Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome

Samuel Chibuzo Ajekwu; Sunday Olurotimi Ogundiniyi; Mustafa Yakubu Aliyu; Joshua Falade

doi:doi:10.11648/j.js.20251302.11

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Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome

Samuel Chibuzo Ajekwu^*

, Sunday Olurotimi Ogundiniyi

, Mustafa Yakubu Aliyu

, Joshua Falade

Published in Journal of Surgery (Volume 13, Issue 2)

Received: 13 February 2025 Accepted: 28 February 2025 Published: 18 March 2025

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Abstract

We present an uncommon case of genital mutilation in a 24 year old Nigerian man who presented to the Accident and Emergency Wing of our hospital on account of self-inflicted complete penile amputation and scrotal avulsion injury without the amputated stump, following an episode of auditory hallucination. There was a background history of substance abuse. He had initial resuscitation with intravenous fluid and a pint of blood transfused on account of low hematocrit. He was equally evaluated by the Mental Health Physician at presentation. The wound was packed with saline soaked gauze for further exploration in the operating room. Tetanus injection was administered. Intra – operatively under regional anesthesia, wound exploration, thorough irrigation with saline and wound debridement was done with findings of penile stump exposing the cavernous body and urethra, as well as the testes in situ. A stump refashioning using the scrotal skin flap was done and a neo-urethral created with the use of absorbable vicryl 3/0 sutures. The wound healed satisfactorily, voiding per urethra and was discharged on day 10 after surgery. This report reveals refashioning of the stump as a viable treatment option using a scrotal skin flap in the absence of an amputated stump or facility for micro vascular repair. It also points out this syndrome as one of the rare complication of drug induced psychosis.

Published in	Journal of Surgery (Volume 13, Issue 2)
DOI	10.11648/j.js.20251302.11
Page(s)	37-40
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2025. Published by Science Publishing Group

Keywords

Genital Self- Mutilation, Klingsor Syndrome, Penile Amputation, Stump Refashioning, Substance Abuse

1. Introduction

Genital self-mutilation (GSM) in men otherwise referred to as klingsor syndrome is quite rare. It is indeed an uncommon urological condition

[1]

and equally an emergency that requires a prompt intervention to restore hemodynamic stability, but more importantly a functional micturition, reproductive and cosmetic outcome.

Very rare and few cases have been reported in the literature

[1]

. This condition, most often than not have a background psychopathology as the underlying cause beyond bizarre religious belief, which is the premise for the initial definition

[2]

. Substance abuse psychosis and mental illnesses stood out as the predominant features in individuals with GSM reported thus far. A recent published report in the literature of a young Nigerian man by Odeyemi et al revealed a background substance abuse.

The type of penile amputation depends on the level of severance of the phallus. It is described as peri-pubic, proximal phallus or glans amputation. The latter is commonly seen in children following circumcision mishap.

The case of individuals with GSM requires a multi- disciplinary approach. The bleeding associated with the injury makes the initial resuscitation mandatory to ensure hemodynamic stability. The Mental Health Physician’s review is equally important in order to achieve mood stabilization. The definitive care depends on a lot of factors. The availability of the amputated stumps, micro vascular skills and the time of presentation. The surgical options include penile reimplantation, penile reconstruction and stump refashioning

[3-6]

. In a low resource setting and the absence of amputated stump, the last option may be the only option. In addition, diligent follow up is required.

2. Case Presentation

A 24 year old unemployed unmarried man with a background history of substance abuse presented with self-mutilated external genital with a knife following an episode of auditory hallucination. On arrival at home, he was brought to the Emergency Unit of the hospital hours after the incident by the relatives, however, without the penile stump, which could not be located.

He was disoriented at presentation with unstable hemodynamic status and underwear soaked with blood. Blood loss could not be quantified but the hematocrit was 25%. Initial fluid resuscitation was instituted and a pint of fresh whole blood was transfused (and was fully optimized). Broad spectrum parenteral antibiotic was administered as well as tetanus toxoid injection. Genitalia was packed with wet gauze. He had a review by the mental health physician.

