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Urological Manifestation of Cryptic Severe Psychiatric Illness

Article  in  Military Medicine · November 2018

DOI: 10.1093/milmed/usy320

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MILITARY MEDICINE, 00, 0/0:1, 2018

Urological Manifestation of Cryptic Severe Psychiatric Illness

Huckelberry A. Finne, LCDR MC USN*; Jared K. Heal, LT, MC, USNR†

Downloaded from https://academic.oup.com/milmed/advance-article-abstract/doi/10.1093/milmed/usy320/5194150 by guest on 15 February 2019

ABSTRACT Penile cellulitis has rarely been reported in the literature and never secondary to self-injury with subse-
quent sexual activity. It presents a challenging diagnostic situation in that the patient will likely be less than forthcom-
ing about the etiology of his symptoms despite his willingness to seek formal medical attention. We present a case of
penile cellulitis secondary to dermatitis artefacta in a severely depressed new submarine sailor. Initial studies for a
more serious etiology were negative and he was treated with PO antibiotics for “syphilis” by the local civilian emer-
gency department. After responding well to antibiotics, he subsequently presented back to medical in order to offer up
the etiology of his penile wounds. In this report, we review the published literature on penile cellulitis and genital der-
matitis artefacta. This case shows that military providers should always have psychiatric causes in their differential and
not hesitate to ask about genital abnormalities. Recognition of underlying psychiatric etiology may play a key role in
helping the patient get the care he or she needs.

He then presented the next day to the undersea medical

CASE PRESENTATION
Penile cellulitis is a rare clinical phenomenon. We present
the case of a 31-year-old junior sailor who presented with
dysuria, pyuria, and a painful penis diagnosed as penile
cellulitis.
A 31-year-old submarine sailor, 5 months into his first
tour with no foreign travel, initially presented to the local
civilian emergency department with chief complaint of
severe dysuria and penile pain with a feeling of incomplete
emptying. He was in a monogamous relationship and had
recently had anal and vaginal intercourse. Laboratory studies
showed a urinalysis with 224 WBCs and 3 RBCs per high
powered field. He was treated empirically for “syphilis” per
the patient with 1 g PO azithromycin, 2.4 million Units IM
bicillin, and 250 mg IM ceftriazone along with being dis-
charged on a ten-day course of co-trimoxazole 800–160 mg
BID. Subsequent review of his emergency department medi-
cal records showed that further laboratory testing was not
completed.
*Naval Special Warfare Group Two Logistics and Support Unit, Joint
Base Little Creek Fort Story, Norfolk, VA 23518.
†Arnot Ogden Medical Center Emergency Medicine Residency
Program, 1001 Hoffman St, Elmira, NY 14905.
The views expressed in this article are those of the author and do not
necessarily reflect the official policy or position of the Department of the
Navy, Department of Defense, nor the U.S. Government. H. Finne and J.
Heal are military service members. This work was prepared as part of our
official duties. Title 17, USC, §105 provides that ‘Copyright protection
under this title is not available for any work of the U.S. Government.’ Title
17, USC, §101 defines a U.S. Government work as a work prepared by a
military service member or employee of the U.S. Government as part of that
person’s official duties.
doi: 10.1093/milmed/usy320
Published by Oxford University Press on behalf of the Association of
Military Surgeons of the United States 2018. This work is written by (a) US
Government employee(s) and is in the public domain in the US.
officer with worsening penile pain despite narcotics and acet-
aminophen. He had a diffusely tender and enlarged penis,
without interstitial edema (Fig. 1). The enlargement appeared
from vascular congestion due to prominent veins. He was cir-
cumcised with a larger than expected urethral meatus that had
a small amount of pus proximal to the meatus along ventral
aspect of the fossa navicularis. Additionally, he had two
<1 mm closed comedones and an approximately 2 mm area
of superficial skin ulceration at the mid-shaft of the dorsum of
the penis (Fig. 1). The penis and scrotum were erythematous
and warm. Testes and prostate were unremarkable.
DIFFERENTIAL DIAGNOSIS
Adleen and Mantell1 list an extensive differential diagnosis
for penile swelling and Rosenblatt et al2 specifically outlined
nonsexually transmitted infections of the male genitalia.
Besides sexually transmitted diseases, other infections etiolo-
gies include cellulitis, necrotizing fasciitis, and abscess;
while non-infectious causes include contact and irritant der-
matitis, molluscum contagiosum, lymphedema, lymphocele,
dermatitis artefacta vs factitious dermatitis malignancy, and
other trauma. Additional potential etiologies include ascites
and nephrotic syndrome.
FURTHER DEVELOPMENTS
Initial examination suggested the penile edema was second-
ary to vascular congestion so, after consultation with the
local civilian urologist, a CT was obtained prior to him
examining the patient. Approximately 60 hours after initial
presentation, the patient’s pain had markedly improved. The
urologist diagnosed penile cellulitis and prescribed comple-
tion of the course of co-trimoxazole.
Approximately 1 week later the patient, represented to the
undersea medical officer. He reported adherence with the

