Clinical Case Studies


Man’s penis turns black after sex partner accidentally bites it

He nearly lost his fruit of the loom.

When a man’s lover accidentally chomped his penis during oral sex, it killed part of his member: A black wound immediately began spreading across the head, a case study published this week in the Visual Journal of Emergency Medicine reports.

“Approximately five days prior, his significant other accidentally bit him on the tip of the penis during sexual intercourse,” says lead study author Marc Zosky, a University of Arizona College of Medicine professor, in a statement. “Since the initial trauma, the patient noted the wound to be worsening in pain and became darker.”

The unnamed 43-year-old patient had no fever and was fine when he drove himself to the emergency room — save the dark mass of rotting tissue spreading across his phallus.

The “necrotic post-traumatic bite wound to the glans” resembled a rotting banana — or a scrawl of black Sharpie marker on the tip of his schlong.

Doctors admitted the man to the hospital, where the urology and infectious disease teams both took a look at his blackening tool and quickly treated him with intravenous antibiotics. There were no drainage issues associated with the wound, the study specifies, and the man was later discharged with an oral antibiotic prescription.

After a month, docs followed up with the patient and found he had made a full recovery with “minimal” deformity of his manhood.

[OA] Zosky M. Necrotic post traumatic bite wound to the glans penis. Visual Journal of Emergency Medicine 2020;18:100702. Necrotic post traumatic bite wound to the glans penis - ScienceDirect

A 43-year-old male presented to the emergency department with a painful wound to his glans penis. Approximately 5 days prior, his significant other accidentally bit him on the tip of the penis during sexual intercourse. Since the initial trauma, the patient noted the wound to be worsening in pain and became darker. On examination, a 3 cm well demarcated black necrotic wound without purulent drainage was present (Fig. 1). The patient was afebrile and otherwise well appearing.
Well this helps define what 'significant other' means. Good thing that he/she/it didn't have lockjaw.

Michael Scally MD

Doctor of Medicine
[OA] 37-Year-Old Man with Fatigue and Erectile Dysfunction

A 37-year-old man presented to the primary care clinic with fatigue, subjective muscle weakness, erectile dysfunction, and decreased libido of several months' duration. These symptoms had progressively worsened over several months. He also reported poor morning erections, decreased motivation, loss of interest in activities he previously found enjoyable, depression, anxiety, sleep disturbance, and snoring. He reported no weight changes, headaches, or vision changes. His medical history was notable for generalized anxiety, gastroesophageal reflux disease, and long-standing obesity.

On physical examination, his blood pressure was 133/86 mm Hg, heart rate was 73 beats/min, and body mass index was 39 kg/m2. His weight had increased 7 kg over 2 years but had been stable for 6 months. Cardiovascular, respiratory, abdominal, and neurologic (including cranial nerve, strength, and sensory) examination results were unremarkable. Neck circumference was 45 cm, and the oropharynx was rated as Mallampati class II. The thyroid gland was nonenlarged, nontender, and had no palpable nodules. The testicles were nontender with normal firmness and size and measured 20 cc bilaterally, with no testicular masses or inguinal hernias noted. The patient's prostate gland was normal in size and morphology. His score on the Patient Health Questionnaire-9 depression screen was 11, indicating moderate depression.

Laboratory evaluation revealed the following (reference ranges provided parenthetically): hemoglobin, 14.3 g/dL (13.2-16.6 g/dL); hematocrit, 43.2% (38.3%-48.6%); hemoglobin A1c, 5.2% (4.0%-5.6%); and creatinine, 0.9 mg/dL (0.74-1.35 mg/dL). Results of liver function testing and a lipid panel were normal. The total testosterone level, checked at 8:20 am, was 168 ng/dL (240-950 ng/dL).

On further questioning, the patient described decreased body hair with less frequent shaving over the preceding several months. He reported normal onset of puberty and development and had 2 biologic children who were conceived with no difficulty. He had no anosmia, previous testicular injury, mumps, local radiation, or current/recent opioid, anabolic steroid, or supplement use. The patient and his wife were not planning to have more children.

Sytsma TT, McCoy RG. 37-Year-Old Man with Fatigue and Erectile Dysfunction. Mayo Clinic Proceedings 2019;94:e85-e90.

Michael Scally MD

Doctor of Medicine
Effect of Testosterone Replacement Therapy on Sarcopenia

LOH syndrome is defined as a combination of low testosterone level, and typical symptoms and signs, such as low sexual desire and erectile dysfunction. It is suggested that clinicians should consider measuring the serum testosterone level when patients present with less specific symptoms and signs, including decreased energy, motivation and depression.

In a population based survey of middle-aged to older men, the prevalence of LOH syndrome was estimated to be approximately 6%, and increased with age. Because many of its symptoms are nonspecific and are often recognized just as geriatric syndrome, it is estimated that more than a few hypogonadal men remain untreated.