Genital wound exploration and stump refashioning was scheduled in the operation room under regional anesthesia. The urethral was catheterized with size 16FR Foley’s catheter. Findings showed a significant loss of penile shaft with the skin exposing the corpora cavernosa and scrotal avulsion, but with intact testes (Figure 1). A thorough saline irrigation of the wound was done, followed by debridement of the edges. The avulsed scrotal skin was used to achieve penile cover – scrotal skin was fenestrated and urethrocutaneous anastomosis with vicryl 3/0 suture was done to form a neo external urethral meatus (Figure 2). Satisfactory wound healing was achieved, urethral catheter was discontinued and discharged home on post-operative day 10 well oriented (figure 3). Currently, patient can void satisfactorily and he is being followed up for possible reconstruction to divide the flap for feasible reproductive function (Figure 4).

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Figure 1. Pre-operative view.

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Figure 2. Post-operative stump refashioning on table.

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Figure 3. Post-operative day 7.

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Figure 4. Post-operative day 45 (6+ weeks post op).

3. Discussion

Male genital mutilation is an uncommon occurrence especially the self-inflicted ones which the literature has coined as klingsor syndrome

[1]

. This pathology is unlike the female genital mutilation, which is very common and widely documented in the literature. The first reported case in literature was in 1901 by Strock

[7]

. It is primarily involvement of the penile shaft, however, may extend to the scrotum as reported in this case. The name, Klingsor, was a reference to a German opera character who self-castrated in order to belong to the Knights brotherhood

[1]

. The initial definition of this syndrome was limited to genital self-mutilation premised a bizarre religious belief. In 1990, Schweitzer posited the extension of the definition to include any causes of psychopathology like schizophrenia, depressive disorders, sexual identity crisis and substance or drug abuse

[2]

. The later was the situation in the index case.

There is no clear cut documented incidence because of the rarity, however, Eke posited the incidence to be an average of 3 cases per year

[7]

. What is obtainable are pockets of report from centers and countries. In Nigeria, the first mention of GSM in the literature was in 1973 by Anumonye in two men

[7]

. Over the past decades, there has been very few reported cases in Nigeria. There is a recent published report by Odeyemi et al

[3]

with a similar clinical background as the index case. GSM has no racial predilection or preponderance. It has been reported across all races

[1, 3, 5, 6, 8]

The index patient was a young man, in his early twenties. In view of the background substance abuse, this is the age of youthful vices and experimentation in search for fulfillment as well as identity crisis. Majority of cases reported thus far, revealed the third decades of life as the predominant age of presentation – within which the young man falls

[3, 4, 6, 8]

^. Some have reported cases outside this age group in older adults

[1, 9, 10]

The outcome for those who presented to the hospital with the penile stump in terms of erectile, reproductive, urinary and cosmetic function are satisfactorily documented especially in center with micro vascular setups and skills for penile reimplantation, despite the ischemic time

[1, 9-11]

. However, this is not so in some cases like the index case, where the only available option of intervention based on the clinical presentation was the refashioning of the stump with the aid of the avulsed scrotal skin flap. Boualaoui et al

[6]

used the Rudy and Border technique - a vascularized dorsal skin flap in their case report. The facility for micro vascular procedure was not readily available in our center. Hence, this calls for an institutional investment in manpower and facility that will enable penile reimplantation in case of future occurrence. This will ensure quality reproductive function and outcome.

Substance abuse psychosis is a well-documented findings amongst young adults with increasing incidence

[12-14]

. There is need with this reported case, to ensure a social re-engineering regarding the dangers of substance or drug abuse in the society to forestall such a rare complication with devastating consequences.

