In this article we report several cases of self-injection of various substances into the penis for the purpose of penis enlargement. In our retrospective study, we had 18 patients, mostly of young age (mean age, 37.4 years). The most common complication at the time of presentation was necrosis (72.2%). The high prevalence of necrosis can be due to the poor hygiene or the absence of sterile equipment used for penile self-injection, since most of our patients had been convicted.(9) Another concern among our participants was pain and swelling of the genitalia (33.3%), which is similar to the proportion of patients (17, 22.4%) reported in another study that included the imprisoned population, who injected Vaseline (petrolatum).(10)
The most common product injected was Vaseline (88%). The timing of presentation ranges greatly from 6 months to 31 years after the injection of foreign substance into the penis. This latency has been also reported in other studies, which reached 30–40 years.(9, 11) Such a long period of time between the self-injection and referral to the clinic can be affected by the hesitancy to seek medical treatment due to possible embarrassment.
In clinical practice there have been described the three stages of oleogranuloma: at stage I the 30% of the penile shaft is involved; at stage II the whole penis is affected; stage III is characterized by the spread of oleogranuloma to nearby anatomic structures such as the perineum, scrotum and pubic area.(12) The possible complications of self-injection of foreign substance into the penis include sexual dysfunction due to granulomatous process and fibrosis,9 ulceration and necrosis of the penile shaft skin.(13, 14) Upon histopathological examination, various inflammatory cells can be visualized, such as neutrophils, macrophages, lymphocytes and giant cells, in addition to a foreign compound.(15)
In our clinical practice there was no superiority of MRI or ultrasonography observed for the assessment of severity and planning further management. A study by Harris et. al reported that MRI is preferable than US for silicone due to the interference of deeper structures on ultrasound, while there are very few studies describing the features of mineral and baby oil on imaging.(16)
The management depends on the extent of the oleogranuloma, clinical presentation and the desired outcomes, while the ultimate treatment is only surgical. There are two surgical options, primary incision and Reich's surgery, for treating oleogranuloma in our country. Patients with distal and small oleogranuloma undergo primary incision, while Reich's surgery is indicated for patients with extensive oleogranuloma, which spread to the scrotum and suprapubic area.
One half of our patients with distal oleogranuloma of penis underwent primary incision of the abnormal tissue, which is the circular excision of the penile skin until the tunica albuginea, followed by covering the defect with intact skin (foreskin) of the penis. This method is used when the size of the abnormal tissue is small and the size of the foreskin is enough to cover the defect.
Due to the extensive indurative skin changes 9 patients underwent radical excision of the altered skin until the tunica albuginea and healthy tissues of the penis, scrotum, and suprapubic region. After excising the oleogranuloma, the exposed part of the penis needs to be covered by the remaining part of the scrotum according to the Reich method. The first stage of Reich's surgery involves the formation of a tunnel under the skin until the base of the scrotum, where an incision is made along the diameter of the penis. The penis is passed through the tunnel, and the glans penis is brought out through an incision in the bottom of the scrotum. The bottom of the scrotum and the remaining skin of glans penis are sutured together. Rich blood supply to the scrotum and its ability to expand in response to occasional penile erection allows adequate wound healing. After 2–3 months, the second stage of Reich's surgery is performed - releasing the penis with the skin of the scrotum from the remaining part. (Fig. 2, 2.1, 2.2, 2.3).
Limitations. The limitation of this study is the retrospective design, a small number of patients and involvement of several hospitals in Astana, which does not represent the extent, diversity of clinical presentation and complications of penile injection of foreign substances across the whole country. Furthermore, only the patients, who were referred by the urologist for surgical management, participated in this study, while those patients, who were managed conservatively on an outpatient basis, and the patients, who were possibly reluctant to look for the medical care were not included, which could affect the actual prevalence and distribution of oleogranuloma in Kazakhstan. In addition, the vast majority of patients had lower level of education and had been imprisoned, hence the data may not be relatable to the general population.
In conclusion, this study demonstrates the higher prevalence of oleogranuloma in Kazakhstan than previously admitted. The findings of this study should raise the awareness about the complications of penile self-injections among high-risk groups (e. g. prisoners) to prevent from performing this procedure or to encourage seeking for medical management in case of injection. Moreover, informing physicians about this practice is important, since many patients may be reluctant to declare the history of undergoing this procedure at first encounter.