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47 Treatment ofTesticular Trauma: II—Complex Interventions
47.2 Testicular Transplantation
Silber reported the rst experience of human testicular transplantation in 1978in St.
Louis (Missouri, USA) involving two identical adult twins, one of whom was born
with anorchia. When they reached 30 years of age, one testis of the normal twin was
harvested and transplanted to his anarchic brother using a microvascular technique
and the results were encouraging in terms of hormonal function and spermatogenesis [16].
Since then, testicular transplantation has mostly been reported by Chinese surgeons for congenital dysplasia and acquired atrophy with good results as per the
authors [17–19]. This technique is obviously hindered by many reasons: ethical,
technical, practical, and so on [20]. The very purpose of this surgery can also be
questioned. Is it for restoring the bodily image? Or for achieving a good androgen
activity for sexual purposes? Or for fathering a child who will carry the donor’s
genome? A silicon prosthesis would be satisfactory for the bodily image, normal
plasmatic androgen level can be achieved through injection of synthesized molecules allowing normal sexual activities, and the need for a child from another man’s
genome can be fullled by adoption.
References
1. Evins SC, Whittle T, Rous SN.Self-emasculation: review of the literature, report of a case and
outline of the objectives of management. J Urol. 1977;118(5):775–6. https://doi.org/10.1016/
s0022- 5347(17)58190- 2. PMID: 916099.
2. Allegretti E, Luca G, Arato I, Falabella G, Garolla A, Mafa R, Ricci G, Ghezzi M, Alfano
C, Foresta C, Calaore R.Full restoration of spermatogenesis and male fertility after posttraumatic ectopic testis implant. Ann Ital Chir. 2014;85:S2239253X14021860. PMID:
24535695.
3. Loloi J, Gottlieb J, MacDonald SM, Aboumohamed A, Ricci JA, Laudano M, Watts
K.Case—Testicular thigh pouches for severe Fournier’s gangrene: a how-to guide. Can Urol
Assoc J. 2022;16(10):374–6. https://doi.org/10.5489/cuaj.7901. PMID: 35621290; PMCID:
PMC9565065.
4. Okwudili OA.Temporary relocation of the testes in anteromedial thigh pouches facilitates
delayed primary scrotal wound closure in Fournier gangrene with extensive loss of scrotal
skin-experience with 12 cases. Ann Plast Surg. 2016;76(3):323–6. https://doi.org/10.1097/
SAP.0000000000000505. PMID: 25785387.
5. Rodríguez Costa A, Romeo C, López G De Viedma A, Agra Cadarso B.Amputación testicular traumática. Reimplantación con éxito mediante microcirugía [Traumatic amputation of
the testicle. Successful reimplantation using microsurgery (author’s transl)]. An Esp Pediatr.
1978;11(12):865–7. Spanish. PMID: 742770.
6. Giuliani L, Carmignani G, Belgrano E, Puppo P. Autotransplantation de testicules dans la
cryptorchidie abdominale. J Urol. 1981;87(5):279–81.
7. Shioshvili T.I: A case of successful replantation of testis after autohemicastration. Eur Urol.
1987;13:285–6. https://doi.org/10.1159/000472797.
8. Xu YM, Wu P, Cai PC, Cheng ZC. Replantation of the testis: report of a case. J Urol.
1988;139(3):596–8. https://doi.org/10.1016/s0022- 5347(17)42539- 0. PMID: 3343750.
9. Altarac S. A case of testicle replantation. J Urol. 1993;150(5 Pt 1):1507–8. https://doi.
org/10.1016/s0022- 5347(17)35828- 7. PMID: 8411440.
References
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10. Starmer BZ, Baird A, Lucky MA.Considerations in fertility preservation in cases of testicular
trauma. BJU Int. 2018;121(3):466–71. https://doi.org/10.1111/bju.14084. Epub 2017 Dec 10.
PMID: 29164757.
11. Tuncer FB, Frautschi RS, Lundy SD, Haber GP, Gastman B.First report of testicular replantation following wrong-site surgery. Urology. 2022;164:267–72. https://doi.org/10.1016/j.urol-
ogy.2021.11.044. Epub 2022 Feb 1. PMID: 35114199.
12. Grifths M, Britto J, Frame J. 5-Year follow-up of replantation of penis and testis in a child.
Lancet. 2003;361(9353):263. https://doi.org/10.1016/S0140- 6736(03)12302- 1. PMID:
12547580.
