Introduction

Penile amputation is a scarce condition reported as an isolated case (Gyan et al. 2010).  The common cause is self-mutilating or as a result of an industrial accident. In the area of psychiatry, penile amputation may occur as a complication of self-mutilation due to a commanding auditory hallucination. We report a case of a total amputation of the penis in a patient with acute paranoid schizophrenia. He responded to the command of his psychopatology and acted by castrating his penis, and the penis was not be able to be constructed due to loss of the remaining part of the genital. 

Case report

This case involved a 31-year-old divorce Rohingya refugee from Myanmar who was given a protection for 8 yrs under United Nations High Commissioner for Refugees (UNHCR) for staying in Malaysia. Patient was brought to Emergency Department in Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Cheras, Kuala Lumpur for an alleged self-harm with total amputation of his penis. Examination under anesthesia was done and he was admitted inthe hospital for further treatment. The wound was cleaned and he was started on intravenous antibiotic Augmentin for 7 days. Later he was transferred to psychiatry wad for further observation. With regard to his past psychiatric history, the man was treated previously in Myanmar for history of psychotic disorder. He had history of hearing voices talking to him and commanding him to get rid of his penis because he belief that his genital was controlled by some external forces. He had past history of alcohol dependence for past few years but denied history of substance abuse and intake. He did not harbour any suicidal ideation, and he had no past history of self-harm behavior. 

In the hospital, after he regained his consciousness, he was given tablet Sulpiride 200 mg ON, an antipsychotic agent to treat his hallucination and tablet Clonazepam 2 mg ON was started to help him for sleeping. In the ward, his psychotic symptoms subsided and no alcohol withdrawal noted.

Discussion

There are  less scientific reports on the prevalence of genital self-mutilation. There were only few cases of genital self-mutilation which were reported in the English literature. No precise data are available on the prevalence of male genital self-mutilation, and such acts are presumably much more frequent than the small number of published cases would suggest.

The patient presented with history of alcohol dependence which resulted in the symptoms getting worse. Earlier researcher such as Nakaya (1996), stated alcohol dependence may contribute self-mutilation because of its tendency to remove inhibition. This case report concluded that although it is difficult to estimate the risk of penile or genital-castration in view of the heterogeneity of the respective patient groups with a different clinical diagnosis, the danger of such deeds should be kept in mind. This is when the above factors, especially a commanding auditory hallucination for self-castration are present in the patient.

Cases of genital self-mutilation seem to be a global phenomenon across racial groups, cultures and religions. Cases involving male far out number female (Schweitzer 1990). Major self-mutilations such as self-amputations are rare in psychiatric practice and most patients are psychotic during such acts. Common types of major self mutilation are damaging to the digits, the eyes or the genitals (Gojendra Singh et al. 2013).  This factor manifested to this case was male, presenting with history of psychotic disorder and the action involved penile or genital self mutilation. Psychopathology presented was commanding auditory hallucination. This symptom was noted as one of the common leading underlying psychopathologies in majority of the reported cases (Ozan et al. 2010).

There was three known groups of genital mutilator which can be divided to group of patient who has psychotic disorder (e.g. schizophrenia), transversites group and a group of patient with complex religious or belief (Yadukul et al. 2015). Various risk factors have been identified in the few previous case reports of genital self-mutilation (Mishra & Kar 2001). Those factors are guilt feeling associated with sexual conflict, disturbance of sexual identity, conflict over masturbatory activities or transsexual tendencies. Profound ambivalence towards adult sexuality, religious psychotic experiences, schizophrenia, affective psychoses, alcohol intoxication, personality disorders, or borderline personality disorder which are associated with genital self-mutilation.

conclusion

Psychotic disorder as discussed in the present report manifested with positive clinical symptoms which lead to penile amputation. This finding suggests that penile amputation may present in case of psychotic disorder specifically in this discussion as schizophrenia.