Wednesday, June 24, 2015

Zip injury to the penis: it happens more often than you think!

Zip! And it's done up. The modern zipper provides an easy and convenient means for fastening clothes. An engineer named Gideon Sundback is credited with inventing this ingenious device in 1913. On garments, it was first marketed as a fastener for children’s clothes because of its ease of use. Since then, it has become especially popular for fastening trousers.
Amusingly (or perhaps not), the zipper is not without its dangers. It's not at all uncommon for a boy (or a grown man, for that matter) to have an embarrassing accident while zipping up his fly: a bit of loose skin from the genitals, usually the foreskin, becomes caught between the zipper's teeth.

Between 2002 and 2010, an estimated 17 616 patients presented to US Emergency Departments with trouser zip injuries to the genitals. The penis was almost always the only genital organ involved. Zipper injuries represented nearly one-fifth of all penile injuries. Quite surprisingly, amongst adults, zips were the most frequent cause of penile injuries. In another study, thirty boys, aged 2-12 years, presented with penile zip entrapment to one Pediatric Accident and Emergency Department over a 7 year period. The rate of presentation was one zip entrapment per 4068 new patient attendances. In contrast to previous reports, injuries occurred most commonly whilst the zip was being done up and whilst underpants were being worn.

Luckily, releasing a zip-entrapped prepuce is usually a fairly easy and straightforward procedure. Several nonsurgical techniques have been developed to help patients in this predicament. One of these methods involves inserting the thin blade of a small screwdriver between the outer and inner faceplates of the zip fastener, and then twisting it toward the median bar. This will widen the gap between faceplates, disengaging the foreskin. This simple technique was used in 12 children and was found to be safe, effective and painless. It can be performed by an attending pediatrician even in nonhospital settings. Another quick and nontraumatic approach involves instantly releasing the prepuce by lateral compression of the zipper with pliers. Other reported interventions have ranged from dismantling the zipper with bone or wire cutters (after opening the zipper teeth, the zipper falls apart and can be removed from the foreskin) to circumcision.

So... guys, best watch what you're doing when you're doing up your fly!
Image courtesy of foto76 at


Bagga HS, Tasian GE, McGeady J, Blaschko SD, McCulloch CE, McAninch JW, Breyer BN. (2013) Zip-related genital injury. BJU Int. 112(2): E191-4. 

Mishra SC.(2006) Safe and painless manipulation of penile zipper entrapment. Indian Pediatr. 43(3): 252-4

Raveenthiran V. (2007) Releasing of zipper-entrapped foreskin: a novel nonsurgical technique. Pediatr Emerg Care. 23(7):463-4.

Wyatt JP, Scobie WG. (1994) The management of penile zip entrapment in children. Injury. 25(1):59-60.

Monday, June 15, 2015

Bifid penis: an old case from Estonia

Bifid means, basically, "split into two equal parts". A bifid penis sounds kinda scary, doesn't it? Yet in the animal world, it's not always an anomaly. Many male marsupials (for example, koalas) naturally have a bifid penis, with two prongs which are simultaneously inserted into the female's two vaginal canals. 

In humans, a bifid penis is a (mercifully) rare congenital defect. It is often present together with hypospadias, a condition where the urinary opening is not located where it should be, on the head of the penis. In the past, boys born with a bifid penis often underwent sex reassignment surgery and were raised as girls, because penile reconstruction was deemed too difficult. They received hormone replacement therapy and developed female characteristics.

In 1924, a case of bifid penis was briefly described in the Journal of Anatomy. The photos were taken at the Surgical Clinic of the University of Dorpat (today - Tartu, the second largest city of Estonia). The author, Alexander Lipschutz, writes:

"In this case the body and glans show complete separation into two parts, giving the appearance of a double penis. The body and glans of each half appear of usual length, but together are slightly wider than normal. The scrotum and testicles are normal in size and position, and this taken in conjunction with the secondary male character of the triangular-shaped distribution of the pubic hair, would indicate that the patient was sexually normal.

It is to be regretted that no other details of this case are available, as the hospital archives were lost during the war and revolution."

And here are the grainy old photos of the anomaly:

If the patient was, as reported, "sexually normal", one can't help wondering - was he capable of achieving an erection and having intercourse? While an erection does seem anatomically possible (so long as the corpora cavernosa, smooth muscles and so on were normally developed and there was no impairment in blood supply), I'm not so sure about the intercourse part - but then, I suppose stranger things have happened.