13. Ramdas S, Thomas A, Arun Kumar S. Temporary ectopic testicular replantation, refabrication and orthotopic transfer. J Plast Reconstr Aesthet Surg. 2007;60(7):700–3. https://doi.
org/10.1016/j.bjps.2007.01.074. Epub 2007 May 29. PMID: 17526441.
14. Onofre J, Baert Y, Faes K, Goossens E.Cryopreservation of testicular tissue or testicular cell
suspensions: a pivotal step in fertility preservation. Hum Reprod Update. 2016;22(6):744–61.
https://doi.org/10.1093/humupd/dmw029. Epub 2016 Aug 27. PMID: 27566839; PMCID:
PMC5099994.
15. Kilcoyne KR, Mitchell RT.FERTILITY PRESERVATION: testicular transplantation for fertility preservation: clinical potential and current challenges. Reproduction. 2019;158(5):F1–F14.
https://doi.org/10.1530/REP- 18- 0533. PMID: 30844751.
16. Silber SJ. Transplantation of a human testis for anorchia. Fertil Steril. 1978;30(2):181–7.
PMID: 680196.
17. Zhao GX, Bai YX, Yang TS, He CQ, Chen YT, Qiao BP, Jiang HY.Homotransplantation of
testis. A report of 11 cases. Chin Med J (Engl). 1993;106(12):907–10. PMID: 8143508.
18. Zhang Y, Jin FS, Li QS, Sun HZ, Zhu FQ, Zhang KQ.Testis homotransplantation: a report of
12 cases. Zhonghua Nan Ke Xue. 2008;14(3):248–50. Chinese. PMID: 18488341.
19. Zhan B, Wang L, Zhang X, Sun Y, Chen M.Homotransplantation of testis: experimental study
and clinical practice (13 case reports). Transplant Proc. 1988;20(1 Suppl 1):918–21. PMID:
3347960.
20. Lee S, Mao L, Wang Y, D’Silva M, Yoo CH, Wolf P, Chung WS, Takahashi E, Chung DY,
Gittes RF. Transplantation of reproductive organs. Microsurgery. 1995;16(4):191–8. https://
doi.org/10.1002/micr.1920160406. PMID: 7674907.
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Prevention, Complications,
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andFollow-Up ofScrotal andTesticular
48
Trauma
In general, violent events are difcult to prevent. However, as blunt testicular trauma
is associated with sports in the young population, the question of scrotal protection
(athletic cup) in these activities has been raised by many researchers [1, 2]. In the
army, after noticing an increase in casualties involving unprotected anatomical
areas such as the pelvis or external genitalia in recent wars (Afghanistan and Iraq),
it was decided to add a detachable genital ap on the Kevlar armor in 2004 [3].
Severe scrotal and testicular injuries expose the patients to the same systemic
early complications as any other severe trauma. A review of the American National
Trauma Data Bank (NTDB) revealed the following intra-hospital complications following testicular trauma: pneumonia (3.1%), deep vein thrombosis (2.3%), acute
respiratory distress syndrome (ARDS) (1.6%), and acute kidney injury (1.6%).
Other less frequent complications include urinary tract infection, pulmonary embolism, severe sepsis, myocardial infarction, unplanned intubation, and ICU admission. The mortality rate was 7.6% [4, 5].
Testicular torsion has been reported as a possible consequence of trauma with an
occurrence of 4–8%. This strengthens the indication of ultrasonography and the
early exploratory approach in patients presenting with scrotal pain and scrotal
swelling after blunt trauma [6].
The post-testicular trauma patient should be followed up psychologically, physically, hormonally, and radiologically. His sexual life and fertility should be assessed
by blood tests and semen analysis. And because of the breach in the blood–testis
barrier, anti-sperm antibodies should also be assayed if technically possible.
Ultrasonography should be performed at regular intervals (3–6months) to detect
testicular atrophy.
For long-term complications, short series showed that blunt trauma was found to
cause testicular atrophy in as much as 13–56% of cases [7–9]. The majority of the
patients (75%) had subfertile semen analysis despite having a normal hormonal
status and only a very small percentage (12.5%) had anti-sperm antibodies [8].
Residual pain is another long-term complication and is observed in 10% of cases [9].
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari. Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_48
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48 Prevention, Complications, andFollow-Up ofScrotal andTesticular Trauma
References
1. Dalton DM, Davis NF, O’Neill DC, Brady CM, Kiely EA, O’Brien MF.Aetiology, epidemiol-
ogy and management strategies for blunt scrotal trauma. Surgeon. 2016;14(1):18–21. https://
doi.org/10.1016/j.surge.2014.06.006. Epub 2014 Aug 21. PMID: 25151340.
