TORONTO - The case of the California man whose estranged wife cut off his penis and put it through the garbage disposal raises no end of questions -- among them what surgeons can do when a man has suffered such a traumatic amputation.
While doctors say the best option is reattachment, it's not known whether that was possible for the unidentified 60-year-old man, whose wife Catherine Kieu, 48, faces a number of charges --including torture and aggravated mayhem.
The assault recalls another high-profile case in 1993, when Lorena Bobbitt chopped off husband John Wayne Bobbitt's penis, then drove in a car and threw the severed penis on the side of a road. His penis was later recovered and successfully reattached.
A more likely alternative in the California case would be penile reconstruction -- called a phalloplasty, said Dr. Robert Nam, a urologic oncologist at Sunnybrook Health Sciences Centre in Toronto.
"The primary treatment approach would be to put in a penile flap," said Nam, explaining that surgeons create a tubular, penis-like structure using skin typically taken from the forearm and muscle from a leg.
A penile prosthesis, which doctors often use to treat erectile dysfunction, would then be implanted inside the flap.
"It's a piece of skin and with the prosthetic it will look like there's something there, but ... it's nowhere close to what a real penis looks like. It's just something there that can be functional for men in the future," said Nam.
The man would be able to have sex but not experience orgasm. That doesn't mean he would be infertile: as long as the scrotum is in place and healthy, sperm can be harvested from the testicles for artificial insemination.
The patient and doctor would also have to decide what to do about the urethra, the tube inside the penis that channels urine from the bladder.
"We could theoretically bring the urethra down to an area called the perineum, between the anus and base of the scrotum," which would allow a man to urinate sitting down with total control, he said. "We do that commonly when patients have penile cancer and they require the whole penis to be removed."
Another option that has been tried is transplanting a penis taken from a cadaver donor, in the same way a kidney or liver is procured.
In 2006, surgeons at Guangzhou General Hospital in China attached a 10-centimetre penis to a 44-year-old man who had lost that part of his genitalia in an accident. The donor penis, from a brain-dead 22-year-old, was functioning well 10 days after the 15-hour operation.
But doctors had to remove the penis two weeks later because the man and his wife were psychologically unable to adapt to the transplant.
Their reaction to the donor organ underscores another issue -- the emotional ramifications of losing any part of the genitalia.
Doctors say the psychological scars can be equally as challenging for a patient as the physical ones.
Dr. Katy Kamkar, a psychologist at the Centre for Addiction and Mental Health in Toronto, said losing an arm, leg or any body part can be difficult for a person to come to terms with.
"Very often when people lose a part of their limb, they do perceive it as being quite traumatic, often perceive it as losing part of their identify, part of themselves," she said Thursday. "And it does take a lot of adjustment."
They may become depressed, experiencing sadness, anxiety and an inability to cope in social situations, said Kamkar. "And sometimes it also could be issues in regards to feeling angry. It could be 'Why me? Why has this happened?"'
While she would not discuss the California case specifically, Kamkar pointed out that women who lose a breast to cancer or have a hysterectomy often suffer a loss of self-image, identity and femininity.
"So one loss can also be followed by so many other losses as well."
Nam suggested that men with a penile injury would also suffer an erosion of self-esteem and sense of masculinity, based on medical literature dealing with men who have lost the ability to have sexual intercourse as a result of prostate cancer surgery.
"We know that it's a significant issue for them. So then add on the loss of a penis and the young age, the psychological impact would be traumatic."
Still, Nam said the penis is not necessary to preserve one's life, and its loss does not negate the ability to reproduce or wipe out masculinity.
"People relate lack of a penis to a lack of drive or they lose their manhood, which is not the case from a medical perspective. Because it's the testicles in the scrotum that produce the testosterone and that's preserved."