Lipschutz A (1924) A Note on a Case of Bifid Penis. J Anat. 58: 254–255.
Wikipedia: Bifid penis

Thursday, June 11, 2015

Reconstructing a destroyed ear almost 90 years ago

Reconstructing the intricate anatomy of the auricle, with its folds and bends of thin cartilage, isn't easy even today. (Many patients decide to opt for an ear prosthesis rather than a reconstructed ear, which can look chunky, unnatural and just plain ugly.) I was surprised to learn that back in the 1920s, when plastic and reconstructive surgery was still in its infancy, some adventurous surgeons were attempting ear reconstruction procedures. One such case is documented in California and Western Medicine - the official journal of the California Medical Association. The case report was published in 1927. The patient, a young man, had been injured in a railway accident, losing all but a small portion of his ear. 

The procedure was largely carried out on a trial-and-error basis. The surgeon, one Harrington B. Graham, writes:

"The tissues on the scalp were undamaged so that I could use the non-hairy parts for the reconstructed portion. My first step was to transplant a piece of septal cartilage the shape of the sole of a shoe to the subcuticular tissues posterior to the defect. I placed this directly behind the defect instead of above and behind, so that when I brought my tissues forward I did not have enough support to keep them high enough. Any cartilage either from the nose of rib, used to keep the soft tissues up and away from the head, should lie, by preference, in the one-third of the completed ear. It is difficult to get enough nasal septal cartilage to fill the demand, so that the lower portion of the lobe may have to be disregarded."

Despite the difficulties with obtaining enough cartilage from the nose, the author is not convinced that rib cartilage would work better. He also stresses the importance of the final cosmetic effect of the surgery, which depends largely on the operator's skill and on the technique used.

"[obtaining rib cartilage] is a difficult task and the shaping might increase the tendency to absorption. It is hard to get a piece of rib cartilage as thin as septal cartilage, and this is a very important factor, as far as the cosmetic appearance of the ear is concerned.

The thinness of the new tissue will depend to a great extent upon the position subcutaneously of the transplant. If it is buried deeply in the tissues, the result must be a thick ear. A superficial position is a difficult one to obtain, but will pay the operator for his pains. Any tissue taken from the arm or chest must be thick, looking like a piece of putty when transplanted. However, time modifies its appearance so that under certain circumstances it may be permissible to use it."

The reconstruction was carried out painstakingly in stages and involved skin grafting from the leg:

"After leaving the cartilage in place for a month, I made a circular incision to the hair line, starting at the upper anterior part of the old ear. This incision was carried to the periosteum and the skin thus outlined, including the cartilage, was raised and folded in such a way as to have the upper border of the ear covered by a continuous layer of skin. The anterior portion was now sewed down to the tragus, and the defect on the scalp remedied by the customary undermining, reduction in size of the opening, and a skin graft taken from the leg [...] Were I to do another I should not fold the upper edge back, as in this case, but would use it entire, placing a graft over the whole posterior surface. This flap, if the cartilage were properly placed, would be quite sufficient to form a new ear without any further addition.

After another month the lower part was incised, carried forward and sewed to the freshened lobule, another graft being placed posteriorly. A few minor operations were done to smooth things out, and an attempt made to stiffen the upper border somewhat by the introduction of celluloid."

Here is a picture from the initial stages of surgical work:

And the final result looked like this:

All images from: Graham (1927)

The author self-critically admits:

"The ear that I constructed is considerably smaller than the normal ear, due to the fact that I did not carry my incision high enough on the head, that I folded too much tissue back in order to get a smooth border, and that my cartilage was not placed high enough. All of these errors should be avoided in future work."

However, the final result of the reconstruction still looks quite impressive, given the times!


Graham HB. (1927) The reconstruction of a completely destroyed auricle. Case report. Cal West Med. 27(4): 518–519. 

Monday, June 8, 2015

The mysterious link between cat bites and depression

Every cat owner knows that these lovely animals are very independent-minded and often quite capricious. They also possess sharp claws and teeth and frequently don't hesistate to use them.
A cat bite is not only painful - it can potentially have serious consequences. Cats are carnivores and harbor some very nasty bacteria in their mouths. A cat bite often leads to a tissue infection, necessitating antibiotic treatment. In rare cases such infections can actually prove fatal.

