe. However, there has been no report in the literature of scrotal self-mutilation using hammered nails. Thus, we were surprised that a man had selected this exceptional and gruesome method for mutilation. This is an extraordinary case of GSM performed using the uncommon method, and the absence of similar reports in the literature may be the result of selective reporting of self-inflicted personal injuries.^3,8

The majority of cases, reported in the literature, have been of patients with psychosis or psychiatric disorders with either functional or organic brain disease. Such cases have been observed in schizophrenia or depression with sexual problems; however, it is sometimes difficult to diagnose these conditions because such a behaviour is usually the only presenting symptom of the psychiatric disorder.

However, a few cases have been described in nonpsychotic persons and often after a period of planning that resulted either from bizarre autoerotic acts or from attempts at crude sex change operations by the transsexuals.^1-6 It has been suggested that there is no difference in the severity of the self-inflicted injuries between psychotic and non-psychotic patients.⁸

As the degree of mutilation varies so does the treatment, which can be complex and quite challenging. It is often a multidisciplinary responsibility between the urologist, psychiatrist, psychologist, and primary care physician. The ultimate goal of surgical treatment includes restoration of the anatomy and function as much as possible.⁵

In this case we have done removal of nail with a minimal incision over the scrotum. Complications resulting from GSM vary according to the severity of the injury inflicted and the extent of surgical repair undertaken.

CONCLUSION

To our knowledge this is the first case reported in literature and the rarest type of injury presented as a bilateral scrotal self-mutilation as should be managed wisely.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Nerli RB, Ravish IR, Amarkhed SS. Genital self-mutilation in nonpsychotic heterosexual males: Case report of two cases. Indian J Psychiatry. 2008;50:285-7.
2. 2. Ozan E, Deveci E, Oral M, Yazici E, Kirpinar I. Male genital self-mutilation as a psychotic solution. Isr J Psychiatry Relat Sci. 2010;47(4):297-303.
3. 3. Rao K, Bharathi G, Chate S. Genital self-mutilation in depression: a case report. Indian J Psychiatry. 2002;44(3):297-300.
4. 4. Hari CS, Reddy CM, Kumar P. Genital self-mutilation in alcohol withdrawal state complicated with delirium. Indian J Psychol Med. 2011;33(2):188-90.
5. 5. Ajape AA, Issa BA, Buhari OL. Genital self-mutilation. Ann Afr Med. 2010;9(1):31-4.
6. 6. Eke N. Genital self-mutilation: there is no method in this madness. BJU Int. 2000;85(3):295-8.
7. 7. Stunell H, Power RE, Floyd JRM. Genital self-mutilation. Int J Urol. 2006;13(10):1358-60.
8. 8. Sudarshan CY, Rao KN, Santosh SV. Genital self-mutilation in erectile disorder Genital self-mutilation in erectile disorder. Indian J Psychiatry. 2006;48:64-5.