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CASE REPORT
Year : 2001  |  Volume : 18  |  Issue : 1  |  Page : 89-91
 

Penile gangrene associated with chronic renal failure - report of 2 cases and review of literature


Department of Urology & Kidney Transplant, PD. Hinduja National Hospital and Medical Research Centre, Munnbai., India

Correspondence Address:
Arvind Goyal
381/17A, Krishna Nagar, Civil Lines, Ludhiana- 141001
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Penile gangrene associated with chronic renal failure, is a rare entity. Patients usually have associated diseases like diabetes, hypertension. Gangrene occurs because the dystrophic calcific infiltration causes huninal obstruction. This is an accompaniment of generalized soft tissue calcification and bony abnormality resulting. from secondary hyperparathyroidism. Calcium phosphate product exceeds plasma solubility causing precipitation of calcium phosphate. Medical treatment may maintain the product below precipitation levels. Mortality in these patients remains high due to the severity of the associated systemic illnesses. Conservative surgical treatment is advocated in view of short life span.


Keywords: Penile Gangrene: Chronic Renal Failure: Diabetes; Secondary Hyperparathyroidism; Calcium Deposition.


How to cite this article:
Goyal A, Gaitonde K, Sagade S N. Penile gangrene associated with chronic renal failure - report of 2 cases and review of literature. Indian J Urol 2001;18:89-91

How to cite this URL:
Goyal A, Gaitonde K, Sagade S N. Penile gangrene associated with chronic renal failure - report of 2 cases and review of literature. Indian J Urol [serial online] 2001 [cited 2019 Aug 21];18:89-91. Available from: http://www.indianjurol.com/text.asp?2001/18/1/89/37468



   Introduction Top


Distal penile gangrene in a patient with chronic renal failure on dialysis is a rare entity with ten cases reported in literature. Most of the reported cases had abnormal parathyroid levels with calcification of vessels causing gangrene from vascular occlusion. 2 patients with thrombotic disease of vessels have been reported. Patients usually suffer from associated disease such as diabetes, hypertension and vascular disorders. We report our experience of 2 patients. who presented with distal penile gangrene. where the cause of gangrene was calcium deposition in the penile vessels causing ischemia and necrosis. Both patients died within few months of treatment because of unrelated causes. We advocate conservative surgical approach rather than aggressive surgical treatment in view of the short life span of these patients.


   Materials and Methods Top


Case 1: A 65-year-old male patient, a diagnosed diabetic with end stage renal disease on peritoneal dialysis. He was referred for foul smelling discharge from the prepuce without accompanying fever & pain. Local examination revealed phimosis with purulent discharge. A dorsal slit was done. The underneath glans revealed an area of blackening measuring 2.5 cms x 1.5 cms with no evidence of cellulitis of adjacent tissue. Patient was started on antibiotics and the necrosis did not progress. Serum calcium & phosphorus product was raised above 70, on few occasions despite patient being on medical therapy while parathyroid hormone level was normal. Partial penectomy was done. The residual corpora showed decreased vascularity with minimal bleeding. The wound healed well after 2 weeks. Microscopically calcification was seen in vessels. causing luminal obliteration. No organism was seen. During the hospital stay patient had tonic clonic seizures, and CT scan showed lacunar infarcts. Subsequently the patient developed peripheral vascular disease with necrosis of right heel and died during same hospital stay.

Case 2: A diagnosed diabetic with hypertension and CRF developed blackening of the prepuce. Clinical examination revealed necrosis of the prepuce suggestive of dry gangrene. Circumcision was done, but the lesion did not settle. Gangrene of glans developed and partial amputation was done. Histopathology showed calcific deposition in the vessel wall. The wound was healthy after that, with no progression of disease. Parathyroid hormone levels were not done. Serum calcium & phosporous product was above 70. Patient developed concomitant diabetic macroangiopathy with dry gangrene of left toe along with diabetic retinopathy. Patient died six months after first presentation.


   Discussion Top


Penile gangrene in patients with CRF and diabetes has been attributed to calcific dystrophic infiltration of blood vessels. These patients usually have altered serum parathyroid levels and raised calcium and phosphorous product. About ten cases of distal penile gangrene associated with abnormal calcium and phosphorous metabolism have been reported. Two cases with thrombus of vessels causing distal penile gangrene have also been reported. Fournier gangrene is an entirely different entity where infection is confined to subcutaneous tissue sparing corpora. Necrotising fascitis in Fournier's gangrene causes wet gangrene.[1]

As many as eighty percent of patients on long-term haemodialysis have soft tissue calcifications and bony abnormalities.[2] Soft tissue calcifications most commonly are arterial but ocular, periarticular, visceral and cutaneous involvements also occur.[3] Arterial calcification occurs in approximately twenty percent of the patients in the early stage of chronic renal failure and up to seventy-five percent of those with advanced hyperparathyroidism.[4] Arterial and metastatic soft tissue calcification in patients with uremia results from secondary hyperparathyrodism with high parathyroid hormone levels, hyperphosphatemia and connective tissue changes.[3] Serum calcium levels in secondary hyperparathyroidism are usually low or normal.[5]

Precipitation of calcium phosphate crystals in arteries, subcutaneous tissues and viscera occurs when serum calcium-phosphate product exceeds plasma solubility that varies from 60 to 75 mg/dl, depending upon normal laboratory values.[6],[7] The fact that calcification rarely resolves and progresses despite successful renal transplantation has been attributed to the phenomenon of calciphylaxis.[8],[9] The histologic appearance of the arteries demonstrates marked luminal compression owing to calcific infiltration of the media, reactive connective tissue swelling and hyperplasia of the intima. By contrast, diabetic small vessel disease results from atheromatous replacement of the intima which eventually causes total obstruction.