2. Bieniek JM, Sumfest JM. Sports-related testicular injuries and the use of protective equip-
ment among young male athletes. Urology. 2014;84(6):1485–9. https://doi.org/10.1016/j.urol-
ogy.2014.09.007. PMID: 25432843.
3. Hudak SJ, Morey AF, Rozanski TA, Fox CW Jr. Battleeld urogenital injuries: changing pat-
terns during the past century. Urology. 2005;65(6):1041–6. https://doi.org/10.1016/j.urol-
ogy.2004.11.031. PMID: 15913731.
4. Grigorian A, Livingston JK, Schubl SD, Hasjim BJ, Mayers D, Kuncir E, Barrios C,
Joe V, Nahmias J. National analysis of testicular and scrotal trauma in the USA. Res Rep
Urol. 2018;10:51–6. https://doi.org/10.2147/RRU.S172848. PMID: 30128306; PMCID:
PMC608960.
5. Vidhate S, Pathak H, Deokar R.Death of a pedestrian due to fatal scrotal trauma: a case report.
Int J Med Toxicol Forensic Med. 2016;6(2(Spring)):108–11. https://doi.org/10.22037/ijmtfm.
v6i2(Spring).10447.
6. Seng YJ, Moissinac K.Trauma induced testicular torsion: a reminder for the unwary. Emerg
Med J. 2000;17:381–2.
7. Cross JJ, Berman LH, Elliott PG, Irving S. Scrotal trauma: a cause of testicular atrophy.
Clin Radiol. 1999;54(5):317–20. https://doi.org/10.1016/s0009- 9260(99)90562- 7. PMID:
10362239.
8. Kukadia AN, Ercole CJ, Gleich P, Hensleigh H, Pryor JL. Testicular trauma: potential
impact on reproductive function. J Urol. 1996;156(5):1643–6. https://doi.org/10.1016/
s0022- 5347(01)65472- 7. PMID: 8863560.
9. Kleinclauss F, Martin M, Chabannes E, Bernardini S, Della Negra E, Bittard H.Traumatismes
testiculaires: à propos de 56 cas. Prog Urol. 2001;11:486–91.
Part VII
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Male Genital Self-Mutilation: Immersion into a
Transhistorical, Ubiquitous, and Multicultural
Madness
The only antidote to mental suffering is physical pain
Karl Marx (1818–1883)
Introduction toMale Genital Self-Mutilation
Male genital mutilation is an incredibly old phenomenon in which the limitless
insanity and cruelty of humans are matched only by their vivid imagination and
their sake of justication from their Gods. Its origins can be traced to the Egyptian,
Greek, Roman, and Ancient India mythologies where deities were depicted cursing
and punishing each other through castration or attempting to raise their powers by
self-amputating the so-called impure and devilish organs [1].
Outside the mythology context, castration was historically a social means to
enfeeble captive enemies and criminals or to prepare prepubescent boys for special
activities (singer, guardian of harem). In ancient Egypt, Rome, Greece, the Ottoman
empire, China, etc. castration was very frequent, and the phenomenon continued for
centuries only to progressively disappear in the modern era. The consented procedures for non-psychotic persons performing “self-purication” to worship their
gods have almost disappeared as a mass phenomenon in the world (Skoptsy in
Russia) except in India where they are still present through the Hijras who are now
recognized by the legal authorities as the third gender [2]. The Chinese counterpart
of this phenomenon where the individuals were devoted to the Emperor’s court has
completely disappeared (Imperial Eunuchs) [3].
Apart from the Hijras and other eunuchs outside India, cases of male genital
self-mutilation (GSM) are rare, being reported sporadically and their main underlying factors are psychiatric imbalances with or without religious delusions and
transsexualism.
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The present study is an overview of the phenomenon of male GSM, addressing
its mythological and historical origins, and progressing to its modern aspects
through a review of its etiological factors, anatomic pathology, management, and
prognosis.
For self-orchidectomy, the treatment is based on hemostasis and scrotal closure
when one or both testes have been removed. Reanastomosis of the testicular artery
and vas deferens are performed exceptionally. For penile severance, in some cases,
the treatment consists of debridement of the stump if having enough length, or
perineal urethrostomy if the full length of the organ was lost. In other cases where
the amputated penis is viable and a local competence is available, replantation
(macro or microsurgical) is performed with variable successes. To ensure the success of surgical treatment and prevent GSM recurrence, early psychiatric manage-
ment in acute presentation, as well as a close follow-up is of paramount importance.