4. Conclusion

Genital self –mutilation with background psychopathology, otherwise known as Klingsor syndrome is an uncommon urological emergency. It is predominant among young adults with substance abuse as the denominator. The surgical care can be challenging. In a low resource setting and in the absence of the amputated distal stump, refashioning of the stump with a scrotal flap as demonstrated in this report is a viable surgical option. There is a need to curtail the increasing tide of substance abuse to forestall this complication.

Abbreviations

GSM	Genital Self-Mutilation

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Menakuru S, Ali MI, Karasala K. Genitalia self-mutilation commanded by hallucinations: a psychointensive case of Klingsor syndrome. Case Rep. 2018; 2018: bcr. https://doi.org/10.1136/bcr-2018-226838
[2]	Schweitzer I. Genital self-amputation and the Klingsor syndrome. Aust N Z J Psychiatry. 1990; 24(4): 566–9. https://doi.org/10.3109/00048679009062914
[3]	Odeyemi PO, Idowu NA, Abiola OO, Okunade IA. Genital self-mutilation following cannabis-induced psychosis: Klingsor syndrome – a case report. Afr Urol. 2024; 4(1): 36–9. https://doi.org/10.36303/auj.0121
[4]	Aggarwal G, Adhikary SD. Klingsor syndrome: A rare surgical emergency. Ulus Travma Ve Acil Cerrahi Derg Turk J Trauma Emerg Surg TJTES. 2017; 23(5): 427–9. https://doi.org/10.5505/tjtes.2017.30346
[5]	Ishida O, Ikuta Y, Shirane T, Nakahara M. Penile replantation after self-inflicted complete amputation: case report. J Reconstr Microsurg. 1996; 12(1): 23–6. https://doi.org/10.1055/s-2007-1006448
[6]	Boualaoui I, Bote HE, Bellouki O, Ibrahimi A, Sayegh HE, Nouini Y. Rudy and Borden technique for penile self-mutilation in Klingsor syndrome: a case report. Pan Afr Med J. 2021; 38. https://doi.org/10.11604/pamj.2021.38.334.28897
[7]	Eke N. Genital self-mutilation: there is no method in this madness. BJU Int. 2000; 85(3): 295–8. https://doi.org/10.1046/j.1464-410x.2000.00438.x
[8]	Park SC, Park YC, Choi J. A case of Klingsor syndrome in Korea. Psychiatry Clin Neurosci. 2011; 65(7): 680–1. https://doi.org/10.1111/j.1440-1819.2011.02278.x
[9]	Salem MSEK, Alherek A, Muangalayi F, Tshiala AK, Mukendi AM. Successful penile reimplantation after 8 h post penile self‐mutilation: A case report. Clin Case Rep. 2023; 11(6): e7565. https://doi.org/10.1002/ccr3.7565
[10]	Syahrir S, Palinrungi MA, Kholis K, Syarif, Faruk M, Christeven R. Partial penile amputation due to Klingsor syndrome: A case report with a successful macroscopic reconstruction. Int J Surg Case Rep. 2020; 77: 387–91. https://doi.org/10.1016/j.ijscr.2020.10.141
[11]	Eric MM, Hadidjatou O, Agounkpe M, Martin HF, et al. Klingsor Syndrome: An Observation in a Patient with Schizophrenia. Open J Urol. 2024; 14(5): 346–51. https://doi.org/10.4236/oju.2024.145036
[12]	Fiorentini A, Cantù F, Crisanti C, Cereda G, Oldani L, Brambilla P. Substance-Induced Psychoses: An Updated Literature Review. Front Psychiatry. 2021; 12. https://doi.org/10.3389/fpsyt.2021.694863
[13]	H H, Chukwu EO, A I, Rt R, B M, N L. Prevalence of Drug-Induced Psychosis Among Youths Aged (15-30) Years in Maiduguri Metropolitan Council, Admitted in Federal Neuro-Psychiatric Hospital Maiduguri. J Addict Behav Ther. 2(2): 0–0.
[14]	Rognli EB, Taipale H, Hjorthøj C, Mittendorfer-Rutz E, Bramness JG, Heiberg IH, et al. Annual incidence of substance-induced psychoses in Scandinavia from 2000 to 2016. Psychol Med. 2023; 53(11): 5246–55. https://doi.org/10.1017/s003329172200229x