Prevention of soft tissue and vascular calcification depends upon early aggressive medical management of secondary hyperparathyroidism.[7] The establishment of normal calcium & phosphate levels will supress the hyperparathyoid glands. This effect is brought about by use of elemental calcium & Vitamin D analogue.

Most important early aggressive therapy with oral phosphate binders to decrease gastrointestinal absorption of phosphate is indicated to prevent hyperphosphaternia and to maintain the serum calcium phosphate product below its precipitation level. Despite these medical measures, the therapy may be ineffective in controlling the disease.[5] Our patients despite being on appropriate early medical intervention and oral phosphate binders. had an elevated serum calcium-phosphate product and progressive arterial calcification developed.

Although the efficacy of subtotal parathyroidectomy remains controversial, operative intervention has been recommended. by Franklin C. Lowe et al[5] for those urerrlic and transplant patients in whom progressive soft tissue and vascular calcifications develop despite medical therapy. There have been numerous report in literature of distal extremity gangrene associated with abnormal calcium metabolism. Gipstein et al[10] reported on 11 patients with end stage renal diseases, high or high normal serum calcium levels and severe hyperphosphatemia. Of these patients 10 were treated with parathyroidectomy of whom 7 had improvement in the ischernia lesions. Perloff et al[11] and Hallgren et al[12]- have also supported subtotal parathyroidectomy as treatment for progressive calcification.

Markstein et al[1] have reported 7 cases who presented with vascular calcification and had deranged calcium and phosphate metabolism with calcium phosphorus product being greater than 70. They suggested that mortality of this group remains high due to the severity of the associated systemic illnesses. In their series none of the patients underwent parathyroidectomy and 71 percent patients showed stabilization or improvement of disease. This finding compares favorably with those of patients treated with parathyroidectomy, thus casting doubt on efficacy of the treatment.


   Conclusion Top


We present 2 patients who had luminal obstruction because of calcification of blood vessels. The calcium phosphorus product was raised. In our patients the histology revealed calcification of vessel wall and thrombus was seen in the lumen. We advocate conservative surgical approach in view of the short life span of patients due to associated diseases.

 
   References Top

1.Stein M. Anderson C. Ricciardi R et al. Penile gangrene associated with chronic renal failure - Report of 7 cases and review of the literature. J Urol 1994: 152: 2011-2016.  Back to cited text no. 1    
2.Kleeman CR. Massry SG, Coburn JW. Popoutzer MM. The problem and unanswered questions - Renal osteodystrophy. soft tissue calcification. and disturbed divalent ion metabolism in chronic renal failure. Arch Intern Med. 1969: 124: 162.  Back to cited text no. 2    
3.Parfitt AM. Soft tissue calcification in uremia. Arch Intern Med 1969:124:544.  Back to cited text no. 3    
4.Pendras JP. Parathyroid disease in long term maintenance haemodialysis. Arch Intern Med 1969: 124: 312.  Back to cited text no. 4    
5.Lowe FC. Brendler CB. Penile gangrene - A complication of secondary hyperparathyroidism from chronic renal failure. J Urol 1984_ 132: 1189-1191.  Back to cited text no. 5    
6.Conn J. Krumlovsky FA, Del Greco E. Simon NM. Calciphylaxis: Etiology of progressive vascular calcification and gangrene. Ann Sure 1973: 177: 206.  Back to cited text no. 6    
7.Herbert FK. Miller HG, Richardson GO. Chronic renal disease. secondary parathyroid hyperplasia. decalcification ofbone and metastatic calcification. J Path Bac 1941: 53: 161.  Back to cited text no. 7    
8.Ejerblad S. Eriksson 1, Wibell L. Arterial disease with ischemic ulcerations in renal transplanted recipients. Scand J Urol Nephrol 1977: Suppl. 42: 186.  Back to cited text no. 8    
9.Selye H. Calciphylaxis. Chicago, University of Chicago. Press, 1962.  Back to cited text no. 9    
10.Gipstein RM. Cobum JW. Adarns DA. Lee DBN et al. Calciphylaxis in man. A Syndrome of tissue necrosis and vascular calcification in I I patients with chronic renal failure. Arch Intern Med 1976: 136:1273.  Back to cited text no. 10    
11.Perlolf LJ, Spence RK, Grossman RA. Barker CF. Lethal post-transplantation calcinosis. Transplantation 1979: 27: 21.  Back to cited text no. 11    
12.Hailgren R. Wibell L, Ejerblad S. Eiiksson et al. Arterial calcification and progressive peripheral gangrene after renal transplantation - Report of two cases treated with parathyroidectomy. Acta Med Scand 1975: 198: 331.  Back to cited text no. 12    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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    Abstract
    Introduction
    Materials and Me...
    Discussion
    Conclusion
    References
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