Despite the scarceness of reported GSM incidents, it is likely that every urologist
will encounter a case of this malady once in his/her career and it is therefore important for him/her to be mentally, scientically, and technically prepared for its
management.
This topic would have t within the relevant sections on genital trauma (urethral,
penile, scrotal, and testicular injuries). However, a decision was taken to develop it
as a separate entity given its numerous particularities from etiology to the
management.
Male Genital Self-Mutilation: Immersion into a Transhistorical, Ubiquitous, and…
References
1. Wade J.The castrated gods and their castration cults: revenge, punishment, and
spiritual supremacy.Int J Transpersonal Stud. 2019;38(1).
2. Mal S.The Hijras of India: a marginal community with paradox sexual identity.
Indian J Soc Psychiatry. 2018;34:79–85.
3. Cartwright M. Eunuchs in ancient China. World History Encyclopedia, 27 Jul
2017. Web. 25 Jun 2021.
Genital Self-Mutilation inMythology
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49
Ancient civilizations’ mythology is strewn with conict tales among Gods and
between Gods and humans that often ended in emasculation. Further myths and
legends depict self-castrating Gods or worshippers obeying some Goddess
injunctions.
It is unanimously admitted that the very rst genital amputations were reported
from the Egyptian theogony where the God Osiris was murdered and emasculated
by his brother Set. It did not take long for Osiris’ son Horus to avenge his father by
castrating his uncle Set. Another myth originated in Anatolia from the HurriansHittites where Kumarbi overthrew his father Anu, bitted, and swallowed his genitals. In the Greek pantheon, Ouranos was castrated by one of his sons, the Titan
Kronos (Saturn) avenging for having been imprisoned by the former. Following this
assault, Kronos threw his father’s testes into the sea, provoking a foaming that
engendered Aphrodite (Venus), the Goddess of beauty and sexual love. Another
case is the reciprocal emasculation of a Phrygian king and Attis, the priest, and lover
of the Anatolian or Phrygian Goddess Cybele, during a ght. Following the battle,
Attis died, and the Goddess Cybele ordered all the priests to honor his memory by
becoming eunuchs according to one of the many contradictory versions. These
eunuch priests were henceforth referred to as “Galli.” In Hierapolis, the Goddess
Astarte’s cult was remarkably similar to that of Cybele, and historians have observed
many men sacricing their genitals during the paroxysm of their ecstasies [1, 2].
Interestingly, there is also a mythological report of self-castration by Combabus
to escape from the dangerous seduction of the Assyrian Queen Stratonice. With a
similar motivation, Eshmum, a Phoenician beautiful young man who was fond of
hunting, castrated himself to escape from the Goddess Astronoë harassment. He
died following his injury, and the Goddess brought him back to life as the God of
healing.
Similar tales are found in India where the God Indra, a very sexually active deity,
was cursed by the sage and ascetic Gautama Maharishi as a punishment for committing adultery with his wife Ahalya. Indra lost his male genitalia, and his body was
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_49
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49 Genital Self-Mutilation inMythology
covered with a thousand vulvae, later on changed into eyes, while Ahalya was petried. The Indian God Shiva performed self-phallectomy to demonstrate his lack of
interest in sexual attraction and kept his penis as a holy object for his worshippers.
The Goddess Bahuchara Mata self-ablated her breasts preferring death to dishonor
when her caravan was attacked by a bandits’ gang. Later, the aggressors worshiped
her by self-mutilating their genitals, pioneering the Hijra phenomenon that is still
active nowadays [1–3].
Not satised by attributing to Gods the origin of castration (either involuntary or
voluntary and self-inicted), humans also believed that certain animals were selfcastrating. The more the merrier. Hence, old Egyptian and Roman tales stated that
beavers used to cut off their testicles when chased by hunters to leave them as prey
and save their lives [4]. Although this beavers’ behavior has never been corroborated by observations, it is important to know that modern scientic studies have
proved the existence of self-penectomy in mice [5].
References
1. Casadio G. The failing male god: emasculation, death and other accidents in the ancient
Mediterranean world. Numen. 2003;50(3):231–68. www.jstor.org/stable/3270488.