Aging is associated with sarcopenia, and serum testosterone level declines with age. Androgens have potent anabolic effects on skeletal muscle; therefore, TRT is reported to increase muscle mass, as well as produce a moderate increase in muscle strength in men. In the present case, the patient’s Skeletal Muscle Index increased by 10% after 6 months of treatment, and grip strength increased by 19% after 1.5 years, consistent with findings of previous studies.

Although prostate-specific antigen was relatively high in the present patient, there was no significant effect of TRT on prostatic cancer, the need for prostate biopsy or significant increase in prostate-specific antigen. However, it is important to continue evaluating the side-effects of TRT.

Because most symptoms of LOH syndrome can be relieved by TRT, the possibility of LOH syndrome should be considered in older male patients who present with less specific symptoms.

Hosoi T, Kojima T, Ishii S, Ogawa S, Akishita M. Effect of testosterone replacement therapy on sarcopenia: Case report of an older man with late-onset hypogonadism. Geriatrics & Gerontology International 2020;20:85-6.


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Michael Scally MD

Doctor of Medicine

An Indian man who went to hospital with abdominal pain had inserted a mobile phone charger cable into his penis, a doctor who treated him told CNN on Monday.

The man visited a hospital in northeastern India last month, claiming he had ingested some earphones, said Dr. Walliul Islam, a general surgeon at the hospital.

But when the cord didn't appear despite the patient being prescribed laxatives, doctors resorted to surgery.

"He came to us after five days, (and) despite passing stool several times the cable did not come out. We then conducted an endoscopy but still couldn't find anything. As the patient complained of severe pain, we decided to perform surgery and found that there was nothing in his intestine," Islam told CNN.

It was at that point that an x-ray revealed the man to have a two-foot-long charging cable in his bladder -- inserted via his urethra, the tube that leads from the penis to the bladder.

"Then I made an incision there and took out the cord, which was actually a charging cable over 2 feet long," Islam said.

"If he had been honest then it would have saved us the trouble and we could have treated him sooner."

The patient has been discharged and is fine, according to Islam.

"I have read that people used to get sexual gratification by inserting instruments through the penis. This is one such case, and the psychiatrist can help him beyond this point," Islam added.

Michael Scally MD

Doctor of Medicine
[OA] Unmasked Testicular Seminoma During Use of Hormonal Transgender Woman Therapy: A Hidden hCG-Secreting Tumor

Management of gender-affirming hormone therapy (HT) in transgender women includes surveillance of testosterone (T) levels. Failure of T to suppress, despite adherence to therapy, warrants additional investigations for unexpected sources of T or factors stimulating T secretion.

Possible causes include T or gonadotropin production by an occult neoplasm. Testicular cancer is the most common malignancy affecting biological men aged between 15 and 35 years. Patients may be asymptomatic until tumor burden is high and/or metastatic.

Hormone-producing tumors have rarely been reported in treated transgender women. Routine screening tests are recommended in a gender-incongruent person as per the 2017 Endocrine Society guidelines with measurement of T levels every 3 months initially to reach a goal of less than 50 ng/dL. Expectations should be discussed in detail with the transgender person since anticipated physical changes may not be notable for 6 to 18 months.

We herein describe a case of a transgender woman who underwent standard HT including gonadotropin suppression with a gonadotropin-releasing hormone agonist, whose total T level failed to suppress. Testing revealed an elevated serum level of the beta subunit of human chorionic gonadotropin (beta-hCG), diagnostic of an hCG-secreting testicular seminoma, as the underlying cause of unexpected T production.

This case illustrates how easily a testicular cancer can remain unnoticed because it can be asymptomatic and the necessity to be alert to, and act on, anomalous laboratory results during treatment of a transgender person.

Elshimy G, Tran K, Harman SM, Correa R. Unmasked Testicular Seminoma During Use of Hormonal Transgender Woman Therapy: A Hidden hCG-Secreting Tumor. J Endocr Soc 2020;4:bvaa074. Unmasked Testicular Seminoma During Use of Hormonal Transgender Woman Therapy: A Hidden hCG-Secreting Tumor

Michael Scally MD

Doctor of Medicine
Clinical Presentation, Management and Follow-Up Of 83 Patients with Leydig Cell Tumors of The Testis

Study question: When should 'not so rare' Leydig cell tumors (LCTs) of the testis be suspected, diagnosed, and treated?

Summary answer: LCTs are more frequent than generally believed, are associated with male infertility, cryptorchidism and gynecomastia, and should be treated conservatively (in compliant patients) with active surveillance, which appears to be a safe alternative to surgical enucleation.

What is known already: Increasing referrals for testicular imaging have led to an increase in findings of LCTs. The features and natural history of these tumors remain largely unknown, as the available studies are small and heterogeneous. LCTs were previously treated aggressively and follow-up data are lacking.