However, it seems that the vision of a painful, pus-filled wound is not the only reason to fear a cat's teeth. American researchers have discovered an astonishing link between cat bites and human depression.
In a recent data mining study, performed in Michigan on a population of 1.3 million patients, depression was found in 41.3% of patients with cat bites and only 28.7% of those with dog bites. (Overall there were 750 patients with cat bites, 1,108 with dog bites, and approximately 117,000 patients with depression.) Furthermore, 85.5% of those with both cat bites and depression were women, compared to 64.5% of those with dog bites and depression.

It gets even better. Based on over 10 years of data, if a woman presented to the University of Michigan Health System with a cat bite that was serious enough to warrant medical attention, there was a 47.0% chance that she will also be given a diagnosis of depression at some point in her life, compared to 24.2% of men presenting with a similar bite. The gender difference was still present but smaller for dog bites: if a woman presented with a dog bite, there was a 35.8% chance of having depression compared to 21.1% of men. The highest depression rate was for patients who had both a dog bite and a cat bite, with nearly half (47.8%) having depression, all of them women.

The high prevalence of depression in patients who were bitten by a cat, especially women, suggests that screening for depression might actually be appropriate in patients who present to a clinical provider with a cat bite.

Interestingly, the most common types of animal bites in the ICD E906.3 category (which comprises bites of animals other than dogs, rats, snakes, lizards and arthropods) were cats (n = 701, 80.9%), squirrels (n = 45, 5.2%), bats (n = 20, 2.3%) and raccoons (n = 17, 2.0%), although a wide variety of other animals were also mentioned, including moles, monkeys and mice, as well as parrots, pigs, piranhas, and prairie dogs. The majority (58.8%) of cat bites in the study were inflicted by the patients’ own cat, including 56.1% among those who had depression. Being bitten by a stray or feral cat was least common (15.7% of all bites, and 15.2% of bites among those with depression).

As yet, no causative link is known to explain this puzzling statistical association between depression and cat bites. Researchers speculate that, perhaps, Toxoplasma gondii infection (known to be spread by cats, and linked to brain pathologies and personality changes) may play a role. Alternatively, domesticated cats may become more aggressive in response to changes in their owners' mental state and behavior. There is also some evidence that cat owners tend to be more neurotic - and, hence, more prone to depression - than dog owners. Overall, the relationship between cats and human mental illness apparently needs to be investigated further.

Image courtesy of dan at

Hanauer DA, Ramakrishnan N, Seyfried LS. (2013) Describing the Relationship between Cat Bites and Human Depression Using Data from an Electronic Health Record. PLoS One. 2013; 8(8): e70585.

Tuesday, June 2, 2015

Dangerous complications caused by intragastric balloon

Severe, morbid obesity is a life-threatening condition which is becoming more and more prevalent all over the world. When diet and exercise are not enough, bariatric surgery can successfully bring patients' weight under control. There are several types of bariatric operations. Some, e.g. the sleeve gastrectomy procedure, consist in shrinking the stomach to restrict food consumption; others, such as the popular gastric bypass, involve removing or rearranging a portion of the digestive tract to impair the absorption of calories and nutrients.

In the case of younger and less obese patients, reversible procedures such as gastric banding or intragastric balloon are often used. Gastric banding involves placing a band around the stomach, which is then progressively tightened to restrict food intake. An intragastric balloon means that a deflated balloon is placed in the stomach and then filled with saline to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months. This method may be used prior to another bariatric procedure to help the patient reach a safer weight before radical surgery. It is fully reversible and is considered relatively safe. However, in rare cases even this simple procedure can lead to unexpected complications. In one notable case, a metallic ring broke off from the balloon, migrated to the small bowel and caused a potentially life-threatening intestinal perforation.

A 45-year-old man of Middle Eastern origin, morbidly obese, with a body mass index of 39, had an intragastric balloon inserted. The balloon was filled with 500 mL of saline/methylene blue. Initially everything was just fine, but after 8 weeks the patient reported to the emergency department, complaining of abdominal cramps, a lack of appetite and nausea. An ultrasound of the abdomen was performed and confirmed the balloon to be in place without any abnormality. The patient was discharged home on symptomatic medication. Since the pain didn't subside, 2 days later he returned to the ER. This time, a mild generalized abdominal tenderness was noticed on clinical examination, so a computed tomography scan was performed for further evaluation. It revealed that, although the intragastric balloon remained in its proper position, its metallic safety ring had broken off and migrated to the small bowel. There were no clinical or radiological signs of intestinal obstruction. 