2. Androutsos G, Marketos S.La castration à travers les âges. Andrologie. 1993;3(1):61–6.
3. Wade J.The castrated gods and their castration cults: revenge, punishment, and spiritual
supremacy. Int J Transpers Stud. 2019;38(1). https://doi.org/10.24972/ijts.2019.38.1.31
4. Jonckheere F. L’Eunuque dans l’Égypte pharaonique. Revue d’Histoire des Sciences.
1954;7(2):139–55.
5. Hong CC, Ediger RD.Self-mutilation of the penis in C57BL/6N mice. Lab Anim. 1978;12:55–7.
Male Castration inHistory
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50
Male genital amputation or castration has been widely performed since the dawn of
time, especially in the ancient peri-Mediterranean civilizations for multiple reasons:
Weakening the enemies, punishing for misconduct, preparing young boys for future
specic professions (harem guardians, singers…) or for sexual objectication.
Three varieties of eunuchs were recognized in antiquity: (1) Castrati, clean-cut,
both penis and testicles were removed; (2) Spadones, testicles only were removed;
and (3) Thlibiae, testicles were bruised and/or crushed [1–3]. Only ancient
Subsaharan Africa, pre-Colombian America, and pre-colonial Oceania seem to be
spared by this phenomenon possibly due to underreporting.
As will be discussed hereafter, all three monotheist religions (Judaism,
Christianity, and Islam) strongly prohibit castration. Nonetheless, many of their
respective members have been involved directly or indirectly in this phenomenon
throughout human history.
50.1 Pharaonic Egypt
The existence of eunuchs in ancient Egypt serving various purposes such as women
guardians, servants, scribes, priests, and singers is still subject to debate, but there
appears to be evidence tending to corroborate this fact and even the existence of
self-castrated individuals. Horapollon mentioned in his Hieroglyphica about
Egyptians “If they want to portray a male who commits the crime of mutilating
himself, they draw a beaver: because the latter, when chased (by hunters), tears off
its own testicles and leaves them behind as prey” [2].
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
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50 Male Castration inHistory
50.2 Mesopotamia andPersian Empire
The existence of Eunuchs in the Sumerian, Babylonian, Assyrian, and Persian
empires is robustly established since the fourth Millennium in association with the
cult of the Sumerian Goddess Inanna or Ishtar [4]. In the Hammurabi code
(2000BC), castration was the sanction reserved for sexual criminals.
50.3 Greece
It is believed that the concept of castration was introduced in Greece by Phoenicians
who brought Eunuchs from Asian countries [5].
50.4 Roman andByzantium Empires
Roman empire expansion resulted in the adoption of deities and religions from
some conquered territories, including the cult of Cybele, considered the Great
Mother of Gods. The consequence was the increased number of self-castrations for
men and self-mastectomies for women during ceremonies in the honor of Cybele.
There is a castration bronze clamp shed out from the Thames in London proving
that the cult has been practiced even in old Roman Britain (Fig.50.1).
By the year 81 Before Christ, the Roman General and Consul Lucius Cornelius
Sulla enacted a law prohibiting this practice on Roman soil [6].
Epiphanius of Salamis reported on the history of the Valesians, a heretic Christian
sect that advocated self-castration in the second to third century AD. Very little
information is known about these insane men who were also known to forcibly
castrate travelers whom they encountered or guests who visited them. They are
thought to have lived in the land of Philadelphia, the old name of the Jordan Capital
city Amman during the Greek and Roman periods. Disciples of this sect were not
allowed to eat meat until they underwent castration [7].
Many castrates were still imported from outside the roman empire, as the demand
for slaves and eunuchs especially as “Cubicularii” (chamberlains) did not decrease.
Despite the prohibiting laws edited by successive Emperors, the phenomenon persisted up to the reign of the Christian Emperor Justinian I (527–565) who published
a series of more severe and dissuasive laws stipulating that men who castrate others
would be punished by the mutilation of their genitals, will be sent to exile, and their
property would be conscated. And women who perform castration will be permanently banished and their properties will be conscated [6]. Certain Eunuchs occupied remarkably high functions in the roman administration, the so-called
Praepositus sacri cubiculi (Grand Chamberlain), to the point that some researchers
stated that “in the Eastern Empire especially, the real power lay in the hands not of
the emperor nor of his aristocrats, but of his chief eunuch” [6, 8].
Despite being discouraged by Christianity, the phenomenon was still present in
the Middle Ages in the Byzantium empire where slaves were castrated in childhood
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