MILITARY MEDICINE, Vol. 00, 0/0 2018 1

 Case Report
FIGURE 1. Photograph showing diffuse erythema and edema of penis.
One comedone can be seen on the left lateral penis. The other is hidden
from the angle of the photograph. Slightly proximal and on the right dorsum
the self-inflected injury is present. Photograph of patient’s penis.
prescribed antibiotic and noted a complete resolution of
symptoms. The patient admitted to using scissors prior to
intercourse to create a microlaceration on his penis (Fig. 1).
He reported being overcome with emotional pain from a
stressful work environment. He also reported positive signs
of alcohol abuse. Further, he acknowledged severe suicidal
ideation with a plan using his personal pistol along with
unspecific homicidal ideation. He was admitted to inpatient
psychiatry later that day. After several inpatient stays over
several months, he was eventually stable enough to remain
outpatient on a significant medication regimen with final
mental health diagnoses of major depression and anxiety. He
was subsequently discharged from military service.
DISCUSSION
His initial presentation resulted in successful management of
an atypical penile infection without uncovering the underly-
ing pathology of severe psychiatric illness. Penile cellulitis
and penile dermatitis artefacta are both rare clinical diagno-
ses. To our knowledge, we present the only published case
of the concurrent diagnoses. The true etiology was missed
on a series of presentations to various clinicians secondary
to poor history taking. No one found out because no one
asked.
Penile cellulitis, by itself without more extensive disease
such as Fournier’s gangrene, is a rare diagnosis. The authors
searched Embase, Web of Science, and PubMed for papers
using the terms penis/penile cellulitis. Only five uncomplicated
2 MILITARY MEDICINE, Vol. 00, 0/0 2018
(i.e no specific risk factors such as immunocompromise) adult
cases of penile cellulitis found in the literature1,3–6 one of
which was somewhat similar to this case in that skin trauma,
specifically partner biting, prior to intercourse led to cellulitis
with abscess. Mendelsen and Miller5 hypothesized that one of
their cases without comorbidities was secondary to an asymp-
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tomatic infected female partner and microtrauma of unknown
cause on the patients penis similar to our case. This case is the
first in a circumcised male and the first secondary to intentional
self-injury due to psychiatric disease.
The authors searched Embase, Web of Science, and
PubMed for papers using the term dermatitis artefacta.
Individual titles and abstracts were than reviewed for those
mentioning the genital(s) or penis/penile. Five cases7–11 of
penile dermatitis artefacta have been reported. The earliest in
the literature11 coined the term dermatitis erotica, but the
term does not appear to have been used by other authors
since 1976. Typically, the ulcers have had good delineation
between the healthy and damaged skin in areas accessible
with the dominant hand and the lack of ability to describe
exactly when the lesions began. Hernandez-Gil et al9 specifi-
cally noted that a complete and inclusive medical history is
necessary due to the increased risk of dermatitis artefacta
affecting the genitals when the history includes oral sex.
Again, the clinician must ask hard questions even if they
cause discomfort to everyone in the exam room.
“Factitious dermatitis is the term applied to self-inflicted skin
lesions with the intent to elicit sympathy, escape responsibility,
or collect disability insurance. Malingering applies to the latter
two cases, where material gain is the objective. This contrasts
with the usual dermatitis artefacta patient, who has an uncon-
scious goal of gaining attention and assuming the sick patient
role.”12 Although the authors cannot rule out the possibility that
the patient was attempting to elicit sympathy, it is thought, given
his psychiatric distress, he was most likely motivated by the
unconscious goal of gaining attention. Two articles by
Fabish13,14 offer particular insight. He comments that these
patients have “emotional immaturity… and when difficulties
arise with which they are unable to deal adequately within their
isolation.” This description is consistent with our evaluation of
this patient and all collateral information subsequently obtained.
Fabish notes that these patients will often have the predisposing
