Urinary Retention, Erectile Dysfunction and Penile Anaesthesia After Circumcision: A Mixed Dissociative (conversion) Disorder

Introduction

Several patterns of somatic dysfunction may present in the absence of known organic disease. The up to date rather confusing terminology in the description of these often impressive phenomena clearly reflects a limited understanding of the complex interaction between physical and psychological factors. The Austrian physician Sigmund Freud (Figure 1) provided the first conceptual framework for hysteria as adisease entity.

The World Health Organisation (WHO) has meanwhile provided a simpler nomenclature based upon the nature ofthe bodily functions that are impaired.

The case reported herein fulfills all three criteria (Table 1) for the definite diagnosis of a mixed dissociative (conversion) disorder.

Case report

In 1979, an infant boy underwent temporary bilateral ring ureterostomy and transurethral valve resection for classical posterior urethral valves. He had early recovery and stabilisation of renal function. In April 1990, the boy, now aged 11 years was circumcised. The procedure was completely uneventful, but the boy was highly distressed by the procedure. In addition (although not known to his doctors) his mother was diagnosed with breast cancer at the same time. While he was able to void normally immediately postsurgery, he reported progressive dificulty in passing urine during the next two days. Complete painless retention followed and required catheterisation. After several days, a supra-pubic catheter was inserted. Clean intermittent selfcatheterisation was started 18 months later. Although he developed well during puberty with good genital growth, he experienced gradual fading of erections and a condom-form anaesthesia of the penis as a teenager. A complete urodynamic and neurophysiological workup of the pelvic floor were performed without pathological findings. Detrusor muscle biopsies showed normal innervation pattern and morphology. Nitrousoxide synthesis de.ciency was excluded.

Table 1. Diagnostic guidelines for a definite diagnosis of dissociative (conversion) disorders (ICD-10, WHO, 1993)

The following should be present:
(a) the clinical features as specified for the individual disorders in F44;
(b) no evidence of a physical disorder that might explain the symptoms;
(c) evidence for psychological causation, in the form of clear association in time with stressful events and problems or disturbed relationship (even if denied by the individual).

Since the boy complained of alternating diarrhoea and constipation, barium meal and follow through, barium enema, colonoscopy, oesophago-gastroduodenoscopy and duodenal biopsies were performed to exclude coeliac and in.ammatory bowel diseases. All studies were normal and irritable bowelsyndrome was assumed.

When the patient was 18 years old, his mother died of metastatic breast cancer. He immediately started to void spontaneously with a good stream. Three years later, he describes normal erections and has a steady sexual relationship.

Discussion

His case fulfils all three WHO criteria (Table 1, (a–c)) for the definite diagnosis of a mixed dissociative (conversion) disorder (F44.7)¹. The patient presented with the distinct clinical features of urinary retention and erectile dysfunction (dissociative motor disorder) and penile anaesthesia (dissociative sensory loss) (a). No evidence of a physical condition existed that might explain the symptoms (b). Other physical illnesses had been ruled out appropriately by exhaustive urological and neurological evaluation. Exclusion of organic disease is a compulsory diagnostic criterion for mixed dissociative disorder and must be completed before psychiatric opinion and psychological management. Most authors recommend limiting investigations to an essential minimum², which seems unrealistic. The clear association in time of symptom onset and cessation with apparently highly stressful events (circumcision; mothers death) seems acceptable as evidence forpsychological causation (c).

An early history of a physical or psychological trauma relating to the urogenital tract (e.g. repeated infections, operations, excessive attention on urinary functions) may predispose a child to later expression of psychological problems through urinary retention³. Although posterior urethral valves can be associated with significant long-term morbidity requiring close surveillance well beyond puberty, neither reversible urinary retention nor impotence have yet been documented as sequelae of this rare anomaly⁴.

While uncomplicated circumcision does not explain the symptoms from a strictly technical point of view some authors suggest that circumcision is perceived by the child as an act of aggression and castration⁵. Although the latter is perfectly symbolised by erectile dysfunction and penile anaesthesia in our patient, that may well be an over-interpretation. The additional trauma of the mothers initial diagnosis with breast cancer may be relevant. As psychiatric evaluation was rejected, denying a psychogenic aetiology prevented a professional assessment of potentially abnormal patterns of family function.

In the treatment of somatic symptoms, most authorities advocate active rehabilitation and attempts to help the child and family understand why abnormal illness behaviour has developed². Suggestion and encouragement towards a gradual resumption of normal function are often useful. However, trials of therapy and good systematic descriptions of the disorder are lacking.

Address for correspondence: Privatdozent Dr.med. Elmar Gerharz, Department of Urology, Bavarian Julius Maximilians University Medical School, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
Phone: +49 931 201 32012; Fax: +49 931 201 32013
E-mail:  Gerharz_E@klinik.uni-wuerzburg.de

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