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APA Style

Ajekwu, S. C., Ogundiniyi, S. O., Aliyu, M. Y., Falade, J. (2025). Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome. Journal of Surgery, 13(2), 37-40. https://doi.org/10.11648/j.js.20251302.11

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ACS Style

Ajekwu, S. C.; Ogundiniyi, S. O.; Aliyu, M. Y.; Falade, J. Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome. J. Surg. 2025, 13(2), 37-40. doi: 10.11648/j.js.20251302.11

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AMA Style

Ajekwu SC, Ogundiniyi SO, Aliyu MY, Falade J. Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome. J Surg. 2025;13(2):37-40. doi: 10.11648/j.js.20251302.11

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@article{10.11648/j.js.20251302.11,
  author = {Samuel Chibuzo Ajekwu and Sunday Olurotimi Ogundiniyi and Mustafa Yakubu Aliyu and Joshua Falade},
  title = {Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome
},
  journal = {Journal of Surgery},
  volume = {13},
  number = {2},
  pages = {37-40},
  doi = {10.11648/j.js.20251302.11},
  url = {https://doi.org/10.11648/j.js.20251302.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.js.20251302.11},
  abstract = {We present an uncommon case of genital mutilation in a 24 year old Nigerian man who presented to the Accident and Emergency Wing of our hospital on account of self-inflicted complete penile amputation and scrotal avulsion injury without the amputated stump, following an episode of auditory hallucination. There was a background history of substance abuse. He had initial resuscitation with intravenous fluid and a pint of blood transfused on account of low hematocrit. He was equally evaluated by the Mental Health Physician at presentation. The wound was packed with saline soaked gauze for further exploration in the operating room. Tetanus injection was administered. Intra – operatively under regional anesthesia, wound exploration, thorough irrigation with saline and wound debridement was done with findings of penile stump exposing the cavernous body and urethra, as well as the testes in situ. A stump refashioning using the scrotal skin flap was done and a neo-urethral created with the use of absorbable vicryl 3/0 sutures. The wound healed satisfactorily, voiding per urethra and was discharged on day 10 after surgery. This report reveals refashioning of the stump as a viable treatment option using a scrotal skin flap in the absence of an amputated stump or facility for micro vascular repair. It also points out this syndrome as one of the rare complication of drug induced psychosis.
},
 year = {2025}
}

Copy | Download

TY - JOUR
T1 - Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome

AU - Samuel Chibuzo Ajekwu
AU - Sunday Olurotimi Ogundiniyi
AU - Mustafa Yakubu Aliyu
AU - Joshua Falade
Y1 - 2025/03/18
PY - 2025
N1 - https://doi.org/10.11648/j.js.20251302.11
DO - 10.11648/j.js.20251302.11
T2 - Journal of Surgery
JF - Journal of Surgery
JO - Journal of Surgery
SP - 37
EP - 40
PB - Science Publishing Group
SN - 2330-0930
UR - https://doi.org/10.11648/j.js.20251302.11
AB - We present an uncommon case of genital mutilation in a 24 year old Nigerian man who presented to the Accident and Emergency Wing of our hospital on account of self-inflicted complete penile amputation and scrotal avulsion injury without the amputated stump, following an episode of auditory hallucination. There was a background history of substance abuse. He had initial resuscitation with intravenous fluid and a pint of blood transfused on account of low hematocrit. He was equally evaluated by the Mental Health Physician at presentation. The wound was packed with saline soaked gauze for further exploration in the operating room. Tetanus injection was administered. Intra – operatively under regional anesthesia, wound exploration, thorough irrigation with saline and wound debridement was done with findings of penile stump exposing the cavernous body and urethra, as well as the testes in situ. A stump refashioning using the scrotal skin flap was done and a neo-urethral created with the use of absorbable vicryl 3/0 sutures. The wound healed satisfactorily, voiding per urethra and was discharged on day 10 after surgery. This report reveals refashioning of the stump as a viable treatment option using a scrotal skin flap in the absence of an amputated stump or facility for micro vascular repair. It also points out this syndrome as one of the rare complication of drug induced psychosis.