factors of problems going back to infancy and childhood along
with now finding themselves in a situation that may “upset the
emotional equilibrium to the point where help is needed. Given
the difficulties of communicating with others, some individuals
will try to attract attention by a somatic signal rather than by ver-
balizing.” Further, Koblenzer15 noted that these patients often
have emotional deprivation early in life and dependent and
manipulative relationships.
Gattu et al16 propose that “dermatitis artefacta…develops as
an emotional escape valve or an appeal for help in an attempt
to fill a need of which the patient is not aware.” Gupta et al17
in their review of psychologic trauma and dermatology, posit
 Case Report
that self-injurious dermatological conditions constitute the
focus of tension-reducing behavior because of the skin’s role
in disrupted early attachment when abuse occurs early in life.
Usually, there is no obvious secondary gain thus separating it
from malingering. Indeed, this patient cheerfully returned to
work after his initial infectious manifestation underwent suc-
cessful treatment. Joe et al18 specifically note that the self-
injury may represent “an appeal for help in [the] face of a
stressful life situation.” In 1920 Davis19 wrote about dermatitis
artefacta in soldiers, but, with today’s lens, one would likely
classify his cases as malingering. Cohen and Vardy published
a case20 series of dermatitis artefacta in soldiers found to be
malingering in that the patients aimed to gain a reduction in
duties. However secondary to this sailor’s extensive history of
psychological trauma, malingering was not suspected and con-
sidered very unlikely.
In 1979, Greilsheimer and Groves21 reviewed all pub-
lished cases of male genital self-mutilation. Although they
questioned the traditional tripartite penile self-harm model of
psychosis, gender need [to occupy the female social role], or
unconscious forces, the model(s) they proposed do not apply
here either. However, 100% of their cases consisted of far
more damage than this patient. Mago22 in his case report of
non-psychotic penile incision, suggested that many non-
psychotic penile self-harmers do it as an outlet during times
of extreme stress. This certainly seems like a possibility in
this case. Although the submarine force has a psychological
screening program, submarine service is physically and men-
tally demanding. In recent years, the Submarine Force loses
an average of 225 sailors each year to mental health issues
(Personal communication, CAPT Matthew Hickey, Medical
Officer of the Submarine Force). In recent years, the subma-
rine force has instituted specific programs in order to help
young sailors develop resilience, and maximizing sailor suc-
cess remains a difficult leadership challenge. In the authors’
experience, this typically manifests itself via depression,
adjustment disorder, or suicidal ideation. Two of these apply
to this patient and the initial presentation should be seen as a
cry for help that both the emergency physicians and the first
author missed because they did not ask probing and uncom-
fortable questions.
Nerli et al23 published a case series of two self-amputations
that seem to bear some semblance to this patient in that both
were posited to be undergoing severe mental stress. In our
case the patient stated, he had cut his penis due to the extreme
emotional stress he had felt while serving aboard the ship. In
the authors’ experience, it is not uncommon that individuals
with trauma earlier in life start to manifest significant effects of
that trauma during their initial tour aboard a submarine.
Treatment for dermatitis artefacta most importantly con-
sists of managing the underlying psychiatric condition of
this psychocutaneous manifestation. In this case, after exten-
sive inpatient and outpatient psychiatric treatment and
MILITARY MEDICINE, Vol. 00, 0/0 2018
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medications, the patient’s depression and anxiety were rela-
tively stable and his suicidal ideation was manageable.
Further, separating from the submarine service and military
removed the stressor. Most importantly from this case, doc-
tors must not hesitate to ask potentially uncomfortable ques-
tions about seemingly minor trauma on the genitals. Perhaps
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this patient would have been more forthcoming had he been
asked on initial presentation.
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