Study design, size, duration: A case-cohort study of consecutive patients diagnosed with LCTs over a 10-year period was prospectively enrolled from 2009 to 2018 and compared to matched cohorts of patients with seminomas or no testicular lesions screened in the same timeframe.

Participants/materials, setting, methods: Of the 9949 inpatients and outpatients referred for scrotal ultrasound, a total of 83 men with LCTs were included. Enrolled subjects underwent medical history and clinical examination and were asked to undergo routine blood tests, hormone investigations (FSH, LH, total testosterone, estradiol, inhibin B, sex hormone-binding globulin (SHBG), prolactin), and semen analysis.

Patients who consented also underwent contrast-enhanced ultrasound, elastography, gadolinium-enhanced scrotal magnetic resonance imaging, and hCG stimulation test (5000 IU i.m.) with serum total testosterone and estradiol measured at 0, 24, 48, and 72 hours.

Main results and the role of chance: In total, 83 patients diagnosed with LCTs were compared against 90 patients diagnosed with seminoma and 2683 patients without testicular lesions (NoL). LCTs were diagnosed by enucleation (48.2%), orchiectomy (13.3%), or clinical surveillance (38.5%).

Testicular volume, sperm concentration, and morphology were lower (P = 0.001, P = 0.001, and P < 0.001, respectively) in patients with LCTs than in the NoL group. FSH, LH, and SHBG were higher and the testosterone/LH ratio was lower in LCTs than in the NoL group (P < 0.001). The LCT group showed higher SHBG (P = 0.018), lower sperm concentration (P = 0.029), and lower motility (P = 0.049) than the seminoma group.

Risk factors for LCTs were cryptorchidism (χ2 = 28.27, P < 0.001), gynecomastia (χ2 = 54.22, P < 0.001), and low testicular volume (χ2 = 11.13, P = 0.001). Five cases were recurrences or bilateral lesions; none developed metastases during follow-up (median, 66 months).

Limitations, reasons for caution: This study has some limitations. First, hCG and second-line diagnostic investigations were not available for all tumor patients. Second, ours is a referral center for infertility, thus a selection bias may have altered the baseline features of the LCT population. However, given that the comparison cohorts were also from the same center and had been managed with a similar protocol, we do not expect a significant effect.

Wider implications of the findings: LCTs are strongly associated with male infertility, cryptorchidism, and gynecomastia, supporting the hypothesis that testicular dysgenesis syndrome plays a role in their development.

Patients with LCTs are at a greater risk of endocrine and spermatogenesis abnormalities even when the tumor is resected, and thus require long-term follow-up and prompt efforts to preserve fertility after diagnosis.

LCTs have a good oncological prognosis when recognized early, as tissue-sparing enucleation is curative and should replace orchiectomy. Conservative surgery and, in compliant patients, active surveillance through clinical and radiological follow-up are safe options, but require monitoring of testicular failure and recurrence.

Pozza C, Pofi R, Tenuta M, et al. Clinical presentation, management and follow-up of 83 patients with Leydig cell tumors of the testis: a prospective case-cohort study. Hum Reprod. 2019;34(8):1389-1403. doi:10.1093/humrep/dez083 Clinical presentation, management and follow-up of 83 patients with Leydig cell tumors of the testis: a prospective case-cohort study

Michael Scally MD

Doctor of Medicine
The Role of Hormone Stimulation in Men with Non-Obstructive Azoospermia Undergoing Surgical Sperm Retrieval

Non obstructive azoospermia, (NOA) is the most common cause of azoospermia. NOA is characterised by hypergonadotrophic hypogonadism, testicular failure, and impaired spermatogenesis. The recent development of surgical sperm retrieval techniques such as microsurgical testicular sperm extraction (mTESE) has, for the first time, allowed some men with NOA to father biological children.

It is common practice for endocrine stimulation therapies such as gonadotrophins, selective oestrogen receptor modulators (SERMs) and aromatase inhibitors to be used prior to mTESE to increase intra-testicular testosterone synthesis with the aim of improving sperm retrieval rates; however, there is currently a paucity of data underpinning their safety and efficacy.

We present two cases of men with NOA undergoing endocrine stimulation therapy and mTESE. We also discuss the current evidence and controversies associated with the use of hormonal stimulation therapy in couples affected by this severe form of male infertility.

Tharakan T, Salonia A, Corona G, Dhillo W, Minhas S, Jayasena C. The role of hormone stimulation in men with non-obstructive azoospermia undergoing surgical sperm retrieval [published online ahead of print, 2020 Aug 18]. J Clin Endocrinol Metab. 2020;dgaa556. doi:10.1210/clinem/dgaa556 role of hormone stimulation in men with non-obstructive azoospermia undergoing surgical sperm retrieval


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