VL - 13
IS - 2
ER -

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Author Information

Samuel Chibuzo Ajekwu

Department of Surgery, University of Medical Sciences Teaching Hospital, Ondo, Nigeria

Contact Email

http://orcid.org/0000-0003-3085-1220
Sunday Olurotimi Ogundiniyi

Department of Surgery, University of Medical Sciences Teaching Hospital, Ondo, Nigeria

http://orcid.org/0000-0001-8636-9674
Mustafa Yakubu Aliyu

Department of Surgery, University of Medical Sciences Teaching Hospital, Ondo, Nigeria

http://orcid.org/0009-0006-8525-3489
Joshua Falade

Department of Mental Health, University of Medical Sciences Teaching Hospital, Ondo, Nigeria

http://orcid.org/0000-0002-6612-0705

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APA Style

Ajekwu, S. C., Ogundiniyi, S. O., Aliyu, M. Y., Falade, J. (2025). Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome. Journal of Surgery, 13(2), 37-40. https://doi.org/10.11648/j.js.20251302.11

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ACS Style

Ajekwu, S. C.; Ogundiniyi, S. O.; Aliyu, M. Y.; Falade, J. Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome. J. Surg. 2025, 13(2), 37-40. doi: 10.11648/j.js.20251302.11

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AMA Style

Ajekwu SC, Ogundiniyi SO, Aliyu MY, Falade J. Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome. J Surg. 2025;13(2):37-40. doi: 10.11648/j.js.20251302.11

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@article{10.11648/j.js.20251302.11,
  author = {Samuel Chibuzo Ajekwu and Sunday Olurotimi Ogundiniyi and Mustafa Yakubu Aliyu and Joshua Falade},
  title = {Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome
},
  journal = {Journal of Surgery},
  volume = {13},
  number = {2},
  pages = {37-40},
  doi = {10.11648/j.js.20251302.11},
  url = {https://doi.org/10.11648/j.js.20251302.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.js.20251302.11},
  abstract = {We present an uncommon case of genital mutilation in a 24 year old Nigerian man who presented to the Accident and Emergency Wing of our hospital on account of self-inflicted complete penile amputation and scrotal avulsion injury without the amputated stump, following an episode of auditory hallucination. There was a background history of substance abuse. He had initial resuscitation with intravenous fluid and a pint of blood transfused on account of low hematocrit. He was equally evaluated by the Mental Health Physician at presentation. The wound was packed with saline soaked gauze for further exploration in the operating room. Tetanus injection was administered. Intra – operatively under regional anesthesia, wound exploration, thorough irrigation with saline and wound debridement was done with findings of penile stump exposing the cavernous body and urethra, as well as the testes in situ. A stump refashioning using the scrotal skin flap was done and a neo-urethral created with the use of absorbable vicryl 3/0 sutures. The wound healed satisfactorily, voiding per urethra and was discharged on day 10 after surgery. This report reveals refashioning of the stump as a viable treatment option using a scrotal skin flap in the absence of an amputated stump or facility for micro vascular repair. It also points out this syndrome as one of the rare complication of drug induced psychosis.
},
 year = {2025}
}

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TY - JOUR
T1 - Genital Self-Mutilation in a Young Nigerian Man: A Case of Klingsor Syndrome

VL - 13
IS - 2
ER -

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