The patient was hospitalized for observation, advised to eat and drink nothing, and was started on IV fluids. He became completely asymptomatic. The next morning, he underwent an upper gastrointestinal endoscopy and the balloon was retrieved.

The following night, the patient suddenly experienced severe abdominal pain, so an X-ray of the abdomen was performed and showed free air under the right dome of the diaphragm. An emergency laparotomy was performed and two small perforations were found at the site where the metallic ring was entrapped. The ring was removed and the perforations were repaired. 

Free air under the diaphragm.

Endoscopic and gross eye views of both balloon and its broken ring after extraction.  
All images from: Zubaidi et al. (2015)

The metallic safety ring prevents distal migration of the device if the balloon ruptures. However, 
in this case, the ring became detached from the rest of the system and migrated down to the jejunum while the balloon remained in the stomach. The resulting jejunal perforation required immediate surgical repair.

The patient can probably consider himself fairly lucky, since prompt medical attention and emergency surgery helped him avoid much more severe complications (e.g. peritonitis) or even death.

Zubaidi AM, Alghamdi HU, Alzobydi AH, Dhiloon IA, Qureshi LA. (2015) Bowel perforation due to break and distal passage of the safety ring of an adjustable intra-gastric balloon: A potentially life-threatening situation. World J Gastrointest Endosc. 7(4): 429–432.

Saturday, May 30, 2015

Tasmanian devils and their deadly transmissible facial cancer

Today's post is about a strange and horrid disease which you've possibly never heard about, unless you happen to live in Australia. It doesn't affect humans. Its unfortunate victims are Tasmanian devils.

The Tasmanian devil (Sarcophilus harrisii) is a carnivorous marsupial approximately the size of a small dog, with a stocky build, black fur and a keen sense of smell. These animals are solitary nocturnal scavengers that weigh up to 12 kg and generally live for 5 or 6 years in the wild. The island of Tasmania is the only place where a wild population of devils still survives - but, possibly, not for long. Since 1996, their numbers have become decimated by a nasty malady known as devil facial tumor disease (DFTD).

DFTD is a non-viral transmissible cancer which is spread by direct transfer of living cancer cells through biting. Infection can occur when animals fight with each other, e.g. during the mating season, or when an infected carcass is ingested.

The first signs of this disease are lesions and lumps around the mouth. They subsequently develop into large, soft, ulcerated cancerous masses which can spread from the face to various organs. Infected animals typically die within six months of organ failure, secondary infection or starvation, since the tumors make it difficult to ingest food. Scientists are working on a vaccine or cure, but without success. It is predicted that if no treatment for DFTD is found, Tasmanian devils could become extinct by 2035.

Genomic analysis suggests that the transmissible facial cancer first arose from a female Tasmanian devil and that the clone has subsequently become genetically diverse during its spread across Tasmania.

Below are the photos of two sick animals. Behold the unusual cancer that has survived beyond the death of the individual that spawned it by becoming adapted to transmission between hosts.


Murchison EP. et al. (2012) Genome Sequencing and Analysis of the Tasmanian Devil and Its Transmissible Cancer. Cell. 148(4): 780–791.

Wikipedia: Devil facial tumor disease

Friday, May 8, 2015

Abscess of the auricle gets drained

A while ago, I published a post with an assortment of videos showing yucky abscesses being lanced. Today, I've found yet another cool educational clip on YouTube where a painful, pus-filled problem is being tackled with a scalpel.

Some poor person has an infection of the auricle (that's the external part of your ear - also called the pinna), or more precisely - of that little hanging fleshy part where earrings are inserted, the lobe. The earlobe is very red, swollen and it looks like the condition must be agonizing to say the least. The surgeon carefully injects some local anesthetic around the abscess, then makes an incision with a scalpel and a stream of whitish pus flows out. Afterwards, the doctor packs the bleeding abscess cavity with gauze. Unfortunately, the text of the video is all in Spanish. The original video was posted on YouTube by one DrCarbonell.