British Journalof Urology (1993), 71,750-759 Q 1993 British Journal of Urology

Case Reports

Sequential Self-castration and Amputation of Penis

A. RANA and A. D. JOHNSON, Department of Surgery, Ormskirk and District General Hospital, Ormskirk

Case Report A 38-year-old trans-sexual presented to the Casualty Department with a profusely bleeding scrota1 wound. He had “castrated” himself at home using a razor blade, saying he had “opened the scrotum, dissected the left testis and removed it from its root.” Severe bleeding prevented him from repeating the procedure on the opposite side.

Since the age of 12 he had considered his sexual organs to be abnormal. He was unmarried and was generously supported by his parents. His own doctor and a team of psychiatrists had counselled him on many occasions, had regularly prescribed oestrogens and cyproterone acetate, and finally recommended sex reassignment surgery (SRS). On learning that the waiting list for such operations was many years, he decided to do it himself.

He had a 7.5 x 2.5 cm laceration on the scrotum with a missing left testis and epididymis. After debridement, the severed spermatic cord stump was transfixed and the wound closed. Next day, he was examined by a psychiatrist. No further medication was prescribed but early SRS was recommended. An appointment was arranged and 6 months later he saw the specialist. Again he learned that there was a 2-year waiting list. He returned home and next day “castrated” himself on the other side.

Exploration revealed a laceration similar to the previousone, with the right testis andepididymis missing. This was dealt with accordingly. He was examined by another duty psychiatrist and attempts were made to expedite SRS but these were unsuccessful. Three months later he amputated his penis.

Comment This patient would satisfy the American Psychiatric Association criteria for a primary trans-sexual (Lavin, 1987). Genital mutilation following pater- nal death or psychiatric illness has been reported by Thompson and Abraham (1983), but this is the first report of sequential self-castration and ampu- tation of penis. It could be argued that the prospect of being on a long waiting list because of lesser priority for SRS led to desperation in this case.

Neither psychotherapy nor hormone therapy on its own has proved successful (Lundstrom et al., 1984). Thus primary trans-sexuals should be prop- erly identified, thoroughly counselled and should then receive SRS without delay.

References Lavin, M. (1987). Mutilation, deception, and sex changes. J .

Med. Ethics, 13,86-91. Lundstrom, B., Pauly, I. and Walinder, J. (1984). Outcome of sex

reassignment surgery. Acta Psychiarr. Scand., 70,289-294. Thompson, J. N. and Abraham, T. K. (1983). Male genital self

mutilation after paternal death. Br. Med. J., 287,727-728.

Requests for reprints to: A. Rana, Department of Urology, Western General Hospital, Edinburgh EH4 2XU.

Sulphur Calculi from Ingestion of Sulphasalazine

D. B. SILLAR and D. KLEINIG, Department of Urology, Gold Coast Hospital, Southport, Australia

Case Report A 46-year-old man with severe ulcerative colitis was in hospital for correction of dehydration and adjustment of therapy using sulphasalazine (Salazopyrin). He developed typical ureteric pain on the left side during this admission.

A radiolucent lesion partially obstructing the left mid- ureter and a similar lesion in the left renal pelvis were demonstrated by intravenous urography (Fig. 1). A CT scan confirmed the filling defect in the left renal pelvis

750